Downloaded from http://gh.bmj.com/ on October 16, 2017 - Published by group.bmj.com Research Understanding and defining sanitation insecurity: women’s gendered experiences of urination, defecation and menstruation in rural Odisha, India Bethany A Caruso,1,2 Thomas F Clasen,2 Craig Hadley,3 Kathryn M Yount,4,5 Regine Haardörfer,1 Manaswini Rout,6 Munmun Dasmohapatra,6 Hannah LF Cooper1 To cite: Caruso BA, ABSTRACT Clasen TF, Hadley C, et al. Background Research suggests that the lived Key questions Understanding and defining experience of inadequate sanitation may contribute sanitation insecurity: women’s to poor health outcomes above and beyond pathogen What is already known about this topic? gendered experiences of ► Poor or non-existent sanitation facilitates faecal urination, defecation and exposure, particularly among women. The goal of this research was to understand women’s lived experiences pathogen exposure, which can lead to numerous menstruation in rural Odisha, infectious disease outcomes, including diarrhoea, India. of sanitation by documenting their urination-related, BMJ Glob Health soil-transmitted helminth infection, trachoma and 2017;2:e000414. doi:10.1136/ defecation-related and menstruation-related concerns, schistosomiasis among others. bmjgh-2017-000414 to use findings to develop a definition ofsanitation A small but growing line of research suggests that insecurity among women in low-income settings and ► inadequate sanitation poses specific health risks Handling editor Seye Abimbola to develop a conceptual model to explain the factors to women beyond infectious diseases, like adverse that contribute to their experiences, including potential ► Additional material is pregnancy outcomes, non-partner violence and stress. published online only. To view, behavioural and health consequences. please visit the journal online Methods We conducted 69 Free-List Interviews and What are the new findings? (http:// dx. doi. org/ 10. 1136/ eight focus group discussions in a rural population in ► Toilet access enables a choice but not a solution; bmjgh- 2017- 000414). Odisha, India to identify women’s sanitation concerns women identified a multitude of concerns and to build an understanding of sanitation insecurity. associated with their urination, defecation and Findings We found that women at different life menstruation experiences even if they owned Received 18 May 2017 stages in rural Odisha, India have a multitude of functional toilets. Revised 4 September 2017 unaddressed urination, defecation and menstruation Accepted 6 September 2017 ► Women’s ability to attend to their needs were concerns. Concerns fell into four domains: the strained by the gendered roles they were expected sociocultural context, the physical environment, the to uphold and their access to and dependence on social environment and personal constraints. These social support systems. varied by season, time of day, life stage and toilet ► Life stage, weather conditions and time of day ownership, and were linked with an array of adaptations influenced the intensity of women’s sanitation- (ie, suppression, withholding food and water) and related concerns. consequences (ie, scolding, shame, fear). Our derived definition and conceptual model of sanitation insecurity Recommendations for policy reflect these four domains. ► Using our findings, we propose a definition for Discussion To sincerely address women’s sanitation sanitation insecurity, which can initiate discourse and needs, our findings indicate that more is needed further research to validate or refine the definition. than facilities that change the physical environment ► Current sanitation global policy and practice typically alone. Efforts to enable urinating, defecating and focuses on defecation, leaving women’s urination and managing menstruation independently, comfortably, menstruation-related needs underserved. safely, hygienically, privately, healthily, with dignity ► Sanitation programmes have the potential to be and as needed require transformative approaches that gender transformative through programming that also address the gendered, sociocultural and social tackles the social norms that make women’s environments that impact women despite facility sanitation needs second to the obligations she access. This research lays the groundwork for future has to her household and family. For numbered affiliations see sanitation studies to validate or refine the proposed end of article. definition and to assess women’s sanitation insecurity, INTRODUCTION Correspondence to even among those who have latrines, to determine Globally, approximately 2.3 billion people Bethany A Caruso; what may be needed to improve women’s sanitation lack access to basic sanitation, unshared bcaruso@ emory. edu circumstances. household facilities that hygienically Caruso BA, et al. BMJ Glob Health 2017;2:e000414. doi:10.1136/bmjgh-2017-000414 1 Downloaded from http://gh.bmj.com/ on October 16, 2017 - Published by group.bmj.com BMJ Global Health separate human excreta from human contact.1 Of conceptualised toilet insecurity as ‘when safe, usable toilets these, 892 million people lack access to any sanitation are not available’ (p. 19).28 While safety and usability of and practice open defecation.1 Poor or non-existent a facility are critical, we expect women may experience sanitation facilitates faecal pathogen exposure, which sanitation insecurity regardless of having a safe and func- is associated with multiple infectious disease outcomes, tional toilet. As with research on water and food inse- including diarrhoea, soil-transmitted helminth infec- curity, we hypothesise that sanitation insecurity extends 2 3 tion, trachoma and schistosomiasis. The Millennium beyond access, is multidimensional, and also considers Development Goals aimed to increase coverage of experiences, perceptions and preferences, associated improved sanitation by 2015 to combat these health with the sociocultural context. impacts. Recognising that coverage alone is insuffi- This research aimed to: (1) document the full cient, the Sustainable Development Goals go further, range of voiced urination, defecation and menstrua- calling for access to adequate and equitable sanitation tion concerns of women in rural Odisha, India, and and hygiene for all, with special attention to the needs to use findings to (2) develop a definition and (3) of women and girls, including managing defecation, conceptual model of sanitation insecurity that shows urination and menstruation needs with dignity.4 the factors that contribute to sanitation insecurity and India represents a major sanitation challenge; 40% the impacts it may have on behaviour and health. We of the population lack sanitation access, including focus on urination, defecation and menstrual hygiene, 56% of rural residents.1 A succession of government as these are the key personal behaviours noted in programmes has emphasised building toilets to end open defecation. The current programme, the Swachh goal 6 of the Sustainable Development Goals. We Bharat Mission, aims to provide sanitation to all house- document concerns because concerns may be ever- holds to end open defecation by October 20195. Yet, present, impacting behaviour, events and life, regard- rigorous evaluations of the previous campaign found less of whether or not they are actualised. A woman limited increases in latrine coverage and no detectable may worry about assault while tending to her needs, health impacts.6–8 Furthermore, overall use of latrines for example, but never be assaulted. Her concern built through these campaigns also remains low.9–11 for harm, however, influences her decision-making, A small but growing line of research suggests that behaviour and well-being. Her concern becomes her inadequate sanitation poses health risks beyond infec- experience. By documenting these insights, we strive tious diseases to women in India and beyond. Open not to ignore women’s resilience or depict women defecation has been associated with adverse pregnancy solely as vulnerable. Rather, we seek to unpack their outcomes in India and higher odds of non-partner experiences to inform programmes serving women’s violence in India and Kenya.12–14 Greater access to needs, identify drivers of latrine use and non-use improved sanitation has been associated with decreased and uncover potentially overlooked health risks. Our odds of maternal mortality.15 In India and Kenya, women approach strives to move beyond sanitation research consider their sanitation conditions to cause stress due previously carried out in Odisha that identified envi- to compromised privacy, inability to change conditions ronmental, social and sexual stressors contributing to 16–20 and the potential for harm when addressing needs. sanitation-related psychosocial stress.17 18 We suspect Women in Uttar Pradesh, India reported increased that women’s concerns, their sanitation insecurity, challenges defecating when menstruating, noting a risk contribute to stress, but may also influence depression, 20 of greater shame if seen. In rural Odisha, research well-being and overall quality of life. found that women lacked power, control of money and Our evidence-based definition of sanitation insecurity confidence, which men corroborated, resulting in their can eventually help establish a standard for assessing sani- exclusion from decision-making, particularly regarding 21 tation programmes. This study served as the basis of a sani- toilet construction. Research that further elucidates