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

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.

Examining toilet use and menstrual hygiene practices among beneficiary households of Swachh Bharat Abhiyaan (Clean India Mission) in rural areas of Mayurbhanj district of Odisha, India

Background

Basic sanitation and waste management have always remained a central issue in India. The country launched its flagship sanitation program - Swachh Bharat Abhiyan (SBA) (Clean India Mission) in 2014 to abolish open defecation and achieve universal sanitation coverage.

Objective

This study aimed to examine barriers to toilet use and women's menstrual hygiene practices in relation to the availability of toilets among rural residents.

Materials and Methods

Using a cross-sectional design and multi-stage sampling method, 120 households were selected from rural villages of the Mayurbhanj district of Odisha. Structured questionnaires and direct observation methods were used for data collection.

Results

All the houses had SBA latrines, yet 25% population defecated outside. About 40% households reportedly never cleaned their toilets. Most menstruating women (86.2%) preferred to change their menstrual pads/cloths in their bedroom instead of bathrooms. Incomplete construction was reported as the major reason for not using toilets. Large family size and low caste were found to be other predictors of non-use of toilets. Rural women did not use toilets for menstrual purposes as they do not consider these places as clean and safe.

Conclusion

This study clearly suggests that constructing toilets without adequate behaviour change interventions would not solve the problem of hygiene and sanitation in India, particularly in rural areas. There must be adequate monitoring of SBA scheme and utilization of funds for toilet usage. Development and implementation of suitable behaviour change strategies for toilet use in rural areas are essential to achieve the goal of open defaecation-free India.

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.

"There just isn't any other option-so we just have to put up with it": mental health in women's cycling and the necessity of structural change

Historically, bicycle riding connoted freedom, independence, and enhanced mental and physical wellbeing for women. Persevering through criticism and moral panic, female cyclists have been competitive since the late 19th century-many earning substantial prize money and prestige. Unfortunately, this progress was not linear in its trajectory and contemporary professional women's cycling continues to be pervaded by structural and cultural challenges, which can have deleterious effects on athlete mental health. Notably, socioeconomic pressures endure, like unstable employment terms, limited team support, and role conflicts. Furthermore, sexual harassment, body shaming, and manipulation may characterize women's experiences with their coaches and teams. Sizable investment gaps between men's and women's teams and competitions often underpin these scenarios of disadvantage. Alongside hindering the development of women's cycling, these adverse circumstances may induce psychosocial risk factors. Within this context, by highlighting sport-specific and sex-specific considerations, the emerging subdiscipline of sports psychiatry can be valuable for protecting and promoting athlete welfare in women's cycling. Raising awareness about extant symptoms, vulnerabilities, contributing behaviours, and systemic issues, can bolster efforts to develop better conditions and care equivalence. To that end, this perspective article draws upon anecdotal and scholarly evidence to provide an overview of psychiatric concerns in women's professional cycling. This informs recommended strategies to improve mental health and advance equality within the sport, which should involve actions from several stakeholders, such as athletes, teams, and governing bodies.

Sanitation-related violence against women in informal settlements in Kenya: a quantitative analysis

Introduction

Approximately 3.6 billion people around the world do not have access to safe sanitation options. Those lacking access are not only at risk of diarrheal disease, other tropical diseases, and parasitic infections, they are at greater risk of experiencing violence, particularly women and girls. The burden of lack of access to safe sanitation is disproportionately experienced by women in informal settlements in lower- and middle-income countries, where violence rates tend to be higher and access to sanitation lower. Women lacking access to safe toilets often have to walk long distances to access a facility or open site or use shared toilet facilities, which increase their vulnerability to violence.

Methods

We explore the prevalence and multilevel factors associated with women's experiences, observations, and exposure to stories about past-year sanitation-related violence in a probability sample of 550 women in a large informal settlement in Nairobi, Kenya using chi-square tests and multivariate logistic regressions.

Results

Findings suggest that social/community engagement and social/cultural beliefs are important considerations for hearing about and observing sanitation-related violence, but less so experiences of sanitation-related violence. Alternatively, individual-level and technological factors may be critical factors in actual experiences of violence.

Discussion

Sanitation-related violence and creating an environment of safety in which women can take care of their sanitation-related needs in ways that also protect them, their families, and their communities is critical for meeting sanitation-related development agendas and goals such as Sustainable Development Goal 6.2 to achieve access to adequate and equitable sanitation and hygiene for all by 2030.

Evidence on the links between water insecurity, inadequate sanitation and mental health: A systematic review and meta-analysis

BACKGROUND

Water insecurity and inadequate sanitation have adverse impacts on the mental health of individuals.

OBJECTIVE

To review and synthesize evidence on the relationship between water insecurity, inadequate sanitation, and mental health globally.

DATA SOURCES

Relevant studies were identified by searching PubMed, PsycINFO, and EMBASE databases from inception up to March 2023.

STUDY ELIGIBILITY CRITERIA

Only quantitative studies were included. The exposure was water insecurity and or inadequate sanitation. The outcome was common mental disorders (CMD: depression or anxiety), mental distress, mental health or well-being. There was no restriction on geographical location.

PARTICIPANTS

General population or people attending health facilities or other services.

EXPOSURE

Water insecurity and/ or inadequate sanitation.

RISK OF BIAS

The effective Public Health Practice Project (EPHPP) assessment tool was used to assess quality of selected studies.

SYNTHESIS OF RESULTS

A meta-analysis was conducted using a random effects statistical model.

RESULTS

Twenty-five studies were included, with 23,103 participants from 16 countries in three continents: Africa (Kenya, Ethiopia, Ghana, Uganda, South Africa, Malawi, Mozambique, and Lesotho), Asia (Nepal, Bangladesh, India, and Iran) and the Americas (Brazil, Haiti, Bolivia and Vietnam). There was a statistically significant association between water insecurity and CMD symptoms. Nine studies reported a continuous outcome (5,248 participants): overall standardized mean difference (SMD = 1.38; 95% CI = 0.88, 1.87). Five studies reported a binary outcome (5,776 participants): odds ratio 5.03; 95% CI = 2.26, 11.18. There was a statistically significant association between inadequate sanitation and CMD symptoms (7415 participants), overall SMD = 5.36; 95% CI = 2.51, 8.20.

LIMITATIONS

Most of the included studies were cross-sectional which were unable to examine temporal relationships.

CONCLUSIONS

Water insecurity and inadequate sanitation contribute to poorer mental health globally.

IMPLICATIONS OF KEY FINDINGS

Interventions to provide basic water, sanitation and psychosocial support, could substantially contribute to reducing the burden of CMD alongside other health and social benefits.

TRIAL REGISTRATION

PROSPERO registration number: CRD42022322528.

Measurement in the study of human exposure to animal feces: A systematic review and audit

BACKGROUND

Human exposure to animal feces is increasingly recognized as an important transmission route of enteric pathogens. Yet, there are no consistent or standardized approaches to measurement of this exposure, limiting assessment of the human health effects and scope of the issue.

OBJECTIVE

To inform and improve approaches to the measurement of human exposure to animal feces, we audited existing measurement in low- and middle-income countries.

METHODS

We systematically searched peer-reviewed and gray literature databases for studies with quantitative measures of human exposure to animal feces and we classified measures in two ways. First, using a novel conceptual model, we categorized measures into three 'Exposure Components' identified a priori (i.e., Animal, Environmental, Human Behavioral); one additional Component (Evidence of Exposure) inductively emerged. Second, using the exposure science conceptual framework, we determined where measures fell along the source-to-outcome continuum.

RESULTS

We identified 1,428 measures across 184 included studies. Although studies overwhelmingly included more than one single-item measure, the majority only captured one Exposure Component. For example, many studies used several single-item measures to capture the same attribute for different animals, all of which were classified as the same Component. Most measures captured information about the source (e.g. animal presence) and contaminant (e.g. animal-sourced pathogens), which are most distal from exposure on the source-to-outcome continuum.

DISCUSSION

We found that measurement of human exposure to animal feces is diverse and largely distal from exposure. To facilitate better assessment of the human health effects of exposure and scope of the issue, rigorous and consistent measures are needed. We recommend a list of key factors from the Animal, Environmental, and Human Behavioral Exposure Components to measure. We also propose using the exposure science conceptual framework to identify proximal measurement approaches.

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.

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

OBJECTIVE

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

METHODS

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

FINDINGS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

NCT01233531; Post-results.

Revalidation and adaptation of the Menstrual Practice Needs Scale (MPNS) in a cross-sectional survey to measure the menstrual experiences of adult women working in Mukono District, Uganda

OBJECTIVES

The Menstrual Practice Needs Scale (MPNS) is a comprehensive measure of menstrual self-care experience including access to sufficient, comfortable materials to catch or absorb bleeding, supportive spaces for managing menstruation and for disposal and laundering of used materials. It addresses a critical measurement gap to improve quantitative menstrual health research and programme evaluation. The scale was validated in a population of adolescent schoolgirls. This study appraises its performance among adult women.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

Seven cognitive interviews provided insights into the interpretability of scale items. A survey of 525 working women who had menstruated in the past 6 months (435 working in markets, 45 in schools and 45 working in healthcare facilities) in Mukono District, Uganda was used to test the dimensionality, reliability and validity of the measure.

RESULTS

The 36 scale items were well understood by the study population. Dimensionality was tested for the 28 items relevant to women disposing of menstrual materials and 32 items relevant to those washing and reusing materials. The original subscale structure fit with the data, however, fell short of recommended thresholds for those disposing of materials (root mean squared error of approximation, RMSEA=0.069; Comparative Fit Index, CFI=0.840; Trucker-Lewis Index, TLI=0.824). An alternative subscale structure was an acceptable fit for those disposing (RMSEA=0.051; CFI=0.911; TLI=0.897) and reusing materials (RMSEA=0.053; CFI=0.915; TLI=0.904). MPNS total and subscale scores demonstrated acceptable internal consistency. Higher scores reflected more positive menstrual experiences and were associated with well-being (total score r=0.24, p<0.001), not missing work due to the last menstrual period (total score OR=2.47 95% CI 1.42 to 4.30) and confidence to manage menstruation.

CONCLUSIONS

The MPNS offers a valid and reliable way to assess menstrual health needs. The revised factor structure can be used for samples of adult workers. Findings also highlight challenges in assessing the variety of experiences relevant to managing menstrual bleeding.

Measuring and valuing broader impacts in public health: Development of a sanitation-related quality of life instrument in Maputo, Mozambique

Two billion people globally lack access to a basic toilet. While improving sanitation reduces infectious disease, toilet users often identify privacy, safety and dignity as more important. However, these outcomes have not been incorporated in sanitation-related economic evaluations. This illustrates the general challenge of outcome measurement and valuation in the economic evaluation of public health interventions, and risks misallocating the US$ 20 billion invested in sanitation in low- and middle-income countries every year. In this study in urban Mozambique, we develop an instrument to measure sanitation-related quality of life (SanQoL). Applying methods from health economics and the capability approach, we develop a descriptive system to measure five attributes identified in prior qualitative research: disgust, health, shame, safety and privacy. Sampling individuals from the intervention and control groups of a sanitation intervention trial, we elicit attribute ranks to value a SanQoL index and assess its validity and reliability. In combination with a measure of time using a sanitation service, SanQoL can quantify incremental benefits in a sanitation-focused cost-effectiveness analysis. After monetary valuation based on willingness to pay, QoL benefits could be summed with health gains in cost-benefit analysis, the most common method in sanitation economic evaluations.

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

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

Gender and Sanitation: Women’s Experiences in Rural Regions and Urban Slums in India

Without adequate sanitation facilities, environmental, social, and health risks are common and worsen as the state of sanitation stagnates. Vulnerable groups, specifically women, are unequally affected by poor sanitation. Attitudes towards and perceptions of gender and menstruation have created a health and social discrepancy between women and men. Women must undergo additional obstacles when practicing proper sanitation and managing menstruation. This article utilizes the sanitation insecurity measure to assess the lived experience of women in rural and urban India. This article also discusses accounts of women’s experiences managing menstruation in both the rural regions and urban slums of India and discusses the social implications of the state of sanitation. Examining the issue of sanitation by focusing on menstruation and the dichotomy of men’s and women’s experiences with sanitation and hygiene will indicate that achieving gender equity requires sanitation to be viewed as a human rights, social justice, and education issue.

Global estimated Disability-Adjusted Life-Years (DALYs) of diarrheal diseases: A systematic analysis of data from 28 years of the global burden of disease study

BACKGROUND

Diarrheal disease (DD)-associated mortality has declined since 1990; however, the incidence of DD has experienced a less-pronounced decrease. Thus, it is important to track progress in managing DD by following loss of healthy years. A disability-adjusted life-year (DALY), which combines data on years-of-life lost (YLL) and years-lived with-disability (YLD), is a metric that can track such a burden.

METHODS AND FINDINGS

Using all 28 years of data in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, we compared DD DALYs among different demographic subsets including sex, age, country, and World Bank (WB) income level. We also evaluated DD DALYs as a function of the socio-demographic index (SDI), a measure of a region's socio-demographic development. On a global level, DD DALYs have decreased by approximately 85.43% from 1990 to 2017. Incidence and prevalence have decreased by 1.53% and 4.45%, respectively. A dramatic decrease in DD DALYs were observed for WB low-income countries, but not for WB high-income constituents. The temporal decrease in DD DALY rates in WB low-income countries was likely driven by a decrease in YLL. Alternatively, temporal increases in both YLL and YLD may have contributed to the apparent lack of progress in WB high-income countries. Regardless of WB income classification, children under the age of five and the elderly were the most vulnerable to DD. In nearly every year from 1990 to 2017, DD DALYs for females were higher than those for males in WB high-income regions, but lower than those for males in WB low-income constituents. The reason for these differences is not known. We also observed that the rate of DD DALYs was highly correlated to SDI regardless of WB income classification.

CONCLUSIONS

To the best of our knowledge, this is the only temporal study of DD DALYs that encompasses all 28 years of data available from the GBD. Overall, our analyses show that temporal reductions in DD DALYs are not equivalent across regions, sexes and age groups. Therefore, careful attention to local and demography-specific risk factors will be necessary to tailor solutions in region- and demography-specific manners.

Norms and Social Network-Centric Behavior Change Intervention (Nam Nalavazhvu) for Improved Toilet Usage in Peri-Urban Communities of Tamil Nadu: Protocol for a Cluster-Randomized Controlled Trial

BACKGROUND

Inconsistent toilet usage is a continuing challenge in India. Despite the impact of social expectations on toilet usage, few programs and studies have developed theoretically grounded norm-centric behavior change interventions to increase toilet use in low-income settings.

OBJECTIVE

The objective of this paper is to detail the rationale and design of an ex ante, parallel cluster-randomized trial evaluating the impact of a demand-side, norm-centric behavior change intervention on exclusive toilet use and maintenance in peri-urban Tamil Nadu, India.

METHODS

Following formative research, we developed an evidence-based norm-centric behavior change intervention called Nam Nalavazhvu (Tamil for "our well-being"). The multilevel intervention aims to improve toilet usage by shifting empirical expectations or beliefs about other relevant people's sanitation practices. It also provides action-oriented information to aid individuals to set goals and overcome barriers to own, consistently use, and maintain their toilets. This trial includes 76 wards in the Pudukkottai and Karur districts, where half were randomly assigned to receive the intervention and the remaining served as counterfactuals.

RESULTS

We enrolled wards and conducted a baseline survey among randomly selected individuals in all 76 wards. The 1-year behavior change intervention is currently ongoing. At the endline, we will collect relevant data and compare results between study arms to determine the impacts of the Nam Nalavazhvu intervention on sanitation-related behavioral, health, and well-being outcomes and potential moderators. This study is powered to detect differences in the prevalence of exclusive toilet use between study arms. We are also conducting a process evaluation to understand the extent to which the intervention was implemented as designed, given the special pandemic context.

CONCLUSIONS

Findings from this trial will inform norm-centric behavior change strategies to improve exclusive toilet usage.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04269824; https://www.clinicaltrials.gov/ct2/show/NCT04269824.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24407.

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.

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.

Visible and invisible risks: Exploring washing and hygiene practices with women living on low income in Kenya

Shifting environmental conditions and poor or insufficient hygiene facilitates the transmission of bacteria and viruses between and within species of animals; between humans; and between humans and animals. Taking a One Health perspective, we used interviews to explore with 20 women living on low income in Kenya: their gendered hygiene practices and daily contact with animals; how and why they access water and sanitation facilities for themselves, their families, and any livestock; and their understandings of (zoonotic) health risks and disease transmission within their local environments. The women described how they worked every day to keep bodies and homes clean by washing bodies, surfaces and clothes. Women's hygiene practices focussed on removing visible dirt partly because of concerns for health but also to support their families' social standing in their community. While they were less aware of any 'invisible' risks to health through contact with animals or other hazards present in their daily living environments, most exercised care to source and manage water for drinking. Contaminated water was recognised as a risk to health suggesting that in this case, women accepted that there were 'invisible risks' to health, even in clear water, and took steps to mitigate them.

Where Shared Sanitation is the Only Immediate Option: A Research Agenda for Shared Sanitation in Densely Populated Low-Income Urban Settings

Shared sanitation is not currently accepted within the international normative definitions of "basic" or "safely managed" sanitation. We argue that pro-poor government strategies and investment plans must include high-quality shared sanitation as an intermediate step in some densely populated urban areas. User experience must be considered in establishing the definition of high quality. We call for additional research on effective interventions to reach these quality standards and for the development of rigorous measures applicable to global monitoring.

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.

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.

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.

Environmental Correlates of Health-Related Quality of Life among Women Living in Informal Settlements in Kenya

Informal settlements (slums)—defined as residential areas lacking durable housing; sufficient living and public spaces; access to basic infrastructure, water, sanitation, and other services; and secure tenancy—are presumed to be poor health environments. Research in Kenya suggests that residents of these settlements have the worst health outcomes of any population, yet there is a paucity of research focused on the health and well-being of these residents. Even less attention is given to the role played by environment in health in these settings. The present study addresses these gaps by examining potential environmental correlates, specifically access to water and sanitation, of health-related quality of life (HRQOL) among 552 women in Mathare slum in Nairobi, Kenya. A Kiswahili version of the 36-Item Short Form Health Survey (SF-36) measured HRQOL. Results suggested that access to a toilet at all times was associated with every subscale of the mental health and general well-being domains of the SF-36. Primary water source was also associated with women’s HRQOL. Despite increasing efforts to expand sanitation and water access in informal settlements, more attention should be given to whether the interventions being introduced, which likely affect women’s psychosocial health, are appropriate for all residents, including women.

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 mixed-methods study of women's sanitation utilization in informal settlements in Kenya

While access to safe sanitation is a global issue, there are large disparities in access. Women living in informal settlements, in particular, are disproportionately affected by lack of access to sanitation. Without adequate sanitation, these women may resort to unsafe strategies to manage their sanitation needs, but limited research has focused specifically on this issue. Qualitative and quantitative data were collected from women in the Mathare informal settlement in Nairobi, Kenya in 2016. A latent class analysis (LCA) using the quantitative data yielded five distinct sanitation profiles (SP) among women in Mathare. In-depth interviews and sanitation walks with women added further detail about the characteristics of and motivations underlying each profile. Women’s sanitation profiles in these settlements are complex. A majority of women in this study utilized an unsafe method of disposal at least once in a 24-hour period that increased their risk of direct exposure to waste and harmful pathogens.

Latent variable modeling to develop a robust proxy for sensitive behaviors: application to latrine use behavior and its association with sanitation access in a middle-income country

BACKGROUND

Globally, diarrhea is a leading cause of child morbidity and mortality. Although latrines are integral for reducing enteric pathogen transmission, several studies have shown no evidence that latrine ownership improved child health. There are a number of explanations for these results. One explanation is that latrine access does not equate to latrine use. Latrine use, however, is difficult to accurately ascertain, as defecation behavior is often stigmatized. To address this measurement issue, we measure latrine use as a latent variable, indicated by a suite of psychosocial variables.

METHODS

We administered a survey of 16 defecation-related psychosocial questions to 251 individuals living in rural Ecuador. We applied latent class analysis (LCA) to these data to model the probability of latrine use as a latent variable. To account for uncertainty in predicted latent class membership, we used a pseudo-class approach to impute five different probabilities of latrine use for each respondent. Via regression modeling, we tested the association between household sanitation and each imputed latrine use variable.

RESULTS

The optimal model presented strong evidence of two latent classes (entropy = 0.86): consistent users (78%) and inconsistent users (22%), predicted by 5 of our 16 psychosocial variables. There was no evidence of an association between the probability of latrine use, predicted from the LCA, and household access to basic sanitation (OR = 1.1, 95% CI = 0.6-2.1). This suggests that home access to a sanitation facility may not ensure the use of the facility for every family member at all times.

CONCLUSION

Effective implementation and evaluation of sanitation programs requires accurate measurement of latrine use. Psychosocial variables, such as norms, perceptions, and attitudes may provide robust proxy-measures. Future longitudinal studies will help to strengthen the use of these surrogate measures, as many of these factors may be subject to secular trends. Additionally, subgroup analyses will elucidate how our  proxy indicators of latrine defecation vary by individual-level characteristics.

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

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

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

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

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.

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.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

DISCUSSION

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