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

Water fetching and musculoskeletal health across the life-course in Sub-Saharan Africa: A scoping review

The world is experiencing a global water crisis and Sub-Saharan Africa (SSA) is expected to be a hotspot for increasing global water scarcity in years to come. Water is quintessentially a gendered issue; indeed, sociocultural norms hold women responsible for household water collection, requiring them to travel far distances while carrying water. This paper reports the findings of a scoping review of peer-reviewed and grey literature that examines the relationship between water fetching and the musculoskeletal (MSK) health of women in SSA. The work is informed by a gendered life-course perspective, and the authors follow the PRISMA-ScR guidelines. Results indicate a bidirectional relationship between water fetching and poor MSK health as chronic and acute incidences of water carrying are highly related to MSK pain and dysfunction. This has negative implications for the overall health and wellbeing of women and their households. Gaps in the literature are identified, including the experiences of elderly people and people with various vulnerabilities. Recommendations from the literature are compiled to outline potential avenues of future research and innovation to better support the MSK health of water fetchers in SSA.

Household Toilet and Sanitation Insecurity is Associated With Urinary Symptoms, Psychosocial Burden, and Compensatory Bladder Behaviors

OBJECTIVE

To investigate whether being "at-risk" for toilet and sanitation insecurity in the United States is associated with urinary symptoms, voiding behaviors, and psychosocial burden. Based on census data, nearly 2 million people in the United States do not have access to adequate plumbing. More may have inconsistent access related to cost, inadequate facilities for the number of people in a home, or declining regional infrastructure. The effects of inadequate access in the United States are poorly characterized.

METHODS

This is a secondary analysis of a community-based sample of adults electronically recruited to complete questionnaires on clinical and sociodemographic information, living situations, home toilets and plumbing, urinary symptoms, compensatory bladder behaviors, and psychosocial burden. Multivariable logistic regression was used to assess for associations between being at-risk for toilet and sanitation insecurity and urinary and psychosocial symptoms. Linear regression was used to assess for association with adopting compensatory bladder behaviors.

RESULTS

This sample included 4218 participants, of whom 17% were identified as being at-risk for toilet and sanitation insecurity. Being at-risk for toilet and sanitation insecurity was associated with worse overall urinary symptoms and greater bother from these symptoms, in addition to worse self-assessed mental and physical health, anxiety, stress, depression, and fewer social supports. Finally, those at-risk for toilet and sanitation insecurity were more likely to adopt burdensome and unhealthy compensatory bladder behaviors.

CONCLUSION

As with other social determinants of health, toilet and sanitation insecurity may be an under-appreciated contributor to urinary symptoms, unhealthy toileting behaviors, and psychosocial distress.

Menstrual hygiene management practice and associated factors among high school and preparatory school adolescent students in Debre Markos town, Northwest, Ethiopia: a mixed-method study

BACKGROUND

Despite being a normal occurrence, menstruation requires hygienic care and is associated with a number of myths and wrongdoings. Menstrual hygiene issues have been linked to major health issues, such as urinary tract and reproductive tract infections. Consequently, the purpose of this study was to evaluate the management of menstrual hygiene and related aspects among teenage students in Debre Markos town, North West, Ethiopia.

METHODS

From March 15 to April 15, 2019, teenage pupils in Debre Markos town participated in a cross-sectional mixed study. An in-depth interview and a self-administered structured questionnaire were used to gather data. Quantitative information was imported into Epi Data and then exported to SPSS for examination. A 95% Confidence Interval of p-value ≤ 0.05 was used to declare significance. The method of thematic content analysis was used to examine the qualitative data.

RESULT

This study comprised 531 individuals in total, with a 96.2% response rate. Approximately 260 adolescent females (49%, 95% CI: 39.2, 59.2) had good management practices for menstrual hygiene. Girls whose mothers were private employees (AOR: 0.3, 95% CI: 0.09, 0.99), self-employed (AOR: 0.52, 95% CI: 0.28, 0.98) and housewives (AOR: 0.53, 95% CI: 0.29, 0.98), and parent-adolescent discussions about menstruation (AOR: 1.62, 95% CI: 1.40, 3.34) were significantly associated with good menstrual hygiene management. Adolescence aged 17 years or older (AOR: 2.13, 95% CI: 1.32, 3.44) were found to have good knowledge regarding menstrual hygiene (AOR: 1.59, 95% CI: 1.43, 2.94). The qualitative study found that ignorance, an unfavorable school climate, and cultural and economic factors were the main causes of teenagers' poor menstrual hygiene.

CONCLUSION

Nearly half of adolescent girls had good menstrual hygiene practice. Menstrual hygiene practice was associated with adolescent age, knowledge of menstruation, maternal occupational and discussion with parents. Girls had difficulty to manage menstrual hygiene due to poor knowledge, unsafe school environment, and cultural barriers. Thus, school-based programs aimed at improving knowledge towards menstrual hygiene management are needed.

Protocol for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study in Khulna, Bangladesh: A Prospective cohort to quantify the influence of menstrual health on adolescent girls' health and education outcomes

BACKGROUND

Menstrual health is essential for gender equity and the well-being of women and girls. Qualitative research has described the burden of poor menstrual health on health and education; however, these impacts have not been quantified, curtailing investment. The Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study aims to describe menstrual health and its trajectories across adolescence, and quantify the relationships between menstrual health and girls' health and education in Khulna, Bangladesh.

METHODS AND ANALYSIS

AMEHC is a prospective longitudinal cohort of 2016 adolescent girls recruited at the commencement of class 6 (secondary school, mean age=12) across 101 schools selected through a proportional random sampling approach. Each year, the cohort will be asked to complete a survey capturing (1) girls' menstrual health and experiences, (2) support for menstrual health, and (3) health and education outcomes. Survey questions were refined through qualitative research, cognitive interviews and pilot survey in the year preceding the cohort. Girls' guardians will be surveyed at baseline and wave 2 to capture their perspectives and household demographics. Annual assessments will capture schools' water, sanitation and hygiene, and support for menstruation and collect data on participants' education, including school attendance and performance (in maths, literacy). Cohort enrolment and baseline survey commenced in February 2023. Follow-up waves are scheduled for 2024, 2025 and 2026, with plans for extension. A nested subcohort will follow 406 post-menarche girls at 2-month intervals throughout 2023 (May, August, October) to describe changes across menstrual periods. This protocol outlines a priori hypotheses regarding the impacts of menstrual health to be tested through the cohort.

ETHICS AND DISSEMINATION

AMEHC has ethical approval from the Alfred Hospital Ethics Committee (369/22) and BRAC James P Grant School of Public Health Institutional Review Board (IRB-06 July 22-024). Study materials and outputs will be available open access through peer-reviewed publication and study web pages.

Associations between water insecurity and mental health outcomes among lesbian, gay, bisexual, transgender and queer persons in Bangkok, Thailand and Mumbai, India: Cross-sectional survey findings

Background

Water insecurity disproportionally affects socially marginalized populations and may harm mental health. Lesbian, gay, bisexual, transgender and queer (LGBTQ) persons are at the nexus of social marginalization and mental health disparities; however, they are understudied in water insecurity research. Yet LGBTQ persons likely have distinct water needs. We explored associations between water insecurity and mental health outcomes among LGBTQ adults in Mumbai, India and Bangkok, Thailand.

Methods

This cross-sectional survey with a sample of LGBTQ adults in Mumbai and Bangkok assessed associations between water insecurity and mental health outcomes, including anxiety symptoms, depression symptoms, loneliness, alcohol misuse, COVID-19 stress and resilience. We conducted multivariable logistic and linear regression analyses to examine associations between water insecurity and mental health outcomes.

Results

Water insecurity prevalence was 28.9% in Mumbai and 18.6% in Bangkok samples. In adjusted analyses, in both sites, water insecurity was associated with higher likelihood of depression symptoms, anxiety symptoms, COVID-19 stress, alcohol misuse and loneliness. In Mumbai, water insecurity was also associated with reduced resilience.

Conclusion

Water insecurity was common among LGBTQ participants in Bangkok and Mumbai and associated with poorer well-being. Findings signal the importance of assessing water security as a stressor harmful to LGBTQ mental health.

WaSH insecurity and anxiety among people who inject drugs in the Tijuana-San Diego border region

BACKGROUND

Water, sanitation, and hygiene (WaSH) insecurity increases the risk of water-related diseases. However, limited research has been conducted on psychosocial distress as it relates to WaSH insecurity, especially among people who inject drugs (PWID). We examined the relationship between WaSH insecurity and related anxiety among PWID living in different housing conditions along the US-Mexico border region.

METHODS

From 2020-2021, a cross-sectional study was conducted among 585 people who injected drugs within the last month in Tijuana (N = 202), San Diego (N = 182), and in both Tijuana and San Diego (N = 201). Participants underwent interviewer-administered surveys related to WaSH access, substance use, and generalized anxiety disorder (GAD-7). Quasi-Poisson regressions were used to assess associations between WaSH insecurity and anxiety in the prior 6-months.

RESULTS

Participants were 75% male, 42% were unhoused and 91% experienced WaSH insecurity in the prior 6-months. After adjusting for housing status, gender, and age, lack of access to basic drinking water (Adj RR: 1.28; 95% CI: 1.02-1.58), sanitation (Adj RR:1.28; 95% CI: 1.07-1.55), and a daily bath/shower (Adj RR: 1.38; 95% CI: 1.15-1.66) were associated with mild-severe anxiety. The number of WaSH insecurities was independently associated with a 20% increased risk of experiencing anxiety per every additional insecurity experienced (Adj RR: 1.20; CI: 1.12-1.27). We also found a significant interaction between gender and housing status (p = 0.003), indicating that among people experiencing sheltered/unsheltered homelessness, women had a higher risk of mild-severe anxiety compared to men (Adj RR: 1.55; 95% CI: 1.27-1.89). At the same time, among women, those who are unhoused have 37% increased risk of anxiety than those who live in stable housing conditions (Adj RR: 1.37; 95% CI: 1.01-1.89).

CONCLUSION

The lack of specific WaSH services, particularly lack of drinking water, toilets, and daily showers were associated with higher levels of anxiety among PWID in the Tijuana-San Diego border region. Women experiencing homelessness were especially vulnerable. WaSH interventions that provide safe, 24-h access may help to reduce anxiety and health risks associated with WaSH insecurity.

Development of a behaviour change intervention to promote sanitation and latrine use in rural India

BACKGROUND

Across developing countries poor sanitation is associated with disease often found widespread in rural populations.

OBJECTIVES

This objective of this study was to conduct a formative research and feasibility evaluation of the behavioural intervention designed to improve latrine use in rural India.

METHODS

Study conducted in four villages of Rajasthan, where latrine use is low and open defecation may spread disease. To identify the intervention a literature review was conducted, a survey of 497 households, and focus groups in village households (8-10 women and children). Seven focus groups with 63 women were conducted. Based on the survey results, the behaviour change intervention is developed utilising the Capability-Opportunity-Motivation-behaviour model and MINDSPACE framework. One intervention component involves psychological aspects that engage villagers through a pledge; the other component is provision of small incentives to facilitate latrine use. Feasibility and acceptability of the intervention was examined in the study population. The 30-day intervention was delivered to women in 38 randomly selected households who despite having a functional latrine did not use it. Thematic analysis, binary logistic regression analysis and feasibility evaluation of the intervention conducted. Post-intervention feedback from 22 participating households was obtained.

RESULTS

The piloted intervention was feasible and so a revised design is offered. Results driving this evaluation include barriers identified, and used to improved intervention design in the current study. Village authority figures influenced behaviours across the villages and so did factors of convenience (β = 5.28, p < 0.01), relief (β = 5.49, p < 0.01), comfort (β = 2.36, p < 0.01), Construction cost (β=-1.98, p < 0.01) and safety (β = 2.93, p < 0.01) were significant concerns associated with latrine use in the context of prevalent OD in the region. The logistic regression baseline model for the dependant variables indicated a significant increase in latrine use. Based on the feasibility study, the intervention is refined in several ways.

CONCLUSIONS

Our theory-driven approach improves latrine use in Rajasthan and offers a useful tool to facilitate hygiene behaviour.

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.

Influence of social factors on adoption of sanitation practices in rural areas: a mixed methods study in Nzaui, Kenya

Introduction

provision of adequate sanitation is among the common strategies of preventing sanitation-related diseases. However, provision of sanitation facilities may only be a sustainable solution if the population´s behavior changes and positive perception is embraced. This paper highlights the influence of social factors on adoption of sanitation practices.

Methods

convergent mixed methods design was employed. Quantitative data was gathered using structured questionnaires from 100 household heads selected using cluster and simple random techniques. Logistic regression analysis was performed to explore factors that influenced adoption of sanitation practices. Qualitative data was gathered from a purposively selected focus group and analyzed thematically.

Results

many (57%) of the participants were males. The average age for participants was 39 years, standard deviation (SD)=0.20. From the multivariable regression analysis with adjusted odds, household heads being aged 18-33 years (OR 1.76, 95% CI: 0.62-3.02, p=0.015) and safety of latrines (OR 1.72, 95% CI: 0.70-5.15, p<0.001) was associated with increased open defecation chances; whereas being a female (OR 0.16 95% CI: 0.06-1.81, P=0.01), availability of open spaces near households (OR 0.12, 95% CI: 0.05-1.13, p=0.30), and mason skills (OR 0.29, 95% CI: 0.13-1.65) were associated with reduced likelihood of open defecation practices. Further, being a female (OR 1.06, 95% CI: 0.18-3.16, p=0.043), having knowledge on safe sanitation (OR 1.01, 95% CI: 0.74-3.08, p=0.02), engaging skilled masons for toilet construction (OR 1.299, 95% CI: 1.01-8.95, p=0.005) and financial stability (OR 1.95, 95% CI: 0.98-23.40, P=0.032<0.001) were positively associated with adoption of improved toilets.

Conclusion

the sanitation status in the study area was mainly poor due to the influence of multiple factors like gender, absence of toilets, knowledge on safe sanitation, poverty, mason skills and toilet location in relation to safety. The findings showed the need for innovative planning approaches based on the social aspects of communities for progress in sanitation standards in rural areas. Such approaches should adhere to the sanitation hardware versus software components of communities to promote active utilization of the available toilets, construction of improved toilets and reduction of open defecation.

Menstrual Hygiene Practices in Indian Tribal Females: A Systematic Review and Meta-Analysis

India is native to many tribal communities: Bharia (Madhya Pradesh), Bihl (Rajasthan), Santhal (Bihar, Jharkhand), Bodo (Assam, West Bengal), and many more. They reside in isolated geographical regions, which poses challenges in reaching out to them. In addition, they still have firm beliefs and taboos regarding menstruation. Knowledge about menstrual health and hygiene is one of the most important aspects of tribal health. Therefore, it is important to synthesize the results of menstrual hygiene data from the Indian tribal population. We have calculated the pooled prevalence of sanitary pad use, dustbin disposal, and hygienic reuse of menstrual materials. Online databases, namely PubMed, Cochrane Central, CINAHL, Pan African Journals, EBSCO, and Google Scholar, were searched. After the removal of duplicates, a quality check, and screening of cross-references, 19 articles were selected for final review. Statistical analysis was done by Revman 5.4 and STATA 17.0. A p-value of <0.05 was considered statistically significant. PRISMA guidelines were followed. The protocol registration number was CRD42022331376. This is a non-funded article. The pooled prevalence of sanitary pad use in Indian tribal females was 2% (95% CI 1 to 3). The pooled prevalence of dustbin disposal of menstrual material was 1% (95% CI: 0.00 to 0.02). The pooled prevalence of hygienic reuse of menstrual materials was 1%. Sanitary menstrual hygiene practices are very less prevalent in Indian tribal females. Awareness programs and tribal health policies need to be accelerated for the promotion of menstrual hygiene. Also, literature on the use, disposal, and storage of menstrual adsorbents is scarce in Indian tribes. Health research in this area needs to be emphasized.

Assessment of menstrual hygiene management knowledge, practice, and associated factors among girls in Boset District, Ethiopia: a school-based cross-sectional study

BACKGROUND

Adolescent girls, particularly in lower socioeconomic settings, lack adequate knowledge of menstrual hygiene management and have subpar hygiene habits. Likewise, the factors related to it have not been well addressed, and schoolgirls are facing a range of challenges. To develop effective intervention approaches, a context-specific assessment of menstrual hygiene practices is useful. Thus, this study aimed to assess menstrual hygiene management knowledge, practice, and associated factors among girls in the Boset district, Ethiopia.

METHODS

A school-based cross-sectional study was conducted at Boset district secondary schools among 629 randomly selected girls using the multi-stage sampling technique. Data were collected using a self-administered, structured questionnaire. The collected data were entered into Epi-info version 7 and analyzed by Statistical Package for Social Science (SPSS) version 26. Binary logistic regression analysis was used to model the association between dependent and independent variables. An adjusted odds ratio and 95% confidence interval were used to measure the strength of the association, and a p-value < 0.05 was used to declare statistical significance.

RESULT

Of the total study participants, 51.2% (95% CI: 46.6-55.8%) had an appropriate practice of menstrual hygiene and 57.9% (95% CI: 53.3-62.5%) had good knowledge status on menstrual hygiene management. Being an urban resident (AOR = 1.84, 95% CI: 1.20-2.80), having a mother with a secondary and above educational level (AOR = 3.4, 95% CI: 2.07-5.57), earning regular pocket money (AOR = 2.19, 95% CI: 1.45-3.313), and discussing menstrual issues with parents and friends (AOR = 3.65, 95% CI: 2.327-5.727) were associated with good practice of menstrual hygiene.

CONCLUSION

In this study, nearly half of the school girls had good practice and knowledge of menstrual hygiene management. Educating mothers and promoting discussion about menstrual hygiene management issues, especially in rural areas, should be priority actions.

Assessing sustained uptake of latrine and child feces management interventions: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh 1-3.5 years after intervention initiation

BACKGROUND

Sanitation interventions typically result in modest increases in latrine access, and any gains in latrine access and use are often not sustained over time. Sanitation programs also rarely include child-focused interventions such as potties. We aimed to assess the sustained effect of a multi-component sanitation intervention on access to and use of latrines and child feces management tools in rural Bangladesh.

METHODS

We conducted a longitudinal substudy nested within the WASH Benefits randomized controlled trial. The trial provided latrine upgrades, child potties and sani-scoops for feces removal, along with behavior change promotion to encourage use of the delivered hardware. Promotion visits to intervention recipients were frequent during the first 2 years after intervention initiation, decreased in frequency between years 2-3, and ceased after 3 years. We enrolled a random subset of 720 households from the sanitation and control arms of the trial in a substudy and visited them quarterly between 1 and 3.5 years after intervention initiation. At each visit, field staff recorded sanitation-related behaviors through spot-check observations and structured questionnaires. We assessed intervention effects on observed indicators of hygienic latrine access, potty use and sani-scoop use and investigated whether these effects were modified by duration of follow-up, ongoing behavior change promotion and household characteristics.

RESULTS

The intervention increased hygienic latrine access from 37% among controls to 94% in the sanitation arm (p < 0.001). Access among intervention recipients remained high 3.5 years after intervention initiation, including periods with no active promotion. Gains in access were higher among households with less education, less wealth and larger number of residents. The intervention increased availability of child potties from 29% among controls to 98% in the sanitation arm (p < 0.001). However, fewer than 25% of intervention households reported exclusive child defecation in a potty or had observed indicators of potty and sani-scoop use, and gains in potty use declined over the follow-up period, even with ongoing promotion.

CONCLUSION

Our findings from an intervention that provided free products and intensive initial behavior change promotion suggest a sustained increase in hygienic latrine access up to 3.5 years after intervention initiation but infrequent use of child feces management tools. Studies should investigate strategies to ensure sustained adoption of safe child feces management practices.

Menstrual hygiene practice and associated factors among adolescent girls in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Menstrual hygiene has not received adequate attention in Sub-Saharan Africa, and there is a lack of regional representative data. Therefore, this study aimed to estimate the pooled prevalence of good menstrual hygiene practices and associated factors among adolescent girls in sub-Saharan Africa.

METHODS

In this study, the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to develop the review manuscript. Online electronic databases, such as PubMed/Medline, Google Scholar, and CINAHL, were searched to retrieve available studies. The database search was conducted from January 1 to May 17, 2022. The selection, quality assessment, and data extraction of the studies were performed. Quality assessment of the studies was performed using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. Subgroup analysis and meta-regression were performed based on country, study area, and sample size. Publication bias was examined by funnel plots and Egger's test. The statistical analysis was conducted using STATA version 14 software and RevMan software, and statistical significance was declared at a p value of less than 0.05.

PROTOCOL REGISTRATION NUMBER

CRD42020165628.

RESULTS

A total of 229 studies were retrieved, and 14 studies were included in the final meta-analysis. The pooled prevalence of good menstrual hygiene practices was 45% (95% CI, (37, 53). Adolescents from urban residences (OR = 3.03, 95% CI (2.3, 3.97)), able to afford menstrual sanitary products (OR = 2.17, 95% CI (1.42, 3.3)), and from educated mothers (OR = 2.33, 95% CI (1.32, 4.12)) were associated with increased odds of good menstrual hygiene practice.

CONCLUSION

The pooled prevalence of menstrual hygiene practices was low compared to the SDG 6.2 target by 2030. "Achieve access to adequate and equitable sanitation and hygiene for all, paying special attention to the needs of women and girls and those in vulnerable situations". Therefore, improving the accessibility of a safe water supply, hygiene, sanitation facilities and affordability of menstrual products and promoting maternal education are mandatory and should be part of government-level public health policy to prevent related health issues, loss of economic output and education opportunities.

Food, water, and sanitation insecurities: Complex linkages and implications for achieving WASH security

Food, water and sanitation insecurities are complex, multi-dimensional phenomena that entail more than availability and access; food, water, and sanitation resources must be safe and culturally appropriate. Researchers and implementers concerned with these insecurities have demonstrated that there are notable interactions between them resulting in significant psychological and biological outcomes. Recent randomised controlled trials (RCTs) in Bangladesh, Kenya (WASH Benefits) and Zimbabwe (SHINE) demonstrated no effect from water, sanitation and hygiene (WASH) interventions on linear growth, and mixed evidence on enteropathogen burden and risk of diarrhoea in young children. These data suggest a need for a more comprehensive understanding of WASH security. The risks posed by multiple resource insecurities shift depending on the individual, their movement throughout their day, their economically and socially prescribed roles, and ecological features such as seasonality and precipitation. By more fully integrating food, water and sanitation security in interventions and subsequent impact evaluations, we can achieve WASH security-one that addresses myriad transmission pathways and co-occurring diseases-that ultimately would improve health outcomes throughout the world. In this critical review, we outline the complexity of combined resource insecurities as a step towards transformative WASH.

A Systematic Review of Water, Sanitation, and Hygiene for Urban Poor in Low- and Middle-Income Countries during the COVID-19 Pandemic through a Gendered Lens

Inadequate water, sanitation, and hygiene (WASH) among urban poor women is a major urban policy concern in low- and middle-income countries (LMICs). There was a paucity of systematic information on WASH among the urban poor during the pandemic. We reviewed the opportunities and challenges faced by the urban poor in LMICs during the COVID-19 pandemic. We used the PRISMA guidelines to conduct a comprehensive search of 11 databases, including MEDLINE, Embase, Web of Science, and CINAHL, between November 2019 and August 2021. We used thematic analysis to synthesize the qualitative data and meta-analyses to estimate the pooled prevalence. We screened 5008 records, conducted a full-text review of 153 studies, and included 38 studies. The pooled prevalence of shared water points was 0.71 (95% CI 0.37-0.97), non-adherence to hygiene practices was 0.15 (95% CI 0.08-0.24), non-adherence to face masks was 0.27 (95% CI 0.0-0.81), and access to shared community toilets was 0.59 (95% CI 0.11-1.00). Insufficient facilities caused crowding and long waiting times at shared facilities, making physical distancing challenging. Women reported difficulty in maintaining privacy for sanitation, as men were present due to the stay-at-home rule. Due to unaffordability, women reported using cloth instead of sanitary pads and scarves instead of masks.

Female-friendly toilets in schools in Burkina Faso: A mixed-methods study using photo-elicitation

Background

An absence of gender-sensitive sanitation facilities in schools and the negative effects this has on girls has been widely discussed among advocacy groups, though less examined in academic spheres. Drawing on triangulated data, we outline current challenges and respondent-driven solutions to enhance the female-friendly nature of toilets in a context of extreme poverty.

Methods

This mixed-methods study was informed by the tenets of human-centred design. We first quantitatively assessed facilities in 14 secondary schools in the Kossi Province of Burkina Faso. We then collected qualitative data, including 15 focus group discussions and 53 in-depth interviews among schoolgirls, mothers, teachers and key informants. We applied photo-elicitation, a novel method, to explore perceptions of facilities and the desirability and feasibility of interventions to improve gender-friendly sanitation facilities.

Results

No school met international water, sanitation and hygiene (WASH) standards for schools. Roughly one third of schools did not have water and, when present, there was no reliable way to use it within the toilet complex. Schoolgirls shared feelings of shame and stress when menstruating at school, and said that they would avoid using school toilets, if possible. Schoolgirls described water access as the most urgent need to address, followed by fostering privacy and facilitating cleanliness within facilities. Mothers and teachers mostly aligned with these priorities, while key informants additionally emphasised the need to raise awareness on both general and menstrual hygiene and to develop maintenance systems. Photo-elicitation engaged and empowered participants to pinpoint priorities and concrete solutions, namely a need for doors and locks, water containers and cleaning materials.

Conclusions

WASH needs in many schools remain unmet. Women and girls should be involved in decision-making across stages of intervention design and implementation. Young women's voices merit greater inclusion in academic literature. Future interventions should enhance access to water and privacy. Future research could explore maintenance and monitoring strategies to develop guidance on sustainable solutions.

Associations between water, sanitation, and depression among older people in Ghana: empirical evidence from WHO-SAGE Wave 2 survey

BACKGROUND

While depression is the most frequent psychiatric disorder among the older adults, the use of water and sanitation has been associated with both physical and psychological adverse outcomes. We investigated the associations of water and sanitation with depressive symptoms among older adults in Ghana.

METHODS

The study used data from 4,735 participants in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 2 of adults aged ≥50 years. Major depressive episode (MDE) was assessed using the World Mental Health Survey version of the Composite International Diagnostic Interview and we classified water and sanitation sources based on the Joint Monitoring Program. Multivariate logistic regressions evaluated the associations.

RESULTS

Approximately 7.3% of respondents reported a MDE, 90% and 78% used improved water sources and sanitation facilities respectively, and 77% shared sanitation facilities. Individuals who used unimproved water sources and unimproved sanitation were 1.6 and 1.3 times more likely to report MDE respectively. Also, sex-based analysis showed that the effect of the use of unimproved water and sanitation on depression was much appreciable and more substantial among women compared to men.

CONCLUSIONS

The findings suggest the importance of water and sanitation to the well-being of older people, particularly among women. Policies targeted at improving the mental health in old age should include water and sanitation.

Do health risk perceptions motivate water - and health-related behaviour? A systematic literature review

Health-related risk perceptions are important determinants of health behaviours and components of behaviour change theories. What someone thinks or feels will motivate or hinder their intention or hesitancy to implement a certain behaviour. Thus, a perceived potential risk to our health and well-being can influence our health-promoting and/or health-seeking behaviour. We aimed to review and synthesize available peer-reviewed literature to better understand the links between water and health-related risk perceptions and behaviours. We conducted the first systematic review of peer-reviewed literature on risk perceptions and behaviours in the context of water and health, published between 2000 and 2021. A total of 187 publications met the inclusion criteria. We extracted data relating to study characteristics and categorized our results according to the major themes emerging from the literature, namely drinking water, sanitation, hygiene and wasterelated topics, health risk factors, diseases and mental health implications, and preventative measures. Our review shows that the literature has grown over the past twenty years, reporting information from different countries belonging to different income groups around the globe, conducted in various settings and contexts, among different target populations, from various disciplinary angles, using different methods, theories and approaches. Our review provides evidence of health risk perceptions determining behaviour particularly related to drinking water sources and water safety. Evidence on disease prevention, health seeking, variations and changes in perception and behaviour over space, geography, socioeconomic differences and time, and the relevance of cultural context is provided. Our review shows that risk perception studies are vital for WASH governance in terms of policy, raising awareness, education and behaviour change. In order to make risk perception and behaviour studies even more relevant to effective public health planning and health messaging, future research needs to increasingly focus on early culturally sensitive interventions and changes in perceptions and behaviours over time.

Women 'holding it' in urban India: Toilet avoidance as an under-recognized health outcome of sanitation insecurity

Emerging research on sanitation challenges in the Global South increasingly uncovers health and social impacts by gender, particularly lack of sanitation safety. Women may employ strategies to avoid urination or defecation ('holding it') in the absence of safe sanitation, but the practice is not well understood. We quantitatively analyze survey data on women from urban slums across three cities in Maharashtra, India whose households constructed a toilet through an intervention programme. We assess relationships between household versus shared sanitation, perceptions of safety, and women's toilet avoidance behaviours, including diet restriction. At baseline, women have more than three times the odds of reporting avoidance behaviours if they perceive a community toilet to be unsafe, even after controlling for other factors. Household water insecurity is also instrumental in the relationship between avoidance and lack of safety. Finally, avoidance exhibits a significant and major drop upon provision of a household toilet. This study provides substantial support for the prevalence of habitual toilet avoidance among vulnerable urban women without access to safe sanitation. We conclude with recommendations for policy approaches and call for more attention to the health repercussions of habitual toilet avoidance among women as a consequence of sanitation insecurity.

Household sanitation and menstrual hygiene management among women: Evidence from household survey under Swachh Bharat (Clean India) Mission in rural Odisha, India

Introduction

Discussion on women empowerment without addressing their basic needs would be meaningless. As such, the needs of women and girls have been prioritized in global sanitation efforts including menstrual hygiene. However, there is little research on existing approaches on menstrual management. India's most ambitious sanitation campaign named Swachh Bharat Mission or "Clean India Mission" aimed to achieve universal sanitation coverage in every single household, targeted to end open defecation by October 02, 2019. This study aimed to assess the women's perception of household sanitation facilities and menstrual hygiene management experience in Odisha under Swachh Bharat Mission.

Methods

The study is a community-based survey having cross-sectional in nature conducted among 700 rural women and girls aged 15-45 years in the Balesore district of Odisha state in India from January to April 2021. A multi-stage sampling method was adopted to select the study participants. Data was collected using a pretested questionnaire based on the Performance Monitoring and Accountability 2020 survey questionnaire and analyzed by SPSS version 25. Descriptive statistics was used to assess the household sanitation and menstrual hygiene management experience among women.

Results

More than two-thirds (68.4%) of rural households use improved sanitation facilities. Around 30% of families have inadequate sanitation infrastructure, which means at least one household member defecates in the open space. Nearly 64.6% disposed of their menstrual absorbents in the bush or field, while 29.1% disposed in the river and 24.1% in the waste bin. Still, 40.6% of women were using clothes as menstrual absorbents, and 54.9% of the respondents reported washing their menstrual materials for re-use. Of those who washed and re-used, 99.2% said their re-use material was completely dry before re-use. About 69.7% of the respondents mentioned that they change their menstrual absorbents in sleeping areas at home. About 91% of the respondents reported that the place where they changed their menstrual absorbents was safe, clean, and private. Only 22.5% of women responded to having water and soap at their menstruation management area.

Conclusion

The effort for improvements in sanitary techniques during menstruation is partly effective in creating healthy behavior. The current strategy for developing programs to adopt menstrual hygiene measures needs a bottom-up approach with women at the center. Components associated with menstrual hygiene management, such as women's cleanliness, water supply, and the availability and accessibility of disposable sanitary napkins, should be given specific attention. It is essential to acknowledge the issues like toilet construction and behavior change communication to consolidate the gains in an era of "Clean India Mission."

Effect of a combined household-level piped water and sanitation intervention on reported menstrual hygiene practices and symptoms of urogenital infections in rural Odisha, India

Adequate menstrual hygiene management (MHM) requires access to water and sanitation and can be challenging for many women and girls living in resource-poor settings. Inadequate MHM has been associated with urogenital infections. The aim of this study is to assess the impact of a combined household-level piped water and sanitation intervention on MHM practices and urogenital infection symptoms (UGS) among women living in rural communities of Odisha (India). This study was nested within a pair-matched cohort study designed to assess impact of the Gram Vikas MANTRA program, which provided household-level piped water, bathing areas and latrine to all households in intervention villages, on diarrheal disease (primary outcome). The program did not specifically promote menstrual hygiene practices. Forty-five intervention villages were randomly selected from a list of those where implementation was previously completed at least five years before and matched to 45 control villages. Data for the main study was collected in four rounds from June 2015 to October 2016. For the MHM sub study, household surveys were administered in round four to randomly selected women aged 18 or older among study households from the 90 villages, to assess self-reported MHM practicesand urogenital infections symptoms. MHM practices were deemed adequate if they met some of the criteria developed on the basis of international monitoring that the GV program could modify (adequate frequency of absorbent change, washing the body with soap and privacy for managing menstruation). Multilevel mixed-effects logistic regression with a random effect distribution at the level of the pair and village was used to estimate the effect of the intervention on adequate MHM practices (primary outcome) and reported UGS (secondary outcome). A total of 1045 women (517 from intervention and 528 from control) were included in the study. Women who lived in the villages receiving the intervention, were more likely to report adequate MHM practices than those in control villages (Adjusted OR (AOR) 3.54, 95% Confidence Interval (CI): 1.86-6.78). 14.51% and 15.53% of women living in the control and intervention villages reported having at least one UGS. There was no evidence of an intervention effect on reported UGS (AOR = 0.97, 95%CI: 0.64-1.46). While household latrines or bathing areas with access to piped water improve the environment that enable MHM practices related to privacy, the provision of such facilities alone had only a moderate impact in adequate MHM and did not have an effect on self-reported UGS. More targeted inventions that include behavior change strategies and that address other barriers may be necessary to improve MHM practices.

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.

Identifying Risk Factors for Lower Reproductive Tract Infections among Women Using Reusable Absorbents in Odisha, India

A large proportion of women in Odisha, India, use reusable absorbents to manage their menstruation. Yet, the risk factors for lower reproductive tract infections (RTIs) related to menstrual hygiene management (MHM) have not been studied among reusable absorbent users. Women of reproductive age attending one of two hospitals from two different cities in Odisha during two separate study intervals were recruited for the study. Laboratory diagnosis of bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC) were conducted. A questionnaire was used to collect information on MHM practices, water, sanitation, and socio-demographic factors. Among the 509 women who used reusable absorbents, 71.7% were diagnosed with at least one infection. After adjusting for confounders, women with BV were more likely to identify as being a housewife (aOR: 1.8 (1.1-2.9)). Frequent absorbent changing was protective against BV (aOR: 0.5 (0.3-0.8)), whereas frequent body washing increased the odds of BV (aOR: 1.5 (1.0-2.2)). Women with VVC were more likely to be older (aOR: 1.6 (1.0-2.5)), live below the poverty line (aOR: 1.5 (1.1-2.2)), have a non-private household latrine (aOR: 2.2 (1.3-4.0)), dry their absorbents inside the house (aOR: 3.7 (2.5-4.5)), and store absorbents in the latrine area (aOR: 2.0 (1.3-2.9)). Washing absorbents outside the house was protective against VVC (aOR: 0.7 (0.4-1.0)). This study highlights the importance of improving MHM practices among reusable absorbent users to prevent lower RTIs among women reusing menstrual materials in Odisha.

Cross-sectional study to measure household water insecurity and its health outcomes in urban Mexico

OBJECTIVE

To assess the links between structural and household determinants of household water insecurity and test three water insecurity measures against self-reported diarrhoea, dengue fever and perceived stress in the middle-income and low-income urban areas of Torreón, Mexico.

DESIGN

Cross-sectional household survey conducted in two waves (rainy and dry seasons).

PARTICIPANTS

500 households selected via multistage cluster sample in selected communities. Socioeconomic status determined the selection of participant neighbourhoods; five were identified in low socioeconomic status neighbourhoods and five in low-medium socioeconomic status neighbourhoods. We examine how the context of urban water provision is related to a new cross-culturally valid Household Water Insecurity Experiences (HWISE) Scale.

PRIMARY OUTCOME MEASURES

The HWISE Scale, self-reported diarrhoea, dengue fever and the Perceived Stress Scale.

RESULTS

Water system intermittency (adjusted OR (AOR) 3.96, 95% CI 2.40 to 6.54, p<0.001), unpredictability (AOR 2.24, 95% CI 1.34 to 3.74, p=0.002) and the dry season (AOR 3.47, 95% CI 2.18 to 5.52, p<0.001) were structural correlates of the HWISE Scale. This study also found that the HWISE Scale was associated with two health outcomes, self-reported diarrhoea (AOR 1.09, 95% CI 1.03 to 1.15, p=0.002) and perceived stress (β=0.28, SE=0.07, t=4.30, p<0.001), but not self-reported dengue fever (AOR 1.02, 95% CI 0.98 to 1.06). A 3-item hygiene subscore and a 3-item water worry subscore were also both positively associated with self-reported diarrhoea and perceived stress.

CONCLUSION

Short-form screeners of water insecurity may be useful for assessing certain health risks by lay survey workers in settings with limited healthcare resources, particularly in lieu of more expensive microbiological tests that require specialised training and facilities.

How does sanitation influence people's quality of life? Qualitative research in low-income areas of Maputo, Mozambique

Preventing infectious disease has often been the primary rationale for public investment in sanitation. However, broader aspects of sanitation such as privacy and safety are important to users across settings, and have been linked to mental wellbeing. The aim of this study is to investigate what people most value about sanitation in low-income areas of Maputo, Mozambique, to inform a definition and conceptual model of sanitation-related quality of life. Our approach to qualitative research was rooted in economics and applied the capability approach, bringing a focus on what people had reason to value. We undertook 19 in-depth interviews and 8 focus group discussions. After eliciting attributes of "a good life" in general, we used them to structure discussion of what was valuable about sanitation. We applied framework analysis to identify core attributes of sanitation-related quality of life, and used pile-sorting and triad exercises to triangulate findings on attributes' relative importance. The five core attributes identified were health, disgust, shame, safety, and privacy. We present a conceptual model illustrating how sanitation interventions might improve quality of life via changes in these attributes, and how changes are likely to be moderated by conversion factors (e.g. individual and environmental characteristics). The five capability-based attributes are consistent with those identified in studies of sanitation-related insecurity, stress and motives in both rural and urban areas, which is supportive of theoretical generalisability. Since two people might experience the same toilet or level of sanitation service differently, quality of life effects of interventions may be heterogeneous. Future evaluations of sanitation interventions should consider how changes in quality of life might be captured.

How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals

There is increasing global attention to the importance of menstrual health and hygiene (MHH) for the lives of those who menstruate and gender equality. Yet, the global development community, which focuses on issues ranging from gender to climate change to health, is overdue to draw attention to how addressing MHH may enable progress in attaining the Sustainable Development Goals (SDGs). To address this gap, we undertook a collective exercise to hypothesize the linkages between MHH and the 17 SDGs, and to identify how MHH contributes to priority outcome measures within key sectoral areas of relevance to menstruating girls in low- and middle-income countries. These areas included Education, Gender, Health (Sexual and Reproductive Health; Psychosocial Wellbeing), and Water, Sanitation and Hygiene (WASH). These efforts were undertaken from February - March 2019 by global monitoring experts, together with select representatives from research institutions, non-governmental organizations, and governments (n = 26 measures task force members). Through this paper we highlight the findings of our activities. First, we outline the existing or potential linkages between MHH and all of the SDGs. Second, we report the identified priority outcomes related to MHH for key sectors to monitor. By identifying the potential contribution of MHH towards achieving the SDGs and highlighting the ways in which MHH can be monitored within these goals, we aim to advance recognition of the fundamental role of MHH in the development efforts of countries around the world.

Acceptability of menstrual products interventions for menstrual hygiene management among women and girls in Malawi

Background

A key challenge for menstruating girls and women in low-resource countries is the inadequate and unreliable supply of menstrual products. Although development partners are implementing menstrual product interventions to address this challenge in Malawi, there is a paucity of information on the distribution of menstrual products and the acceptability of these interventions among users.

Methods

We conducted in-depth interviews with girls (n = 20) and women (n = 26) and 4 focus group discussions (FGDs) with women (n = 35) and 7 FGDs with girls (n = 60) to explore the acceptability of menstrual products interventions in 8 districts. Teachers (n = 12), community leaders (n = 6), community health workers (n = 8) and service providers (n = 9) were also interviewed to explore implementation issues and their views regarding the effect of menstrual products interventions on girls and women. Data were analyzed using content analysis.

Results

Common menstrual products being promoted include locally made reusable pads, commercially made disposable pads and menstrual cups. Overall, adult women preferred reusable pads and young girls preferred disposable pads. Reported benefits of using any type of material distributed included enhanced cleanliness and reduced school absenteeism for girls. While community leaders and teachers applauded the use of disposable menstrual products they expressed concern that they are not affordable for an average Malawian and bemoaned the indiscriminate disposal of used disposable pads. Women and girls highlighted their lack of facilities to effectively wash and dry reusable pads. Service providers bemoaned poor coordination and the lack of national standards to regulate the quality of menstrual products distributed at national level. Improved inclusion of males and health workers could enhance the sustainability of programmes.

Conclusion

While the available menstrual products interventions are acceptable among participants, we note several challenges including affordability, poor disposal methods, lack of attention on sanitation facilities and the lack of standard protocols to regulate the quality of menstrual products. Recommendations to address these issues are reported.

Women are more likely to expect social sanctions for open defecation: Evidence from Tamil Nadu India

Social sanctions can be effective for sustaining beneficial norms by harnessing the power of social pressure and peer monitoring. Yet, field evidence regarding how norms might be linked to perceived risk of sanction is limited. In this study, we focused on communities located in peri-urban areas of Tamil Nadu, India, and examined how people’s perceived prevalence of a socially desirable behavior (i.e., toilet use) relates to the perceived risk of sanctions for deviating from this behavior (i.e., open defecation) in the sanitation domain. Cross-sectional data from 2427 participants in 75 communities revealed that the majority (77%, n = 1861) perceived the risk of informal sanctions related to open defecation. Among those, verbal reprimand was the most common (60%), followed by advice (30%) and gossip (7%). Results from multilevel logistic regression indicated that those who believed toilet use was prevalent in their community were more likely to perceive the risk of social sanctions for open defecation. Moderation analysis revealed that this relationship was robust among women, but attenuated among men. Our findings suggest that women are more likely to expect social sanctions if they deviate from what is perceived as the prevalent sanitation behavior (e.g., toilet use) in their community. Open defecation practices are known to cause psychosocial stress among women due to their experiences with sanitation insecurity, which may include fear of disapproval from community members. Our results highlight the need for gendered intervention strategies when sanitation programs leverage social influence for behavior change.

Coping with water insecurity at the household level: A synthesis of qualitative evidence

Water insecurity is a key public health and developmental challenge for many communities across the world. Using a meta-ethnographic synthesis, this study examines how households cope with water insecurity, as well as the socio-economic consequences and determinants of water insecurity coping strategies. A systematized keyword search was conducted in various electronic databases (PubMed, CINAHL EBSCOHost, Embase Ovid, Science Direct, Medline, Global Health, SCOPUS, Google and Google scholar). Out of 1352 potential articles, 21 studies were selected for review. Households employed nine key coping strategies. These strategies include water storage, construction of alternative water source, water sharing and borrowing from social networks, buying water from private vendors, water management and reuse, illegal connections to public water networks, water harvesting, fetching water from distant sources, and water treatment to improve the quality. Some of these coping strategies had far-reaching health and economic consequences, including the risk of water contamination, adverse psychosocial health, and impacts on household savings. We found that poor households, due to their over-reliance on short term labour-intensive and time-consuming coping strategies, are further economically disadvantaged by water insecurity. From a policy perspective, we recommend that investments in effective and efficient water supply infrastructure are needed to help alleviate the day-to-day hassles of water users. While policymakers are looking for long term solutions to these problems, some of the coping strategies identified in this synthesis, such as water conservation, water reuse, and purification of water before consumption, could be encouraged as supplementary strategies to meet households' immediate water needs.

Water risk perceptions across the life-course of women in Kenya

Inadequate access to water, sanitation and hygiene (WaSH) exposes many vulnerable populations, especially women and girls, to preventable diseases around the world. This paper reports findings from a photovoice project that explored water-related risk perceptions and health outcomes among women in Nyanchwa, Kenya. Thirteen women in four age categories were recruited for this study in July 2016 using the 'snowball' technique. From the results, inadequate access to WaSH was associated with increased water collection burden on women and children; environmental pollution; poor educational outcomes; loss of time due to water collection and poor sanitation infrastructure. Some barriers to change identified include financial barriers and inadequate government support. The identified risks and barriers are important considerations for the design, evaluation and mainstreaming of WaSH programs in resource constrained settings.

Practices and Perspectives on Latrine Use, Child Feces Disposal, and Clean Play Environments in Western Kenya

Exposure to fecal pathogens contributes to childhood diarrhea and stunting, causing harmful short- and long-term impacts to health. Understanding pathways of child fecal exposure and nutritional deficiencies is critical to informing interventions to reduce stunting. Our aim was to explore determinants of latrine use, disposal of child feces, and perceptions and provisions of a safe and clean child play environment among families with children under two (CU2) years to inform the design of a behavior change intervention to address water, sanitation, and hygiene (WASH), and nutrition behaviors. In 2016, we conducted a mixed-methods formative research in western Kenya. We conducted 29 key informant interviews with community leaders, health workers, and project staff; 18 focus group discussions with caregivers of CU2 years; and 24 semi-structured household observations of feeding, hygiene, and sanitation behaviors. We used the capability, opportunity, motivation, and behavior model as our theoretical framework to map caregiver behavioral determinants. Latrine use barriers were lack of latrines, affordability of lasting materials, and social acceptability of unobserved open defecation. Barriers to safe disposal of child feces were lack of latrines, time associated with safe disposal practices, beliefs that infant feces were not harmful, and not knowing where children had defecated. Primary barriers of clean play environments were associated with creating and maintaining play spaces, and shared human and animal compounds. The immediate cost to practicing behaviors was perceived as greater than the long-term potential benefits. Intervention design must address these barriers and emphasize facilitators to enable optimal WASH behaviors in this context.

Assessing Women's Menstruation Concerns and Experiences in Rural India: Development and Validation of a Menstrual Insecurity Measure

Qualitative research has documented menstruator's challenges, particularly in water and sanitation poor environments, but quantitative assessment is limited. We created and validated a culturally-grounded measure of Menstrual Insecurity to assess women's menstruation-related concerns and negative experiences. With cross-sectional data from 878 menstruating women in rural Odisha, India, we carried out Exploratory (EFA) and Confirmatory (CFA) Factor Analyses to reduce a 40-item pool and identify and confirm the scale factor structure. A 19-item, five factor model best fit the data (EFA: root mean square error of approximation (RMSEA) = 0.027; comparative fit index (CFI) = 0.994; Tucker-Lewis index (TLI) = 0.989; CFA: RMSEA = 0.058; CFI = 0.937; TLI = 0.925). Sub-scales included: Management, Menstrual Cycle Concerns, Symptoms, Restrictions, and Menstruation-Related Bodily Concerns. Those without access to a functional latrine, enclosed bathing space, water source within their compound, or who used reusable cloth had significantly higher overall Menstrual Insecurity scores (greater insecurity) than those with these facilities or using disposable pads. Post-hoc exploratory analysis found that women reporting experiencing tension at menstrual onset or difficulty doing work had significantly higher Menstrual Insecurity scores. This validated tool is useful for measuring Menstrual Insecurity, assessing health inequities and correlates of Menstrual Insecurity, and informing program design.

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.

Concept mapping: Engaging stakeholders to identify factors that contribute to empowerment in the water and sanitation sector in West Africa

Research has shown that inadequate access to water, sanitation, and hygiene (WASH) affects women and girls in several ways, including lowering their participation in the labour market and community activities and contributing to psychosocial stress and poor educational outcomes. There is growing awareness that addressing the gender inequalities related to WASH that many women and girls face on a daily basis must go beyond focusing on delivery of infrastructure and facilities alone and include attention to issues of empowerment. Yet there is limited exploration of how the concept of empowerment is defined and applied in the WASH sector and thus limited information on how it could be measured. This study used concept mapping to uncover the meaning and key dimensions of empowerment in WASH among 34 and 24 stakeholders in Asutifi North District, Ghana, and Banfora Commune, Burkina Faso, respectively. The study was part of initial steps toward choosing indicators for developing an Empowerment in WASH Index. In Ghana and Burkina Faso, 42 and 29 items were generated, respectively. These items were thought to empower men and women in WASH at the household and community levels. In both case studies, 7 clusters were generated and named by participants, and themes related to sharing of information, sociocultural norms, participation, and accessibility of WASH services were associated with empowerment. Some themes were unique to each case study site. Participants also showed a multidimensional and multilevel understanding of empowerment. Concept mapping created an effective balance between individual and group contributions and facilitated accessible, rapid, and contextually relevant data collection. The findings can be used to generate domains of empowerment in future quantitative research as well as inform the design of the Empowerment in WASH Index.

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.

Sanitation for Low-Income Regions: A Cross-Disciplinary Review

Sanitation research focuses primarily on containing human waste and preventing disease; thus, it has traditionally been dominated by the fields of environmental engineering and public health. Over the past 20 years, however, the field has grown broader in scope and deeper in complexity, spanning diverse disciplinary perspectives. In this article, we review the current literature in the range of disciplines engaged with sanitation research in low- and middle-income countries (LMICs). We find that perspectives on what sanitation is, and what sanitation policy should prioritize, vary widely. We show how these diverse perspectives augment the conventional sanitation service chain, a framework describing the flow of waste from capture to disposal. We review how these perspectives can inform progress toward equitable sanitation for all [i.e., Sustainable Development Goal (SDG) 6]. Our key message is that both material and nonmaterial flows-and both technological and social functions-make up a sanitation "system." The components of the sanitation service chain are embedded within the flows of finance, decision making, and labor that make material flows of waste possible. The functions of capture, storage, transport, treatment, reuse, and disposal are interlinked with those of ensuring equity and affordability. We find that a multilayered understanding of sanitation, with contributions from multiple disciplines, is necessary to facilitate inclusive and robust research toward the goal of sanitation for 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.

'It's like a burden on the head': Redefining adequate menstrual hygiene management throughout women's varied life stages in Odisha, India

There has been growing recognition of menstrual hygiene management (MHM) as a significant public health issue. However, research has predominately focused on the experiences of adolescent girls in school settings. The purpose of this research is to examine detailed accounts of menstruation for women in rural Odisha, India at various life stages with a view toward improving international monitoring of MHM. Focus group discussions and in-depth interviews were conducted to understand women’s experiences of menstruation across four life stages (unmarried women, recently married women, married women, and older women). Thematic analysis was used to identify menstruation-related challenges and needs. We found women voiced needs that aligned with those captured by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) definition for MHM: access to clean materials, privacy for changing materials, soap and water for bathing, and disposal facilities for materials. However, we also found women require materials that are not only clean but comfortable and reliable; soap and water for more than bathing; privacy for the full spectrum of menstruation-related practices, not just when changing; and disposal facilities that are private and safe, not just accessible. Additionally, we identified needs that extend beyond the existing definition: pain management, social support, and an enabling sociocultural environment. Overall, women representing all life stages discussed menstruation challenges, including bathing, pain, and washing, drying, and storing cloth materials. Cloth management challenges were most acute for unmarried and recently married women, who were concerned that practices could reveal their menstrual status and harm their reputations, thus informing their preference for disposable materials, if attainable. We propose a revised definition of adequate MHM for this population that more comprehensively captures their needs. This definition may also prove useful for other populations, future research, creating measures of assessment, and guiding interventions and program priorities.

A study of utilization of sanitary facilities by adolescent girls in an urban slum of Central India

Background

Hygienic sanitation facilities are crucial for public health. Investment on sanitation brings the single greatest return for any development intervention. Poor sanitation, open defecation and lack of awareness about hygiene have detrimental effect on the health of women and children living in slums.

Objective

The objective of this study was to perceive/assess the barriers to access of hygienic sanitary facilities for adolescent girls in an urban slum.

Methodology

This study included 98 adolescent females (10-19years) living in urban slums Ward no 19 Raipur. Simple random sampling by 'note method' was used to select one administrative division of this area.

Result

Mean age of adolescent girls in the present study was 15.44 ±2.2years (Range: 12 to 19 years) and a majority of them were in High School 60 (60.2%). About half (42%) of the study subjects were living in Semi pucca house and only 38% had access to an independent toilet facility, 9% were practicing open defecation and remaining (51%) were using public toilets.

Conclusion

The availability of sanitation facility and latrine utilization rate of the households were satisfactory. Privacy is a concern in public toilet, uses of sanitary pad was also less and changing of absorbent material in toilets was also a matter of concern for the girls.

A rite of passage: a mixed methodology study about knowledge, perceptions and practices of menstrual hygiene management in rural Gambia

BACKGROUND

Appropriate menstrual hygiene management (MHM) is impeded by taboos and secrecy surrounding menstruation. Unhygienic menstrual practices and unpreparedness for managing menstruation has been associated with adverse health and social outcomes among adolescent girls. In The Gambia, there is limited data on menstrual practices among girls and women in rural communities and the sources of information about menstruation for the adolescents. This study aimed to explore knowledge, preparedness and practices of menstruation and its management among adolescents, mothers and teachers in rural Gambia.

METHODS

A mixed methods study was conducted in the rural Kiang West district of The Gambia. Twenty focus group discussions and thirteen in-depth interviews were conducted among mothers, adolescents and teachers to explore their views on menstruation, cultural beliefs, sources and level of knowledge on menstruation and MHM practices. In addition, a survey was done among 331 school girls to assess their knowledge, practices and attitudes of menstruation and its management. Inductive content analysis was used to analyse the qualitative data, and descriptive analysis and chi-squared tests were used to analyse quantitative data.

RESULTS

All participants had different levels of knowledge about menstruation. Knowledge score was higher among post-menarche girls compare with pre-menarche girls (p = 0.0001). All groups expressed difficulties, embarrassment and shame in relation to discussing menstruation. Two thirds of the surveyed girls reported having learnt about menstruation before menarche, however at menarche most felt unprepared. Teachers were the main source of information, but when asking for advice most girls preferred to ask their mothers. Mothers reported facing difficulties in discussing menstruation with their children and felt that boys did not need to be taught about it, however boys were very curious to know about. Most girls used reusable cloth unless they are given free pads from school.

CONCLUSION

Taboos, secrecy and embarrassment associated with discussing menstruation hinder adolescents from seeking advice from parents and teachers on appropriate MHM practices. Strategies to encourage positive social norms towards menstruation would help to promote more open discussions about it at the family, community and national level, which will support improvements in MHM in this and similar communities in low and middle income settings.

Determinants of Latrine Use Behavior: The Psychosocial Proxies of Individual-Level Defecation Practices in Rural Coastal Ecuador

There is increasing appreciation that latrine access does not imply use-many individuals who own latrines do not consistently use them. Little is known, however, about the determinants of latrine use, particularly among those with variable defecation behaviors. Using the integrated behavior model of water, sanitation, and hygiene framework, we sought to characterize determinants of latrine use in rural Ecuador. We interviewed 197 adults living in three communities with a survey consisting of 70 psychosocial defecation-related questions. Questions were excluded from analysis if responses lacked variability or at least 10% of respondents did not provide a definitive answer. All interviewed individuals had access to a privately owned or shared latrine. We then applied adaptive elastic nets (ENET) and supervised principal component analysis (SPCA) to a reduced dataset of 45 questions among 154 individuals with complete data to select determinants that predict self-reported latrine use. Latrine use was common, but not universal, in the sample (76%). The SPCA model identified six determinants and adaptive ENET selected five determinants. Three indicators were represented in both models-latrine users were more likely to report that their latrine is clean enough to use and also more likely to report daily latrine use; while those reporting that elderly men were not latrine users were less likely to use latrines themselves. Our findings suggest that social norms are important predictors of latrine use, whereas knowledge of the health benefits of sanitation may not be as important. These determinants are informative for promotion of latrine adoption.

Analysing progress of sustainable development goal 6 in India: Past, present, and future

The attainment of sustainable development in water and sanitation i.e. Sustainable Development Goal 6 (SDG 6) requires a comprehensive monitoring and knowledge base of social and economic water needs at national scale in such a way that should not cause negative environmental manifestations from regional to global scale. India holds a key position among developing economies with a complex interconnected web of fast-growing population, coupled with biophysical stress, social deprivation and economic inequality related to utilization, availability and access to water resources and sanitation facilities. This study addresses some of these challenges related to monitoring and implementation of the targets of the UN SDG 6 in India. Acknowledging the contribution of society and economy in sustainability paradigm, here we have chosen 28 indicators (clustered into 11 dimensions) under two major groups, concerning biophysical and social development aspects of water and sanitation. We have shown declining level of per capita biophysical water resource and slow to rapidly developing societal indicators related to SDG 6 in India. From past trends, we have calculated probable scenario of biophysical consumption of India up to 2050. We have also analysed the interrelationship of water and sanitation (SDG 6) with health (SDG 3) and end to poverty (SDG 1) in India. These show a positive impact of increasing per capita GDP on improving sanitation related indicators, which in turn positively influence to reduce water and sanitation related diseases, especially in children and aged population. This cumulative assessment framework contributes a tool to prioritize water resource appropriation and assessment of sanitation, management response and policy implementations to national level inclusive sustainability of water and sanitation sector, keeping in mind the societal and economic development scenario in India.

Impact of social capital, harassment of women and girls, and water and sanitation access on premature birth and low infant birth weight in India

BACKGROUND

Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes.

METHODS AND FINDINGS

This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification.

CONCLUSIONS

The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India.

Association between unhygienic menstrual management practices and prevalence of lower reproductive tract infections: a hospital-based cross-sectional study in Odisha, India

Background

The extent to which reproductive tract infections (RTIs) are associated with poor menstrual hygiene management (MHM) practices has not been extensively studied. We aimed to determine whether poor menstrual hygiene practices were associated with three common infections of the lower reproductive tract; Bacterial vaginosis (BV), Candida, and Trichomonas vaginalis (TV).

Methods

Non-pregnant women of reproductive age (18–45 years) and attending one of two hospitals in Odisha, India, between April 2015 and February 2016 were recruited for the study. A standardized questionnaire was used to collect information on: MHM practices, clinical symptoms for the three infections, and socio-economic and demographic information. Specimens from posterior vaginal fornix were collected using swabs for diagnosis of BV, Candida and TV infection.

Results

A total of 558 women were recruited for the study of whom 62.4% were diagnosed with at least one of the three tested infections and 52% presented with one or more RTI symptoms. BV was the most prevalent infection (41%), followed by Candida infection (34%) and TV infection (5.6%). After adjustment for potentially confounding factors, women diagnosed with Candida infection were more likely to use reusable absorbent material (aPRR = 1.54, 95%CI 1.2–2.0) and practice lower frequency of personal washing (aPRR = 1.34, 95%CI 1.07–1.7). Women with BV were more likely to practice personal washing less frequently (aPRR = 1.25, 95%CI 1.0–1.5), change absorbent material outside a toilet facility (aPRR = 1.21, 95%CI 1.0–1.48) whilst a higher frequency of absorbent material changing was protective (aPRR = 0.56, 95%CI 0.4–0.75). No studied factors were found to be associated with TV infection. In addition, among women reusing absorbent material, Candida but not BV or TV - infection was more frequent who dried their pads inside their houses and who stored the cloth hidden in the toilet compartment.

Conclusion

The results of our study add to growing number of studies which demonstrate a strong and consistent association between poor menstrual hygiene practices and higher prevalence of lower RTIs.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3384-2) contains supplementary material, which is available to authorized users.

Development and Application of Novel Caregiver Hygiene Behavior Measures Relating to Food Preparation, Handwashing, and Play Environments in Rural Kenya

Exposure to fecal pathogens results in both acute and chronic sequalae in young children. Diarrhea causes nearly 20% of all under-five mortality, while even sub-clinical enteric infections may lead to growth shortfalls. Stunting affects nearly 165 million children globally and results in lifelong and intergenerational effects for the world's poorest populations. Caregiver hygiene behaviors, such as those surrounding handwashing and food preparation, play a critical role in exposure to fecal pathogens; standard metrics to assess these behaviors are warranted to provide a means of quantifying the impact these behaviors have on enteric infections and to evaluate the success or failure of interventions and programs. This paper documents the development of three novel caregiver hygiene behavior measures: hygienic food preparation and storage, handwashing at key times, and provision of a safe play environment for children under two years. We developed these measures using formative qualitative work, survey creation and deployment theoretically underpinned by the COM-B model of behavior change, and exploratory and confirmatory factor analysis. The final measure for hygienic food preparation and storage includes 10 items across two factors; the final measure for handwashing at key times includes 15 items across three factors; and the final measure for safe play environment contains 13 items across three factors. Future researchers may employ these measures to assess caregiver behaviors in other populations, identify specific behavioral dimensions that should be the focus of interventions, and evaluate interventions and programs.

Making the Case for a Female-Friendly Toilet

Inadequate access to a private, comfortable, and well-located toilet remains a critical challenge for many girls and women around the world. This issue is especially acute for girls and women living in densely populated urban slums, displacement camps, and informal settlements, often resulting in anxiety, embarrassment, discomfort, and gender-based violence. The unique sanitation needs of girls and women are rarely accounted for during the design and construction of toilet facilities, including needs related to their physiology, reproductive health processes, prevalent social norms, and their heightened vulnerability to violence. It is critical that a new norm be developed regarding the design of female-friendly toilets which better enables girls and women to feel confident, safe, and dignified while managing their daily sanitation needs. This includes adopting specific design measures which account for their menstrual hygiene, personal safety, and dignity-related needs. Ultimately, an enhanced dialogue must take place among designers, policy makers, water, sanitation, and hygiene (WASH) practitioners, and other relevant actors, in addition to the target female users themselves, about how to adapt toilets in a range of development and emergency contexts and operations to better address these critical needs of girls and women.

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.