Water, Sanitation, and Women’s Empowerment: A systematic review and qualitative metasynthesis

Abstract

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.

Protocol for development and validation of instruments to measure women’s empowerment in urban sanitation across countries in South Asia and Sub-Saharan Africa: the Agency, Resources and Institutional Structures for Sanitation-related Empowerment (ARISE) scales

“…Details of the methods and results of the systematic review are described elsewhere. 11 We developed sanitation-specific definitions for each subdomain of empowerment, drawing on the conceptual model’s definitions with adaptations informed by the literature and team members’ expertise ( table 2 ). Adaptations included removing the mention of ‘girls’ and excluding the market and state subdomains of institutional structures, as well as laws and policies, to focus on adult women’s empowerment at individual, household and community levels.…”

“…Of note, we identified and defined two additional subdomains of empowerment relevant to sanitation from the systematic review: privacy and freedom of movement (within resources and agency, respectively). 11 …”

“…Using this conceptual model, we conducted a systematic review of peer-reviewed literature related to empowerment in WaSH. Details of the methods and results of the systematic review are described elsewhere 11. We developed sanitation-specific definitions for each subdomain of empowerment, drawing on the conceptual model’s definitions with adaptations informed by the literature and team members’ expertise (table 2).…”

“…Adaptations included removing the mention of ‘girls’ and excluding the market and state subdomains of institutional structures, as well as laws and policies, to focus on adult women’s empowerment at individual, household and community levels. Of note, we identified and defined two additional subdomains of empowerment relevant to sanitation from the systematic review: privacy and freedom of movement (within resources and agency, respectively) 11…”

Decolonizing WASH Research: Results of a qualitative study and consensus-building process to develop principles for increasing equity in WASH Research

“…There are various actors addressing components of Sustainable Development Goal (SDG) 6 to “ensure availability and sustainable management of water and sanitation for all.” Water, sanitation, and hygiene (WASH) is a distinct sub-sector within global health including the global monitoring system of the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation, and Hygiene (JMP), academic conferences, and a distinctive sectoral recognition led by UNICEF within the Humanitarian Cluster system alongside clusters like Food Security and Nutrition. Within the context of WASH, there is an increasing focus on inequity, especially on gendered user experiences of WASH services (Caruso et al, 2021) and imbalances in sectoral leadership (Worsham, Sylvester, Hales, McWilliams, & Luseka, 2021). The history of global health undoubtedly influences the power dynamics found in the WASH landscape.…”