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Opening the Doors to the Hidden Water, Sanitation and Hygiene Needs of Women from the Onset of the Perimenopause in Urban Ghana

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Opening the Doors to the Hidden Water, Sanitation and Hygiene Needs of Women from the Onset of the Perimenopause in Urban Ghana Opening the doors to the hidden water, sanitation and hygiene needs of women from the onset of the perimenopause in urban Ghana ...................................................... by Amita Natiksha Bhakta Doctoral Thesis Submitted in partial fulfillment of the requirements for the award of Doctor of Philosophy of Loughborough University (2019) © Amita Natiksha Bhakta 2019 Supervisors: Dr Julie Fisher and Brian Reed “However difficult life may seem, there is always something you can do and succeed at. It matters that you don’t just give up.” ~ Professor Stephen Hawking DEDICATION To all of the perimenopausal and menopausal women who are at the very heart of this thesis and have so kindly shared their stories. In memory of James, a friend in Accra who taught me the importance of playing hard as well as working hard in the field. Finally, to the woman who did everything she could to make it possible for me to complete this journey, by believing in me and standing by me from the day I was born, even when others did not, and taught me to never give up: the most important woman in my life, my mum, Dr. Padma Bhakta. i ACKNOWLEDGEMENTS I begin by thanking my supervisors, Dr Julie Fisher and Brian Reed. Your immeasurable support and faith in me in so many ways has been the pillar of this process, with valuable advice and enjoyable discussion throughout, academically and beyond. I also thank Prof. M. Sohail Khan for his feedback in the closing stages. I thank Loughborough University for the PhD studentship to enable me to do this research, and a special thanks to Dr Brigette Vale and the Doctoral College for their support in enabling me to complete this journey. I thank the examiners, Dr Sarah Jewitt, Michael Smith and Rebecca Scott for their useful feedback on the thesis. This research would not have been possible without all of the women who are at the very heart of this thesis, I am truly grateful to you for kindly sharing your stories of the perimenopause with me. I thank the environmental health professionals who I met in Ghana for giving insightful feedback on the findings. So many people in Ghana made this research possible. Special thanks to Harold Esseku and Yvonne Esseku for providing me with the opportunity to come and work and to make another home in Ghana, and to Gloria Annan and Benjamin Lartey for their central role in the fieldwork. Thanks to community leaders and members, and to Juliet, Osu, Phylliss and Adjoa for their support and making me feel so welcome. I thank Dr Kwabena Nyarko and Nehimiah Samwini of Kwame Nkumrah University of Science and Technology, for their support in the research and facilitating ethical approval. Thank you to Acheampong and Joe for making the ride to and from the field fun each day, and to staff at the guest houses for making my stay a wonderful experience. Medaase! My thanks go to the entire WEDC team and the School of Architecture, Building and Civil Engineering for their valuable insights and support throughout. I want to thank Tricia Jackson for supporting me in trying to uncover the hidden knowledge upon which this thesis is based. A special thanks to Rod Shaw for providing the graphical imagery for this thesis. This research would not have happened without the fantastic support and dedication throughout from Dr Manuel Alonso, Hazel Thompson, Sharron Sturgess, Caroline Donoghue, and the wider Disability team at Loughborough University. I wish to thank the many people who have provided practical support for the research. A very special thanks to my friend, Dr Kate Simpson, for her fantastic support at home and abroad, and for making adventures throughout the PhD unforgettable and fun. It was a true honour to share them with you. A very special thanks to my friend, Dr Kate Moore, for kindly producing the maps for this thesis, ii for sharing numerous lunches with me over the years which have helped me to get through the process, and for your overall support throughout. Very special thanks also to Dr Rachel Fowler, Rachel Potter and Dr Emma Sik for their excellent support in the closing stages of this PhD. Thanks to my friends for your support throughout. Thanks to friends at Loughborough, especially Dr Louise Medland, Dr Claire Furlong, Susie Goodall, and Dr Wendy Jones for insightful advice and debate. A special thanks to my friends, Dr Kate Moore, Dr Adam Barker and Madeleine Edgeworth for proofreading my thesis, and to Dr Freya Brooks and Prof. Gavin Brown, for always being there. You have all kept me smiling. I thank all of those who contributed so much to my development in childhood, and built the foundations for making this journey possible. Finally, thank you to my family: to Mummy, Daddy, Grandma, Apeksha and Krish. You have been my strength throughout the PhD, as you have been through my life. Thank you for believing in me, always. iii TABLE OF CONTENTS DEDICATION ....................................................................................................................... i ACKNOWLEDGEMENTS ...................................................................................................... ii TABLE OF CONTENTS ........................................................................................................ iv LIST OF TABLES ............................................................................................................... xix LIST OF FIGURES .............................................................................................................. xx LIST OF ABBREVIATIONS ................................................................................................ xxii ABSTRACT .....................................................................................................................xxvi CHAPTER ONE: INTRODUCTION – DOOR TO THE RESEARCH TOPIC ..................................... 2 1.3.1 Background and origins of research ........................................................................ 3 1.3.2 Ageing ...................................................................................................................... 4 1.3.3 The perimenopause ................................................................................................. 5 1.3.4 WASH needs and the Sustainable Development Goals .......................................... 6 1.3.5 Opening the doors to hidden knowledge: the need to place women at the centre of the research ............................................................................................. 7 1.3.6 A starting point: Feminism ...................................................................................... 9 1.5.1 Evolution of research objectives and research approach: an iterative process ... 11 1.5.2 Exploring the factors which influence the WASH needs of PM women: the need for the Sustainable Livelihoods Framework ................................................. 13 1.5.3 The logical framework analysis approach ............................................................. 14 1.6.1 Research objective 1: ............................................................................................ 16 iv 1.6.2 Research objective 2: ............................................................................................ 16 1.6.3 Research objective 3: ............................................................................................ 17 CHAPTER TWO: LITERATURE REVIEW – DOOR TO THE KNOWLEDGE GAP ......................... 21 2.2.1 Systematic literature searching ............................................................................. 22 2.2.2 Literature search process ...................................................................................... 22 2.2.3 Results of the literature search ............................................................................. 23 2.2.4 Analysis of the literature search results ................................................................ 26 2.3.1 The 1970s-1990s: Women in Development to Gender and Development .......... 26 2.3.2 Gendered approaches to WASH ............................................................................ 27 2.3.3 The 2000s: Gender mainstreaming ....................................................................... 28 2.3.4 WASH services for women .................................................................................... 28 2.3.5 Equity and inclusion in the 2010s: Rights, caste, disability, MHM, and gender- based violence ....................................................................................................... 29 2.4.1 Climacteric, perimenopause and menopause ....................................................... 31 2.4.2 Hormonal changes of the perimenopause ............................................................ 32 2.4.3 Symptoms of the perimenopause ......................................................................... 33 2.4.4 Cultural perspectives ............................................................................................. 35 2.4.5 Social exclusion and ‘vulnerability’: perimenopausal women as a hidden group 37 2.5.1 Medical symptoms ................................................................................................ 38 2.5.2 Cultural beliefs ....................................................................................................... 42 v 2.5.3 The relevance of medical and cultural literature on the menopause from the Global South to the research ................................................................................
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