India - Women, WASH and Health in Rural Pune District - Identifying stress and unmet needs - 2013-2014 (Release 2017)

v1: Data for public distribution

2014

BACKGROUND

The project has been developed in response to a “Request for Proposals - The effects of poor sanitation on women and girls in India” issued by SHARE and WSSCC in early 2013. The request for proposal provided the following background information

(Abridged)

SHARE stands for Sanitation and Hygiene Applied Research for Equity, and is a five year initiative (2010-2015) funded by the UK Department for International Development. SHARE is a consortium of five organisations that have come together to generate rigorous and relevant research for use in the field of sanitation and hygiene. The SHARE consortium is led by the London School of Hygiene and Tropical Medicine and has four partners: the International Centre for Diarrhoeal Disease Control, Bangladesh; the International Institute for Environment and Development; Slum/Shack Dwellers International; and WaterAid.

The Water Supply and Sanitation Collaborative Council (WSSCC) is a global multi-stakeholder partnership and membership organization that works to save lives and improve livelihoods. It does so by enhancing collaboration among sector agencies and professionals who are working to improve access to safe sanitation and clean drinking water, with the goals of poverty eradication, health and environmental improvement, gender equality and long-term social and economic development. With coalitions in 20 countries and members in more than 160 countries, WSSCC is funded by the Governments of Australia, Finland, the Netherlands, Sweden, Switzerland and the United Kingdom.

SHARE works in two regions with historically low levels of sanitation access: sub-Saharan Africa and South Asia. SHARE has four focus countries: India, Bangladesh, Malawi and Tanzania. Both of these are priority regions for WSSCC and the WSSCC Global Sanitation Fund operates in all four SHARE countries.

The SHARE India Research Group, including representatives from government and other national sector stakeholders, agreed a set of priority research questions around sanitation and hygiene in India. Taking account of other research initiatives, the Group prioritised research that would consider the multiple and cumulative effects of poor sanitation and hygiene on women across the duration of their lives. At the same time, WSSCC designed and delivered a menstrual hygiene laboratory as part of the Nirmal Bharat Yatra between September and November 2012 in India in order to identify key areas for research.

Together, four priority questions for this topic were deemed to be of importance in India and to have the potential to improve policy and practice if researched:

1. The conditions and effects of WASH in health facilities, particularly around childbirth

2. Operational research into menstrual hygiene management Psycho-social stress linked to ignorance, taboos, shame and silence around menstruation The link between menstrual hygiene and infections and/or other health related impacts Operational research on the design and unit costs for safe reuse and disposal options.

3. Psycho-social stress resulting from violence1 experienced by women in the course of using sanitation facilities or practicing open defecation.

4. The practice of limiting, postponing or reducing food and liquid intake to control the urge to urinate or defecate: the prevalence of this behaviour and related health risks.

RELEVENCE

The importance of sanitation and hygiene and the goals of the Total Sanitation Campaign as an essential feature of rural development have long been acknowledged in India in the National Rural Health Mission, the 12th five-year plan as well as previous five-year plans. In 2011, the former department in charge of water supply and sanitation was elevated to ministerial status as the Ministry of Drinking Water and Sanitation (MIDWS). Priorities of the MIDWS include the development of the required infrastructure for toilets in homes, schools and other institutions to fulfil acknowledged responsibilities of the government. On a regional scale, the priority of sanitation has been acknowledged for South Asia in the Colombo declaration of April of 2011. As of today, many goals are yet to be achieved in a country where the 2011 census reported more households with cell phones (59%) than toilets (47%). Although the Right of Children to Free and Compulsory Education Act 2009 requires all public and private schools to provide toilet facilities, many schools lack separate toilets for girls and findings of the Annual Status of Education Report for 2012 indicate half of all these toilets were locked or unusable in the relatively advanced state of Maharashtra. Research in rural Haryana in 2001 found it was not just a lack of material resources that explained why only 29% of the rural population had latrines or toilets in homes; motivation and behaviour were identified as barriers to sanitation. Research on gender differences showed that poor urban women in Bhopal more frequently lacked access to communal sanitation facilities than men.

Stress is likely to result from limited access to WASH facilities. Stress, e.g. the threat of violence and the fear of victimization, may in turn limit access even where facilities are available. Cultural values make women particularly vulnerable to limitations in WASH-related resources and further amplify stress arising from limited resources. The links between stress and WASH are not well-studied, however. WASH-related research topics are more likely to focus on engineering challenges, material needs (toilets and latrines), economic constraints and environmental issues than the impact of culture, gender and stress on community experience, priorities and behaviour. Accused of failing to adequately consider such issues, the Nirmal Gram Yojana sanitation programme has been criticized as insensitive to the impact of water scarcity and limited resources for maintenance. Furthermore, because surveys and interventions typically focus on residents, they tend to ignore the needs of migrant populations that may be large in certain areas, including rural Pune district.

Disregard for needed privacy of adolescent girls and unmet demand for menstruation hygiene remain barriers to their education. Although the need for better education about the normal experience of menstruation has been documented in poor urban and rural areas, the combined impact of limited knowledge and limited facilities pose challenges that require study. In health facilities, pregnant women in rural antenatal clinics may be confronted by the indignity of testing urine for glucose and albumin without access to a toilet, and unimproved sanitary conditions might be health hazards and reduce the appeal of health facilities, e.g. for institutional births.

Research is also needed to clarify the relative influence and interrelationship of stress, resources and motivation with regard to WASH, and ways of coping with such stress and resource limitations. Coping strategies to deal with inadequate WASH facilities may also lead women to cope in ways that result in unintentional self-harm, e.g., by restricting intake of food and fluids.

This study focused on the perceived adequacy of WASH-related resources, stress from inadequate resources and access, and the experience, practice and materials for menstrual hygiene. We aimed to identify and guide a response to specific needs while recognizing the enhanced burden on women arising from gender-based cultural values concerning modesty, reluctance to acknowledge bodily functions, and culturally based ideas of cleanliness, purity and pollution. This study identified local priorities and needs, and it provided essential information to guide development that is sensitive to WASH-related priorities for women in rural Pune district and comparable areas of rural India.

Sample survey data

Individual