Optimizing household survey methods to monitor the Sustainable Development Goals targets 6.1 and 6.2 on drinking water, sanitation and hygiene: A mixed-methods field-test in Belize

Indicators for National and Global Monitoring of Girls' Menstrual Health and Hygiene: Development of a Priority Shortlist

PURPOSE

Despite the importance of menstrual health and hygiene (MHH) for adolescent girls' health, education, and gender equality, few countries monitor MHH. MHH needs remain underprioritized, and progress achieved through policies, programs, or investments go unmeasured. This article reports the systematic development of an indicator shortlist to monitor adolescent girls' MHH at the national and global levels across low- and middle-income countries.

METHODS

A core group of MHH researchers and practitioners collaborated with stakeholders from three countries with demonstrated commitment to monitoring MHH (Bangladesh, Kenya, and the Philippines), measures experts, and a global advisory group. The approach included the following: (1) define domains for monitoring MHH; (2) review and map existing indicators and measures; (3) iteratively shortlist indicators through appraising quality, feasibility, and stakeholder input; and (4) refine the shortlist and develop guidance for use.

RESULTS

The shortlist comprises 21 indicators across seven domains covering menstrual materials, water, sanitation, and hygiene facilities, knowledge, discomforts and disorders, supportive social environments, menstrual health impacts, and policies. Indicators are accompanied by measures that have been tested or are expected to provide reliable data, alongside justification for their selection and guidance for use.

DISCUSSION

The shortlisted indicators reflect the multisectoral collaboration necessary for ensuring girls' MHH. Uptake requires integration into monitoring systems at national and global levels. Future work remains to evaluate the performance of the indicators over time and to support their widespread use. Governments and stakeholders can use these indicators to track the progress of programs and policies, monitor unmet MHH needs, identify disparities, and set targets for improvement.

Menstrual hygiene access and practices in Latin America: scoping review

OBJECTIVE

to synthesize available evidence related to menstrual hygiene access and practices in Latin America and the Caribbean.

METHOD

literature scoping review with research protocol registered in the Open Science Framework, carried out in the bibliographic databases: PubMed, Scopus, Web of Science and Portal Regional da Biblioteca Virtual em Saúde. Data were analyzed using simple descriptive statistics and thematic analysis.

RESULTS

15 publications were included, the majority of which addressed adolescents in Brazil: 12 articles, two technical reports and a course conclusion monograph. As recurring themes in the publications, the following stand out: Access to dignified conditions for managing menstrual hygiene; Need for access to information on menstrual hygiene management; and Practices for managing menstrual hygiene.

CONCLUSION

adolescents report difficulties in accessing toilets, water and absorbent materials, and lack of information about menstrual health, including in schools, leading to school absenteeism. Thus, gaps in the Latin American scientific literature reveal inequalities and diversity in menstrual experiences intersected by categories such as gender, social class and ethnicity.

HIGHLIGHTS

(1) Lack of access to hygiene products, toilets and water for personal hygiene. (2) Invisibility of the problem of period poverty in Latin America. (3) Lack of physical structure in schools aggravates and leads to school absenteeism. (4) Menstrual health literacy was insufficient for the demands of adolescents. (5) Primary studies on menstrual hygiene in Latin America are scarce.

Drinking water and the implications for gender equity and empowerment: A systematic review of qualitative and quantitative evidence

BACKGROUND

Safe drinking water is a fundamental human right, yet more than 785 million people do not have access to it. The burden of water management disproportionately falls on women and young girls, and they suffer the health, psychosocial, political, educational, and economic effects. While water conditions and disease outcomes have been widely studied, few studies have summarized the research on drinking water and implications for gender equity and empowerment (GEE).

METHODS

A systematic review of primary literature published between 1980 and 2019 was conducted on drinking water exposures and management and the implications for GEE. Ten databases were utilized (EMBASE, PubMed, Web of Science, Cochrane, ProQuest, Campbell, the British Library for Development Studies, SSRN, 3ie International Initiative for Impact Evaluation, and clinicaltrials.gov). Drinking water studies with an all-female cohort or disaggregated findings according to gender were included.

RESULTS

A total of 1280 studies were included. GEE outcomes were summarized in five areas: health, psychosocial stress, political power and decision-making, social-educational conditions, and economic and time-use conditions. Water quality exposures and implications for women's health dominated the literature reviewed. Women experienced higher rates of bladder cancer when exposed to arsenic, trihalomethanes, and chlorine in drinking water and higher rates of breast cancer due to arsenic, trichloroethylene, and disinfection byproducts in drinking water, compared to men. Women that were exposed to arsenic experienced higher incidence rates of anemia and adverse pregnancy outcomes compared to those that were not exposed. Water-related skin diseases were associated with increased levels of psychosocial stress and social ostracization among women. Women had fewer decision-making responsibilities, economic independence, and employment opportunities around water compared to men.

CONCLUSION

This systematic review confirms the interconnected nature of gender and WaSH outcomes. With growing attention directed towards gender equity and empowerment within WaSH, this analysis provides key insights to inform future research and policy.

Differences in levels of E. coli contamination of point of use drinking water in Bangladesh

This study aimed to quantify the inequalities and identify the associated factors of the UN sustainable development goal (SDG) targets in relation to safe drinking water. The concentration of the gut bacterium Escherichia coli in drinking water at the point of use (POU) and other information were extracted from the latest wave of the nationally representative Bangladesh Multiple Indicator Cluster Survey (MICS 2019). Bivariate and multivariable multinomial logistic regression models were used to identify potential predictors of contamination, whereas, classification trees were used to determine specific combinations of background characteristics with significantly higher rates of contamination. A higher risk of contamination from drinking water was observed for households categorized as middle or low wealth who collected water from sources with higher concentrations of E. coli. Treatment of drinking water significantly reduced the risk of higher levels of contamination, whereas owning a pet was significantly associated with recontamination. Regional differences in the concentrations of E. coli present in drinking water were also observed. Interventions in relation to water sources should emphasize reducing the level of E. coli contamination. Our results may help in developing effective policies for reducing diarrheal diseases by reducing water contamination risks.

Analytical strategies to sense water stress level: An analysis of ground water fluctuations sensing SDGs under pandemic scenario

Groundwater fluctuation is directly linked with the consumption and wastage of water sources during the pandemic interval. That is why water resource planners directly target water resource and sanitation systems in line with the sustainable development goals (SDGs) concept. In this study, District Multan is designated as a study area with 85 distinct station points data sets from four zones taken to pursue this massive investigation. The data sets are studied analytically and graphically to explore the relationships among critical variables like population, average water consumption, groundwater elevation, water table depth, total consumption, wastage of water during the pandemic days, etc. For in-depth analysis, the statistical approaches are employed on these massive data sets to reveal the trend among each dataset point to generate predictive models. The results revealed that groundwater reservoirs and levels are continuously declining on an annual basis in the meantime, the water consumption and extraction are increasing simultaneously. The consumption during pandemic days has been increased so much at the same time the wastage and total consumption of water is rising a lot in contrast to previous daily consumption and water demand. The coefficient of determination (R-square) values vary from 0.41 to 0.93 in this investigation. It will help the utilization of developed models and water-providing organizations to forecast groundwater instabilities for the future. Moreover, the situation in the study area is very alarming in terms of water stress conditions. This study will help the decision-making agencies to produce a policy following the SDGs concept to control water consumption and higher extraction.

Where Do We Stand Now? A Bibliometric Analysis of Water Research in Support of the Sustainable Development Goal 6

The connections between the scientific findings and SDG 6 are often not clear, which results in increasing the gap between technical developments and academic discourse, and the policy practitioners and/or implementers. The present paper explores the existing scientific research on water that directly connects to SDG 6 using a bibliometric analysis. The 637 scientific articles published between 2015–2021 (till 13 May 2021) were investigated for temporal development, scientific collaboration, existing research focus and the gaps. Interdisciplinary journals such as Science of the Total Environment and Journal of Environmental Management are found to be dominant sources along with water specific journals such as Water Research and Water (Switzerland). Open access journals make a dominant footprint and majority of author collaborations are found among authors from countries such as USA and UK while the research connections among authors from Global South are observed to be weak. Targets 6.1 (safe and affordable water), 6.3 (treatment and reuse of wastewater) and 6.5 (IWRM including through transboundary cooperation) are identified to be the highest referred to targets in scientific research in support of SDG 6. Though a significant evolution of scientific research is observed in connection to SDG 6 with increasing studies on groundwater, water governance, wastewater treatment, etc., in recent years, scientific studies connecting emerging concepts such as water security, water-energy-food nexus and ecosystem based approaches are still in an infant stage which calls for more research connecting these concepts and approaches to SDG 6 targets to attain a sustainable water environment by 2030 and beyond. This paper significantly contributes to tracking the progress in scientific research in connection to SDG 6 as well as highlights the hotspots where more collaboration between scientific communities and policy makers are required.

Availability of population-level data sources for tracking the incidence of deaths and injuries from road traffic crashes in low-income and middle-income countries

Introduction

Tracking progress towards Sustainable Development Goal (SDG) 3·6 of reducing traffic deaths and serious injuries poses a measurement challenge in most low-income and middle-income countries (LMICs) due to large discrepancies between reported official statistics and estimates from global health measurement studies. We assess the extent to which national population censuses and health surveys can fill the information gaps.

Methods

We reviewed questionnaires for nationally representative surveys and censuses conducted since 2000 in LMICs. We identified sources that provide estimates of household ownership of vehicles, incidence of traffic deaths and non-fatal injuries, and prevalence of disability.

Results

We identified 802 data sources from 132 LMICs. Sub-Saharan African countries accounted for 43% of all measurements. The number of measurements since 2000 was high, with 97% of the current global LMIC population having at least one measurement for vehicle ownership, 77% for deaths, 90% for non-fatal injuries and 50% for disability due to traffic injuries. Recent data (since 2010) on traffic injuries were available from far fewer countries (deaths: 21 countries; non-fatal injuries: 62 and disability: 12). However, there were many more countries with recent data on less-specific questions about unintentional or all injuries (deaths: 41 countries, non-fatal: 87, disability: 32).

Conclusion

Traffic injuries are substantially underreported in official statistics of most LMICs. National surveys and censuses provide a viable alternative information source, but despite a large increase in their use to monitor SDGs, traffic injury measurements have not increased. We show that relatively small modifications and additions to questions in forthcoming surveys can provide countries with a way to benchmark their existing surveillance systems and result in a substantial increase in data for tracking road traffic injuries globally.

Monitoring Drinking Water Quality in Nationally Representative Household Surveys in Low- and Middle-Income Countries: Cross-Sectional Analysis of 27 Multiple Indicator Cluster Surveys 2014-2020

BACKGROUND

The 2030 Sustainable Development Goals (SDGs) set an ambitious new benchmark for safely managed drinking water services (SMDWs), but many countries lack national data on the availability and quality of drinking water.

OBJECTIVES

We quantified the availability and microbiological quality of drinking water, monitored SMDWs, and examined risk factors for Escherichia coli (E. coli) contamination in 27 low-and middle-income countries (LMICs).

METHODS

A new water quality module for household surveys was implemented in 27 Multiple Indicator Cluster Surveys. Teams used portable equipment to measure E. coli at the point of collection (PoC, n=61,170) and at the point of use (PoU, n=64,900) and asked respondents about the availability and accessibility of drinking water. Households were classified as having SMDW services if they used an improved water source that was free of E. coli contamination at PoC, accessible on premises, and available when needed. Compliance with individual SMDW criteria was also assessed. Modified Poisson regression was used to explore household and community risk factors for E. coli contamination.

RESULTS

E. coli was commonly detected at the PoC (range 16-90%) and was more likely at the PoU (range 19-99%). On average, 84% of households used an improved drinking water source, and 31% met all of the SMDW criteria. E. coli contamination was the primary reason SMDW criteria were not met (15 of 27 countries). The prevalence of E. coli in PoC samples was lower among households using improved water sources [risk ratio (RR)=0.74; 95% confidence interval (CI): 0.64, 0.85] but not for households with water accessible on premises (RR=0.99; 95% CI: 0.94, 1.05) or available when needed (RR=0.95; 95% CI: 0.88, 1.02). E. coli contamination of PoU samples was less common for households in the richest vs. poorest wealth quintile (RR=0.70; 95% CI: 0.55, 0.88) and in communities with high (>75%) improved sanitation coverage (RR=0.94; 95% CI: 0.90, 0.97). Livestock ownership (RR=1.08; 95% CI: 1.04, 1.13), rural vs. urban residence (RR=1.10; 95% CI: 1.04, 1.16), and wet vs. dry season sampling (RR=1.07; 95% CI: 1.01, 1.15) were positively associated with contamination at the PoU.

DISCUSSION

Cross-sectional water quality data can be collected in household surveys and can be used to assess inequalities in service levels, to track the SDG indicator of SMDWs, and to examine risk factors for contamination. There is an urgent need for better risk management to reduce widespread exposure to fecal contamination through drinking water services in LMICs. https://doi.org/10.1289/EHP8459.

Safely Managed On-Site Sanitation: A National Assessment of Sanitation Services and Potential Fecal Exposure in Indonesia

Sustainable Development Goal target 6.2 calls for universal access to adequate and equitable sanitation, setting a more ambitious standard for 'safely managed sanitation services'. On-site sanitation systems (e.g., septic tanks) are widely used in low- and middle-income countries (LMICs). However, the lack of indicators for assessing fecal exposure risks presents a barrier to monitoring safely managed services. Furthermore, geographic diversity and frequency of disasters require a more nuanced approach to risk-informed decision-making. Taking Indonesia as an example, the purpose of this paper is to provide insights into current status and practices for on-site sanitation services in the contexts of LMICs. Using a dataset from a national socio-economic survey (n = 295,155) coupled with village census (n = 83,931), we assessed (1) household sanitation practices across Indonesia stratified by city-level population density and meteorological factors, (2) factors associated with septic tank emptying practice, and (3) inequalities in potential fecal exposure as measured by population density and WASH access by wealth quintile. We found a high reliance on on-site sanitation facilities (80.0%), almost half of which are assumed to be 'uncontained' septic tanks and one in ten facilities discharging untreated waste directly into the environment. The most densely populated areas had the highest rates of septic tank emptying, though emptying rates were just 17.0%, while in the lowest population density group, emptying was rarely reported. Multivariate regression analysis demonstrated an association between flooding and drought occurrence and septic tank emptying practice. Higher groundwater usage for drinking among poorer households suggests unsafe sanitation may disproportionally affect the poor. Our study underscores the urgent need to strengthen the monitoring of on-site sanitation in LMICs by developing contextualized standards. Furthermore, the inequalities in potential fecal exposure require greater attention and tailored support mechanisms to ensure the poorest gain access to safely managed sanitation services.

Household practices in accessing drinking water and post collection contamination: A seasonal cohort study in Malawi

Lack of access to safe drinking water on premises remains widespread in low- and middle-income countries. Interventions to improve access to safe water at the point of collection are essential, but water safety at the point of consumption is also an important consideration. This research aimed to 1) improve understanding of household practices in collecting water with respect to seasonality, and 2) to further assess risk associated with post-collection contamination from the point of collection to the point of consumption. A seasonal cohort study, including 115 households, was conducted in Malawi. Along with household surveys and observations, samples of water were tested for microbial water quality at four different stages of water collection: water source, collection container, storage container, cup of drinking water. Using E. coli as an indicator of contamination (cfu/100 ml), the risk of post-collection contamination was assessed. The results indicate that most water sources were free from contamination; contamination was proportionally lower in the dry season when more sources were found to be classified as having a very low risk of contamination. However, the level of risk of contamination was more likely to increase following collection in water sources that were initially free from contamination. Results show that the degradation in water quality from the point of collection to the point of consumption was more important in the rainy season, which is likely to be driven by the effect of seasonality on the household environment. Filling the collection container at the point of collection and storage at the point of consumption were found to be critical stages for an increased risk of E. coli contamination. Understanding household practices in accessing and handling water during both rainy and dry season is necessary to target appropriate interventions to reduce post-collection contamination.

Evaluating self-reported measures and alternatives to monitor access to drinking water: A case study in Malawi

Monitoring access to drinking water is complex, especially in settings where on premises water supply is not available. Although self-reported data are generally used to estimate coverage of access to drinking water, the relationship between self-reported time travelled and true time travelled is not well known in the context of water fetching. Further, water fetching is likely to impact the quantity and quality of water a household uses, but data and measures supporting this relationship are not well documented. The objective of this study was to appraise the validity and reliability of self-reported measurements used to estimate access coverage. A case study was conducted in Malawi to enhance understanding of the self-reported measures and alternatives available to assess and monitor access to drinking water in view of generating global estimates. Self-reported data were compared with objective observations and direct measurements of water quantity, quality and accessibility. Findings from this study highlight the variations between different measures such as self-reported and recorded collection time and raise awareness with regard to the use of self-reported data in the context of fetching water. Alternatives to self-reported indicators such as GPS-based or direct observations could be considered in surveys in view of improving data accuracy and global estimates.

Lack of Safe Drinking Water for Lake Chapala Basin Communities in Mexico Inhibits Progress toward Sustainable Development Goals 3 and 6

BACKGROUND

Access to safe, affordable and accessible drinking water is a human right and foundational to the third and sixth World Health Organization's Sustainable Development Goals (SDGs). Unsafe drinking water is a risk factor for chronic and enteric diseases. Both chronic kidney disease (CKD) and diarrheal disease are highly prevalent in the Lake Chapala basin, Jalisco, Mexico, suggesting disparities in factors leading to successful achievement of these two SDGs.

METHODS

This study aimed to assess progress towards SDG three and six in the Lake Chapala basin. Qualitative, quantitative, and geospatial data were collected between May and August of 2019 from three towns within the municipalities of Poncitlán and Chapala.

RESULTS

Ninety-nine households participated in this study. Water sampling analyses determined 81.18% of samples from water jugs (garrafones) and 70.05% of samples from tap water were contaminated with total coliform bacteria, often including E. coli. Additionally, 32% of garrafón samples and 61.9% of tap water samples had detectable levels of arsenic. Approximately 97.94% of respondents stated that they believe clean water is a human right, but 78.57% feel the Mexican government does not do enough to make this a reality.

CONCLUSIONS

This mixed methods approach highlights water quality as a serious issue in communities around Lake Chapala, and demonstrates inadequate drinking water as a key hazard, potentially perpetuating the high disease burden of both CKD and enteric disease in the region.

The Menstrual Practices Questionnaire (MPQ): development, elaboration, and implications for future research

High-quality evidence is needed to inform policies and programmes aiming to improve menstrual health. Quantitative studies must address the many evidence gaps in this field, and practitioners have increased monitoring and evaluation efforts to track their progress. A significant barrier to improving the rigor of this work is the lack of comprehensive and comparable measures to capture core concepts. The Menstrual Practices Questionnaire (MPQ) is a new tool to support comprehensive and standardised assessment of the activities undertaken in order to collect, contain, and remove menstrual blood from the body in self-report surveys. The questionnaire is freely available online for download and can be adapted for use across contexts and age groups. In this article, we describe the purpose of the MPQ as a best-practice tool to align the description of menstrual practices and provide a foundation for further question refinement. We outline the development of the tool using systematic review of qualitative studies of menstrual experiences, audit of measures used in the study of menstrual health and hygiene, survey of experts, insights from past research, and examples from piloted questions in a survey of adolescent girls in Soroti, Uganda. We describe the identification of menstrual practices as a priority for measurement, coverage of practices included in the MPQ, and justify the inclusion of location-specific questions. For each section of the questionnaire, we outline key reasons for the inclusion of practice items alongside elaboration for users to help inform item selection. Finally, we outline priorities for future research to refine the assessment and reporting of menstrual practices, including the identification of minimum reporting requirements for population characteristics to facilitate comparison across studies, testing the extent to which experiences during the most recent menstrual period reflect those over longer time periods, and further exploration of biases in self-report.

Measurement in the study of menstrual health and hygiene: A systematic review and audit

Background

The lack of established measurement tools in the study of menstrual health and hygiene has been a significant limitation of quantitative studies to date. However, there has been limited exploration of existing measurement to identify avenues for improvement.

Methods

We undertook two linked systematic reviews of (1) trials of menstrual health interventions and their nested studies in low- and middle-income countries, (2) studies developing or validating measures of menstrual experiences from any location. Systematic searching was undertaken in 12 databases, together with handsearching. We iteratively grouped and audited concepts measured across included studies and extracted and compared measures of each concept.

Results

A total of 23 trials, 9 nested studies and 22 measure development studies were included. Trials measured a range of outcomes including menstrual knowledge, attitudes, and practices, school absenteeism, and health. Most measure validation studies focused on assessing attitudes towards menstruation, while a group of five studies assessed the accuracy of women’s recall of their menstrual characteristics such as timing and cycle length. Measures of menstrual knowledge, attitudes, beliefs and restrictions were inconsistent and frequently overlapped. No two studies measured the same menstrual or hygiene practices, with 44 different practices assessed. This audit provides a summary of current measures and extant efforts to pilot or test their performance.

Conclusions

Inconsistencies in both the definition and operationalisation of concepts measured in menstrual health and hygiene research should be addressed. To improve measurement, authors should clearly define the constructs they aim to measure and outline how these were operationalised for measurement. Results of this audit indicate the need for the development and validation of new measures, and the evaluation of the performance of existing measures across contexts. In particular, the definition and measurement of menstrual practices, knowledge, attitudes, norms and restrictions should be addressed.

Review protocol registration

CRD42018089884.

National Monitoring for Menstrual Health and Hygiene: Is the Type of Menstrual Material Used Indicative of Needs Across 10 Countries?

Surveys monitoring population health and sanitation are increasingly seeking to monitor menstrual health. In the absence of established indicators, these surveys have most often collected data on the type of menstrual material used. This study investigated whether such data provides a useful indication of women's menstrual material needs being met. Using data from 12 national or state representative surveys from the Performance Monitoring and Accountability 2020 program, we compared self-reported menstrual material use against respondents' reported menstrual material needs (including needing clean materials, money, or access to a vendor). The use of menstrual pads did not indicate that menstrual material needs were met for many respondents. Of those exclusively using pads, a pooled 26.4% (95% Confidence Interval 17.1-38.5) of respondents reported that they had unmet material needs. More disadvantaged groups were particularly misrepresented; of rural women exclusively using pads, a pooled 38.5% (95%CI 27.3-51.1) reported unmet material needs, compared to 17.1% (95%CI 12.4-23.0) of urban women. Similar disparities were observed for levels of education and wealth, with a pooled 45.9% (95%CI 29.2-63.6) of women in the lowest wealth quintile reporting unmet material needs. Findings suggest that caution is needed when using menstrual material use as an indicator for menstrual health.

Measuring menstrual hygiene experience: development and validation of the Menstrual Practice Needs Scale (MPNS-36) in Soroti, Uganda

OBJECTIVE

This study describes the development and validation of the Menstrual Practice Needs Scale (MPNS-36), which measures the extent to which respondents' menstrual practices and environments meet their needs.

METHODS

A 54-item pool was developed following systematic review of qualitative and quantitative studies and expert feedback. Item reduction and scale validation were undertaken using a cross-sectional survey of 538 menstruating schoolgirls in Soroti, Uganda. Test-retest reliability was assessed in a subsample of 52 girls 2 weeks after the first administration. Construct validity was tested through relationships with hypothesised correlates: confidence to manage menses, self-reported school absenteeism and mental health symptoms.

RESULTS

The MPNS-36 comprises 28 items applicable to all respondents and 8 items capturing washing and drying experiences for those reusing menstrual materials. A four-factor solution for the core 28 items was the best fit for the data (root mean square error of approximation (RMSEA)=0.028-0.029; comparative fit index (CFI)=0.961-0.964; Tucker-Lewis index (TLI)=0.953-0.955), supplemented by two factors for reuse (RMSEA=0.021-0.030; CFI=0.987-0.994; TLI=0.981-0.991). Subscale and total scores were calculated as mean scores to support accessibility for practitioners. The subscales were 'material and home environment needs' (11 items, αordinal=0.84), 'transport and school environment needs' (5 items, αordinal=0.73), 'material reliability concerns' (3 items, αordinal=0.55), 'change and disposal insecurity' (9 items, αordinal=0.80), 'reuse needs' (5 items, αordinal=0.76) and 'reuse insecurity' (3 items, αordinal=0.56). Relationships between subscales and hypothesised correlates supported validity. Home-based and school-based items were more strongly associated with confidence to manage menstruation at home and school, respectively. Higher total scores indicated more positive experiences and were associated with greater odds of not missing school during the last menstrual period (OR=2.62, 95% CI 1.52 to 4.50). Test-retest reliability was moderate (total score: intraclass correlation coefficient, ICC(2,1)=0.69).

CONCLUSIONS

The MPNS-36 demonstrated acceptable reliability and validity. It is the first measure to capture perceived menstrual hygiene and may be useful across a range of study designs. Future research should explore the validity and suitability of the measure across contexts and populations.

Wealthy, urban, educated. Who is represented in population surveys of women's menstrual hygiene management?

Inadequate menstrual hygiene presents a barrier to women's dignity and health. Recent attention to this marginalised challenge has resulted in the first national assessments of menstrual practices. Intuitively, surveys require women to have had a recent menses to be eligible. This study seeks to determine if there are demographic differences between women who are eligible and ineligible to answer questions about their menstrual hygiene during these assessments. Secondary analyses were undertaken on nationally or state representative data collected by the Performance Monitoring and Accountability 2020 survey programme across eight countries (Burkina Faso, Ethiopia, Ghana, India, Kenya, Niger, Nigeria, and Uganda). Female respondents were included in the study and compared on whether they had a menstrual period within the past three months and thus were eligible to answer questions regarding menstrual practices. On average, 29% of surveyed women across samples were ineligible to be asked menstrual hygiene questions. Higher levels of education, wealth, and urban residence were associated with higher odds of eligibility. Young and unmarried women were also more likely to be eligible. Demographic differences between eligible and ineligible women were consistent across all countries. Wealthy, urban, and educated women are more likely to be eligible to answer survey questions about menstrual hygiene. While population surveys may be representative of menstruating women, proportions of menstrual hygiene practices reported underrepresent the experiences of more vulnerable groups. These groups are likely to have greater struggles with menstrual hygiene when they are menstruating.

Establishing Sustainable Development Goal Baselines for Household Drinking Water, Sanitation and Hygiene Services

The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), through the Joint Monitoring Programme (JMP), are responsible for global monitoring of the Sustainable Development Goal (SDG) targets for drinking water, sanitation and hygiene (WASH). The SDGs represent a fundamental shift in household WASH monitoring with a new focus on service levels and the incorporation of hygiene. This article reflects on the process of establishing SDG baselines and the methods used to generate national, regional and global estimates for the new household WASH indicators. The JMP 2017 update drew on over 3000 national data sources, primarily household surveys (n = 1443), censuses (n = 309) and administrative data (n = 1494). Whereas most countries could generate estimates for basic drinking water and basic sanitation, fewer countries could report on basic handwashing facilities, water quality and the disposal of waste from onsite sanitation. Based on data for 96 and 84 countries, respectively, the JMP estimates that globally 2.1 billion (29%) people lacked safely managed drinking water services and 4.5 billion (61%) lacked safely managed sanitation services in 2015. The expanded JMP inequalities database also finds substantial disparities by wealth and sub-national regions. The SDG baselines for household WASH reveal the scale of the challenge associated with achieving universal safely managed services and the substantial acceleration needed in many countries to achieve even basic services for everyone by 2030. Many countries have begun to localise the global SDG targets and are investing in data collection to address the SDG data gaps, whether through the integration of new elements in household surveys or strengthening collection and reporting of information through administrative and regulatory systems.

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

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

Subnational regional inequality in access to improved drinking water and sanitation in Indonesia: results from the 2015 Indonesian National Socioeconomic Survey (SUSENAS)

BACKGROUND

Universal and equitable access to safe and affordable drinking water and adequate sanitation and hygiene in Indonesia are vital to ensure healthy lives and promote well-being for all at all ages.

OBJECTIVES

To quantify subnational regional inequality in access to improved drinking water and sanitation in Indonesia.

METHODS

Data about access to improved drinking water and sanitation were derived from the 2015 Indonesian National Socioeconomic Survey (SUSENAS) and disaggregated by 510 districts across the 34 provinces of Indonesia. Two summary measures of inequality, mean difference from mean and weighted index of disparity, were calculated to quantify within-province absolute and relative inequality, respectively.

RESULTS

While the majority of Indonesian households had access to improved drinking water (71.0%) and sanitation (62.1%), there were large variations between and within provinces. Access to improved drinking water ranged from 93.4% in DKI Jakarta to 41.1% in Bengkulu, and access to improved sanitation ranged from 89.3% in Jakarta to 23.9% in East Nusa Tenggara. Provinces with similar numbers of districts and similar overall averages showed variable levels of absolute and/or relative inequality. Certain districts reported very low levels of access to improved drinking water and/or sanitation.

CONCLUSIONS

There are inequalities in access to improved drinking water and sanitation by subnational region in Indonesia. Monitoring within-country inequality in these indicators serves to identify underserved areas, and is useful for developing approaches to improve inequalities in access that can help Indonesia make progress towards the 2030 Agenda for Sustainable Development.