BackgroundWater and sanitation programs historically have focused on women’s instrumental value in improving effectiveness and impact of programs, though focus is shifting to consider how programming and conditions may contribute to women’s empowerment an gender equality. To date no systematic review has comprehensively assessed and synthesized evidence on water and sanitation and women and girls’ empowerment. The primary aims of this review were to: a) identify empirical water and sanitation research that engaged empowerment and/or empowerment-related domains from a pre-specified conceptual model; b) tabulate and report how empowerment-related terminology was used, where and when research was conducted, what methods were leveraged, and if water and/or sanitation was the primary focus; c) synthesize findings by empowerment domain and water and/or sanitation focus.Methods and FindingsThe conceptual model of women’s and girls’ empowerment developed by van Eerdewijk et.al (2017) informed our search strategy and analysis. The model presents three interrelated domains (agency, resources, institutional structures) and 13 sub-domains of empowerment. We searched MEDLINE, EMBASE, CABI Global Health, PsycINFO, CINAHL and AGRICOLA for any peer-reviewed sources presenting research related to water and/or sanitation and either empowerment and/or related terms from the conceptual model (4 May 2020). Systematic and ancestry and decendency searching identified 12,616 publications, of which 257 were included following screening, representing 1,600,348 participants. We assessed all studies using the Mixed-Method Appraisal Tool (MMAT). We followed the ‘best-fit framework synthesis’ approach for analysis, using the domains and sub-domains of the conceptual model as codes to assess all included sources. During coding, we inductively identified two additional sub-domains relevant to water and sanitation: privacy and freedom of movement. Thematic analysis guided synthesis of coded text by domain and sub-domain. The majority of research took place in Asia (46%; 117) or Africa (40%; 102), engaged adults (69%; 177), and were published since 2010; (82%; 211). A greater proportion of studies focused on water (45%; 115) than sanitation (22%; 57) or both (33%; 85). Over half of articles use the term empowerment yet only 7% (17) provided a clear definition or conceptualization. Agency was the least commonly engaged domain (47%; 122) while the Resources domain was dominant (94%; 241). Measures for assessing empowerment and related domains is limited. This review was limited by only including sources in English and only includes menstruation-focused research in the context of water and sanitation.ConclusionsWater and sanitation research specifically engaging women’s and girls’ empowerment in a well-defined or conceptualized manner is limited. A substantial body of research examining domains and sub-domains of empowerment exists, as does research that illuminates myriad negative impacts of water and sanitation conditions and circumstances women’s and girl’s well-being. Available research should be used to develop and evaluate programs focused on improving the life outcomes of women and girls, which has only been minimally conducted to date. A more comprehensive ‘transformative WASH’ that includes gender-transformative approaches to challenge and reduce systemic constraints on women’s and girls’ resources and agency is not only warranted but long overdue.

IntroductionDespite an increasing emphasis on gender and empowerment in water, sanitation and hygiene (WaSH) programmes, no rigorously validated survey instruments exist for measuring empowerment within the WaSH sector. Our objective is to develop and validate quantitative survey instruments to measure women’s empowerment in relation to sanitation in urban areas of low-income and middle-income countries.Methods and analysisWe are developing the Agency, Resources and Institutional Structures for Sanitation-related Empowerment scales through a process that involves three phases: item development; scale development and initial validation and scale evaluation and further validation. The first phase includes domain specification, item generation, face validity and content validity assessment and item refinement. The second phase involves a second round of face validity and content validity assessment, followed by survey implementation in two cities (Tiruchirappalli, India and Kampala, Uganda) and data analysis involving factor analysis and item response theory approaches as well as reliability and validity testing. The third phase involves a final round of face validity and content validity assessment, followed by survey implementation in three additional cities (Narsapur and Warangal, India and Lusaka, Zambia) and statistical analysis using similar approaches as in phase 2 for further validation.Ethics and disseminationEthics approvals have been received from the Emory University Institutional Review Board (USA); Azim Premji University and Indian Institute of Health Management Research Institutional Review Boards (India); Makerere University School of Health Sciences Research and Ethics Committee (Uganda); and ERES Converge Institutional Review Board (Zambia). The study team will share findings with key stakeholders to inform programming activities and will publish results in peer-reviewed journals.

Historically, water and sanitation programs have focused on women’s instrumental value in improving conditions and behaviors. No reviews have synthesized evidence on water and sanitation and women’s and girls’ empowerment. This review a) identified empirical water and sanitation research that engaged empowerment and/or empowerment-related domains; b) reported empowerment-related terminology used, research locations, methods leveraged, if water and/or sanitation was the focus; and c) synthesized evidence. A conceptual model of women’s and girls’ empowerment, which includes three interrelated domains (agency, resources, institutional structures), informed the search and analysis. We searched MEDLINE, EMBASE, CABI Global Health, PsycINFO, CINAHL and AGRICOLA for peer-reviewed sources presenting research on water and/or sanitation and either empowerment and/or related terms from the model (4 May 2020). We identified 12,616 publications; 257 were included, representing over 1,600,000 participants. We used the Mixed-Methods Appraisal Tool (MMAT) and followed the ‘best-fit framework synthesis’ analysis approach, using the model domains and sub-domains as codes. We inductively identified two additional sub-domains relevant to water and sanitation: privacy and freedom of movement. Thematic analysis guided synthesis of coded text. The majority of research took place in Asia (46%; 117) or Africa (40%; 102), engaged adults (69%; 177), and was published since 2010; (82%; 211). The greatest proportion of studies focused on water (45%; 115). Over half of studies used the term empowerment, yet only 7% (17) provided a clear definition or conceptualization. Agency was the least commonly engaged domain (47%; 122); the Resources domain was dominant (94%; 241). Measures for assessing empowerment are limited. Inclusion of only peer-reviewed sources in English is a main limitation. Well-conceptualized water and sanitation research that engages women’s and girls’ empowerment is limited. A more comprehensive ‘transformative WASH’ that includes gender-transformative approaches to challenge and reduce systemic constraints on women’s and girls’ resources and agency is long overdue.

IntroductionWater is a crucial resource for many household functions, including drinking, cooking, bathing, and washing clothes. Globally, women bear the burden of water collection in households without piped water, as well as responsibility for household chores that require water. Carrying water has a number of health and safety risks, and women often rely on multiple water sources. The goal of this study is to understand how women in rural Odisha, India, an area with high coverage of improved water sources, make decisions on where to collect water.MethodsThis is a grounded-theory, secondary analysis of qualitative data collected from 69 women across life stages in eight villages in rural Odisha. Women were asked about their concerns and difficulties related to water and probed for details in a variety of contexts, including at night, during monsoon season, and during pregnancy.ResultsWomen's standards for water quality vary depending on the planned use of the water. They report a willingness to travel long distances to collect better tasting water for cooking and drinking. When washing clothes, they often prefer a larger body of water. Bathing or washing menstrual cloths requires privacy. Their ability to access water varies based on individual characteristics such as: life stage, as recently married women have less freedom of movement than older women; health status, as older women report difficulties carrying water long distances; cyclical patterns such as seasonality, as certain sources are inaccessible during monsoon season; and characteristics of the water and the source itself, which encompasses distance, perceived quality, and privacy, among others.DiscussionThese findings indicate that public health interventions and surveys that monitor household water should not only consider the presence of a water source on the premises, but should also include multiple source use and consideration of individual members of households and the time of data collection, as water sources may not be equally available or acceptable to all household members at all times. In climate-sensitive areas, multiple water source use may become increasingly necessary as a response to changes in the environment, and should be considered in climate resilience interventions.

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