KathleenO’Reilly,RobertDreibelbis,SeemaKulkarni,SnehaBhat,PoulomyChakraborty,EliseGrover

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TableofContentsBackground............................................................................................................................................4

Aim............................................................................................................................................................4

RuralUttarPradesh............................................................................................................................5Studydesign................................................................................................................................................5

SiteSelection............................................................................................................................................5

Phase1:QualitativePhase................................................................................................................6Methods......................................................................................................................................................6

VillageSelection.......................................................................................................................................6Selectionofparticipants..........................................................................................................................7Datacollection.........................................................................................................................................7Dataanalysis...........................................................................................................................................8

QualitativeResults..............................................................................................................................8SanitationAccess.........................................................................................................................................8Practicesofopendefecation.......................................................................................................................9Sanitation-RelatedPsychosocialStress.....................................................................................................10BehaviouralModification..........................................................................................................................11Menstrualhygiene.....................................................................................................................................13Limitations.................................................................................................................................................13

Phase2:QuantitativeSurvey.........................................................................................................14Methods....................................................................................................................................................14

Sampling,samplesize,andrecruitment................................................................................................14SurveyInstrument..................................................................................................................................14Analysis..................................................................................................................................................15

QuantitativeResults..........................................................................................................................15Demographics............................................................................................................................................15

Table1:Householddata........................................................................................................................16Table2:Socio-demographics.................................................................................................................17

SanitationAccessandPractices.................................................................................................................18Table3:Toiletfacilityaccessandpractices...........................................................................................18

Sanitation-RelatedPsychosocialStress.....................................................................................................18Table4:Summaryscoreall25items.....................................................................................................19Figure1:DistributionofWASHscalescoresamongallwomen............................................................19Table5:Environmentalfactors,scaleitems..........................................................................................20Table6:Physicalsummaryscore(8items)............................................................................................20Table7:Socialfactorscaleitems...........................................................................................................21Table8:Socialsummaryscore(10items)..............................................................................................21Table9:Sexual-violencescaleitems......................................................................................................22

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Table10:Sexual-violencesummaryscore(7items)..............................................................................22Table11:Bivariateassociationsbetweensocio-demographicvariablesand25-itemSRPSscale.........24Figure2:S25-itemSRPSscalebylifestages..........................................................................................27

BehaviouralModificationIndex.................................................................................................................27Limitations.................................................................................................................................................28

Discussion.............................................................................................................................................28

Conclusions..........................................................................................................................................30

PolicyRecommendations................................................................................................................31

References............................................................................................................................................32

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BackgroundIn2013,WSSCCandSHAREsupportedfourstudiesaimedatexpandingtheevidenceforhowwomenandgirlsinIndiaareaffectedbypooraccesstowater,sanitationandhygiene(WASH).Womenandgirls,whoareoftenthemostimpactedbythelackofaccesstoadequatesanitation,donotoftenparticipateinsanitationanddevelopmentplanning.Thefindingsfromthesefourresearchprojectswerefocusedonsanitationpracticesandthepsychosocialimpactsoflimitedservicesonwomeninspecificgeographic/culturalcontexts.Findingsincluded:aconceptualframeworkforSRPS(sanitation-relatedpsychosocialstress(Hullandetal.2015));thedynamicnatureofsanitationrelatedbehavioursandstressorsforwomen(Hullandetal.2015);women'sexperiencesandresponsestosanitationrelatedviolence;andaself-reportedscaleformeasuringsanitation-relatedpsychosocialstress(Chase,R.P.etal.2015).

Poorsanitationaccessandpoorsanitationconditionscaninfluencewomen’sphysiologicalandmentalhealth(Kulkarni,O’Reilly,andBhat2015;Hirveetal.2015).Womenfeelashamedtobeseengoingtodefecateortochangesanitaryabsorbentsinpublic.Additionally,women'sstressduetopoorsanitationconditionsalsovariesbasedontheirstageinthelifecourse(Sahooetal.2015).Levelsofstressalsofluctuatewhenthereisaneedtogooutduringcertaintimesofthedayorincertainseasons.InresponsetotheshameandfearassociatedwithOD(opendefecation),womenrestricttheirmovementsanddisciplinetheirbodiessothattheneedtodefecatedoesnotcomeatinconvenientorunacceptabletimes.

Recentstudiesshowarelationshipbetweenunsafesanitationandviolenceagainstwomen.Theseincludesexualviolence,assaults,harassmentandageneralfeelingofinsecuritywhilecommutingtoandfromthedefecationsites,orwhileaccessinglatrinesneartheirhomesafterdark(Sommeretal.2014;AmnestyInternational2010;WinterandBarchi2016).Womenandgirls'stresslevelsvaryacrossage,occupation,caste,andanumberofothercross-cuttingandintersectingsocio-demographiccharacteristics.

AimTheaimofthisstudywastounderstandruralwomenandgirls'age-specificexperiencesofusingandaccessingsanitation.Thestudyfocussedontheaccessibilityoflatrinesandtheconditionsofsanitationexperiencedacrossage,religion,caste,etc.Thestudyobjectiveswereinformedbyresearchindicatingthatwomenandgirlshaveuniqueneeds,andthattheseneedsvarybetweenurbanandruralenvironments(Sahooetal.2015;Simiyu2015;O’Reilly2015).Specifically,wewereinterestedinassessingthegender,caste,andage-specificexperiencesofSRPSthatruralwomenandgirlsexperience,andtosuggestwaysthatSDGindicatorsandguidelinesforSwachhBharatMission—Rural(SBM)inIndiamightbeadjustedtobemoresensitivetotheuniqueneedsandstressesofruralwomenandgirlswithoutaccesstosanitation.

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RuralUttarPradesh

StudydesignThisstudyusedatriangulationdesigninwhichtwodatasets,onequalitativeandonequantitative,werecollectedindependently,interpretedindependentlyandthensynthesised.OurmethodwasinformedbyrecentresearchonSRPSthatreliedheavilyonquantitativeorqualitativemethods(Sahooetal.2015;Hullandetal.2015).Wechoseatwo-phase,triangulationdesignthatcouldcapturebothwomenandgirls'experiencesinnarrativeformatandprovidestatisticalmeasuresofwomenandgirls'SRPS.

Inthefirst,qualitativephase,weusedgroupdiscussionstoexploreSRPSanditscausesinlightoftheuniquesocialandgeographiccontextsoftheproposedstudyarea.Thefindingsofthequalitativeresearchwereusedtoinformthesecond,quantitativephaseoftheresearch—asurveyofwomenandgirls'experiencesofSRPS.Thisquantitativephaseusedpre-existingmeasuresthatwereadaptedandmodifiedtoreflectcontext-specificfindingsfromthequalitativephase.Thesecontext-specificfindingswereincorporatedintheperiodafterthequalitativedatawascollectedandthequantitativedatahadyettobegin.Thesefindingsincludedknowledgeofsocialnormsandlocalconditionsincluding:castetensions;watersourcesavailableforhygiene;lackofpitemptyingservices;landlessnessoflowestcastes;agenerallackoftoiletsorunusabletoiletsintheareadespiteinterventions;andtheuseoflatrinestructuresforbathing,ifavailable.Theseelementsformthelargercontextof:patternsandvariationsofsanitationuse;behaviouralregulationpractices;andkeysourcesofsanitation-relatedstress.

Wepresentthemethodsandresultsofbothphasesseparatelywithacombineddiscussion.

SiteSelectionUttarPradesh,India:UttarPradesh(UP)haslowcoverageratesoflatrines(lessthan36%)andslowannualgrowthoflatrinecoverage(lessthan1.5%(BonuandKim2009)).ThemostcommontypeoflatrineforUPruralhouseholdsarepourflushpitlatrines(GovernmentofIndia2011).Morethan77%oftheruralpopulationpracticesopendefecation(OfficeoftheRegistrarGeneralandCensusCommissioner,India,2012).RuralareasinUParecharacterisedbycommunalsegregationbasedoncaste.Amenities:ThestudyvillageswerelocatedintheinteriorpartsofJaunpurdistrict.Thoughtherewereproperroadsconnectingthevillages,publictransportwasnotavailable.Electricitywassporadic.Womenreportedthattheyreceivedonlyafewhoursofelectricitydaily.ThoughallthevillageshadAnganwadis(kindergarten)andprimaryschools,fewhadsecondaryschoolsandchildrenhadtogotosecondaryschoolsinnearbyvillages.

Noneofthevillageshadaccesstohealthcareservicesinsidethevillage,meaningthattherewasnoAuxilliaryNurseMidwife/FemaleHealthWorkerorMaleHealthWorkerinthesevillages.TwoofourstudyvillageshadASHA(AccreditedSocialHealthActivist)workers;ASHA'saretaskedwithpromoting

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healthmessagesandconnectingvillagerstohealthservicesoutsidethevillage.Thenearestprimaryhealthcentretoanystudyvillagewas5-6kilometresawaywithnopublictransportaccess.

Therewerenoreportedpipedwaterschemes.Inthreeofthestudyvillages,peopleusedpublichandpumps,reportedasinsufficienttomeetdailyhouseholdrequirements.Intheothervillages,householdshadinvestedininstallingtheirownhandpumps.

Communitiesandoccupation:Familiesintheregiontypicallyhaveeithersmalllandholdingsorwerelandless.Peoplecultivatedfoodgrainsmostlyfortheirownconsumption,andalsoworkedaslabourers.Thethreemostcommoncastesinthestudysiteswere:1.Chamars(leatherworkers),whobelongtotheDalitcaste(officiallyaScheduledCaste),consideredtobetheoppressedandmostexploitedsectionswithinthecastehierarchy;2.BenBansiwhoaretraditionallyabasketweavingcommunity,andpracticedbasketmakingandagricultureinthestudyvillages;and3.Yadavs(officiallyanOtherBackwardClass),whoarehigherthanDalits.Theyoftenholddominantpositionsinsocial,religiousandpoliticalmattersinsociety.Overall,theYadavcommunitieswerebetter-offthantheDalit(ex-untouchable,includingChamarcaste)communities.

Phase1:QualitativePhase

Methods

VillageSelectionPart1:Part1,alsocalledthe‘preliminaryphase’wasconductedinSeptember2015inJaunpurdistrict.DatacollectionforthisphasewasdoneinpartnershipwithaUP-basedorganisationcalledDynamicActionGroup(DAG),whichhasbeenworkingintheareasince1999.Shahganjsub-districtinJaunpurDistrictwaspurposefullyselectedforthestudyduetothelong-termpresenceofDAGthere.ThreestudyvillageswereselectedbasedonsanitationcoveragereportsoftheCensusofIndia,2011.

Thestudyvillagesofpart1characterisedofthreekinds:

Village1:WherelatrineswereconstructedunderanationalhousingschemeforDalits

Village2:Wherenosanitationwasreported

Village3:Wheretotalsanitationwasreported

Part2:FollowingPart1,fouradditionalvillagesandVillage3fromPart1wereselectedfordatacollectioninneighbouringareasofJaunpurdistrict.Implementationofasanitationschemeinthevillageswasthemaincriterionforvillageselection,althoughwewereawarethatasanitationinterventiondidnotnecessarilymeanallhouseholdswouldhavelatrines.TheGOICensus2011wasusedtoselectfourvillagesfromtwoblockswheretheTotalSanitationCampaignhadbeenimplementedinJaunpurdistrict.Village3wasselectedforPart2ofthestudytofollowuponthesemi-structuredinterviewsofPart1withgroupdiscussions.

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SelectionofparticipantsIneachstudyvillage,womenwereinvitedtoparticipateinGroupDiscussion(GDs)aboutsanitationexperiencesandsanitation-relatedstress.Insomevillages,GDswerecomplimentedwithsemi-structuredinterviewswithspecificrespondents.ParticipantselectionvariedinPart1andPart2.

Part1:AtotaloftwolargeGDsandonesemi-structuredinterviewwereconductedinthreevillages.Villageselectionwasbasedonadetailedday-longmeetingwithDAG,tounderstandtheirworkrelatedtosanitationinthedistrict.TheparticipantswerewomeninvolvedinDAG'sactivitiesintheirvillages.Inall,40adultwomenandfive14andabovegirlsparticipated.AllwerefromtheDalitcommunity.

Part2:AtotalofsixGDsand3semi-structuredinterviewswereconductedwithparticipantsfromhouseholdswithandwithoutlatrines.GDswereheldinanopenspaceineachcaste-basedneighbourhoodofthestudyvillages,i.e.,ineachvillageaGDwasheldforwomenofmajoritycastegroups.Adolescentgirlsage14andabove,andwomenacrossallagegroupsself-selectedforGDs.Inall,36women/12girlsfromtheDalitcaste,and13women/3girlsfromtheBenBansicommunityparticipatedinGDs.AmajorityoftherespondentsbelongedtotheChamarcaste(themajoritycastegroupinthestudyarea)

Threesemi-structuredinterviewswereconductedwithafewhouseholdsthathadlatrinesand/orwereinminoritycommunitiesofthevillage.Thesehouseholdswerepurposefullyselectedduringtheresearchers'walkthroughthevillageneighbourhoods.Theyincluded3women/2girlsintheYadavcommunityand2womeninaMuslimhousehold.

Publicgroupdiscussionsinarural,Indiansettingareusuallyboisterousandbystanderscomeandgo,dependingonobligationsandinterest.Forthisreason,allwomenandgirlspresentwereconsented,butnotallspoke.Womenandgirlsparticipatingwerenotindividuallyaskedabouttheirhouseholdsanitationconditions,age,andcaste.AsGDshappenedincaste-basedneighbourhoods,castewasknown.Age-groupwasdeterminedbythefieldteam,andsanitationconditionsfortheneighbourhoodweregenerallythesameforallwomenpresent.Additionalindividualinformationwasvoluntary.Asthepurposeofthequalitativeresearchwastocapturewomenandgirls'experiencesintheirownwords,andquantitativedatacollectionwouldcapturesocio-demographicsindetail,itwaspre-determinedthatGDswouldfollowtheformatandflowtypicalofgroupdiscussionsinthisarea,therebyenablingtopicsimportanttowomenandgirlsemergeorganicallyandconversationally.

DatacollectionEachGDlastedforanaverageof40minutes.TheGDsandsemi-structuredinterviewsweremoderatedandconductedbyfieldworkersfromDAG(part1)andtheresearchteam(part1and2)inthelocaldialectandinHindi.Oralinformedconsentwasobtainedfromtheparticipants.

Theresearchersaskedwomenandgirlsabouthouseholdsanitationconditions,theirsanitationhabits,iftheyusedlatrines,andthereasonsbehindconstructinglatrinesintheirhouses.Theywerealsoaskedaboutthesanitationschemesinwhichtheyparticipatedforgettingalatrineconstructedintheirhouse.

Anote-takertookwrittennotesofallthedatacollectionevents.Recordedfieldnotesindicatedifagirl(14-18years),olderwoman(45+years),orpregnantwomanwasspeaking.Womenintheirmiddleyearswerenotnotedassuch,astheyformedthemajorityofrespondents.(Newlymarriedwomendidnot

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participateinGDsduetoculturalnorms.)DatafromthewrittennotesweretranscribedandtranslatedintoEnglishbytheresearchteamfordataanalysis.CodesweredevelopedthroughaniterativeprocessandMAXQDAsoftwarewasusedtocodetranslateddatasets.

DataanalysisThetranslateddatawassummarisedbasedonthethemesandobjectivesofthestudy.Amixedapproachofdeductiveandinductive(line-by-line)codingwasusedforgeneratingthemes,codes,andsub-codesofthedatasummaries.Detailedcodememoswerewrittenforeachcodeandsub-code.Thecodesandcodememosweremutuallyagreeduponandvalidatedbythestudyteam.Thesecodeswerethenusedtocodetextsegmentsfromthesummariesofthedata.TheprocessofcodingandgenerationoftextsegmentswasdoneusingqualitativedataanalysissoftwareMAXQDA12.ThecodedsegmentswerefurtheranalysedalongthemesandSRPS,theresultsofwhicharebelow.

QualitativeResultsThefollowingsectionsdescribethevariouselementsofpsychosocialstressandthevariousmitigationstrategiesthatwomenundertaketodealwiththeirPSSonadailybasis.

SanitationAccessWiththeexceptionofVillage1inPart1,allstudyvillageshadhadasanitationintervention.Village2(Part1)householdshadgottensupportforbuildinghousesandlatrinesthroughthenationalschemeforpoorfamilies,IndiraAwasYojna.Womenherereportedthattheamountwasinsufficienttobuildahouseandalatrine,soonlylatrinewallswerebuilt.(Presenceoflatrinewallsmadeitpossibleforthestructuretobeapproved,andthefinaltranchetobepaidtothehousehold.)Village3(Part1)householdshadlatrineshastilybuiltthroughtheCleanIndiaPrize(NirmalGramPuraskar).VillagesvisitedinPart2allhadgovernmentlatrine-buildinginterventions,butnearlyallwerenon-functioning.

Faultyconstruction,suchasshallowpits,collapsedwalls,androofsdamagedbythemonsoonswerecommoncharacteristicsofmostofthelatrinespresentinallthecommunities.Otherwomenshowedustheirgovernment-subsidisedunitsthathadneverbeencompleted.Lackofusageoflatrineswereindicativeofthepoorconstructionorinconvenientinfrastructure(e.g.,absenceofadoor).Insomecaseswomenusedthelatrinesforpostdefecationcleaningorbathingbyerectingacurtaininlieuofadoor.Somehouseholdsusedthemasstoragespaces,andothersabandonedthelatrines.

Occasionally,latrineswerebuiltalongthemainroadtraversingthevillage,withdoorsfacingtheroad.Womenexpectedtousetheseunitswerevocalaboutneverusingaunitthataffordednoprivacywhencomingorgoingtouseit.Thesewomenreportedthattheywerenotincludedinthelatrineconstructiondecision-makingprocess.

Amongallthewomenwhoparticipatedinthedatacollectionprocesses,only5-6womenreportedcurrentlyhavingafunctioninglatrineathome.(InoneGD,womentoldusthatotherhouseholdsintheircommunityhadlatrines,butthewomenofthesehouseholdsdidnotparticipateintheGDforunknownreasons.)Themotivationsmentionedforbuildinglatrinesweresomeonebeingillorincapacitatedinthefamily,orforuseforyoungdaughters/daughter-in-laws.“Therearenoproperroads,sohowcanour

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daughters-in-lawgothroughthevillageforOD?,”anolderMuslimwomantoldus.Herfamilybuiltalatrinebecausetheirdaughtersin-lawhadtopassthroughneighbours'propertytogooutforOD.Anotherwomanwhousedahouseholdlatrinewasdisabled.

Womenoftensaidthatthelatrineswerejustbuilt‘forshow’,tofulfiltherequirementsofthescheme.Inoneofthevillageswomensaidthatsomegoodlatrineswerebuiltonlyneartheentranceofthevillagetodemonstratetheimplementationoftheschemetovisitors.Awomaninanothervillagesaidthateventhoughtheyalreadyhadalatrineoftheirown,thevillageheadman(Pradhan)insistedandbuiltanotheroneintheircourtyard,becauseitwastherequirementofthescheme.Bycontrast,agroupofDalitwomentoldusthat,“ThePradhanbelongstoanuppercaste,andhasnotprovidedanyamenitiestothisvillage.”Womeninourstudywhoreportedbuildingalatrineweretypicallyfromwealthierhouseholdsthanothers.Onlytwowomenwithlatrinesmentionedreceivingfinancialassistancefromthevillagescalegovernment.

Nostudyvillageshadpubliclatrines.InoneoftheGDs,publiclatrinesweresuggestedbyayoungwomanasapossiblesolution,giventhelackoffinancialcapacitytobuildprivatelatrines.However,olderwomencountered,sayingthatpubliclatrineswillnotworkduetomanyreasonssuchas:maintainingcleanliness,conflictsoverit,timespentinline,findingspaceforpubliclatrines,etc.Therewaslittleenthusiasmforpubliclatrinesinthecommunity.

Sanitationaccesswasalsopooratlocalschools.Thegirlsfromallthevillages,exceptone,reportedthattheschoollatrineswere"toodirty"touse.InoneGD,thegirlsalsosaidthatthelatrinewasusedbythemaleteachers,andnevercleaned.InanotherGD,theysaidthatneithertheteachersnorthestudentshadusedthelatrineforalongtime,becauseithadnotbeenmaintained.Girlsalsoexpressedthattheywereembarrassedtouselatrinesinthepresenceofboys,sotheywenttonearbyfieldsinstead.College-goinggirlssaidthatthelatrinesincollegewereinbettercondition,andthattheyusedthem.

PracticesofopendefecationLocation:WomenwithoutlatrinesathomemostlyusedemptyfieldsforODoncethecropswerecut.Sincetheycannotusefieldsduringtheagricultureseasontheygotocommonvillagelandswherethereissomecover,orsimplyusethesidesoftheroads.Womeninoneofthevillagesreportedusingthelandinthecemetery.Onewomantoldus,“Thereisfilthineverydirection.”Inmostofvillages,menandwomenuseddifferentplaces.However,wheremenandwomenusedthesameplaces,womenhadtogoveryearlyinthemorningtoavoidencounteringmen.

Seasonality:WomenhadtoadjusttheirplacesforODdependingonchangingseasons.Navigatingwaterandmudduringthemonsoonseason,needingtogooutattimesofheavyrain,andfloodingwerealldescribedasunpleasantandunavoidable.OneDalitwomanreportedthatsheslippedandfellinanunseenpothole.InoneofthevillageswomenshowedtheteambigumbrellasthattheyweregivenbythelocalgovernmenttouseforODduringthemonsoonrains.Time:Mostwomensaidthattheywenttwiceaday,morningandevening.Sincetherewerepeoplearoundduringtheday,andfindingacoveredplacewasdifficult,theyavoidedgoingduringthedaytime

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unlessitwasanemergency.Thetimetogointhemorningdifferedamongwomen,withnoclearpatternofageorcaste.Somewomensaidthattheywentbeforedaybreaktoavoidbeingseen,andtofindaplaceeasily,“Ifwegetupearlythenthereisnotroublefindingaplace”.Otherssaidthattheydidnotwanttogowhenitwasdark,becausetheywerenotabletoseeinsectsoranimals.

Physiologicalhealth:InformationonphysiologicalhealthwasnotsolicitedduringGDs,butwasbroughtupbywomenaspartofthediscussion.InthefirsttwoGDsconductedduringPart1,womensteeredthediscussionbytalkingabouthowODimpactstheirphysicalhealth.Theymentionedtheirriskofurogenitaldiseasesfromgoingtodefecateintheopenspaces.InPart2,womenmentioneddifficultiesduringmenstruationandpregnancy.

Sanitation-RelatedPsychosocialStressNotallwomenexpressedfeelingsofstress,inconvenience,ordiscomfortwithODpractices.Anelderlywomanmentionedthatsheenjoyedgoingoutbecause“Achihavaaatihain”(Iliketofeelthefreshair).WhileanotherfromtheBenBansicommunitysaid,“ForgenerationswehavegoneoutforOD”.Forsomewomennothavingaccesstoalatrinewasstatedas,"ODisjustfine”.OtherwomendidnotrecountODasstressful,evenwhiletheywereunwell.Theyhadcreatedadoptivestrategiessuchas,“Youcanshitinapotandthrowitlater”.

InPart1ofdatacollection,inthepresenceofDAGfieldworkers,womenrespondentsdidvoiceincidencesofsexualviolence;itispossiblethatwomenfeltmorecomfortablespeakingtotheresearchteaminthepresenceofDAGmembersthattheytrusted.ItisalsopossiblethatDAGfieldworkerswouldknowifwomenwerenotforthcoming,sowomenweretruthful;anditispossiblethatresearcherbiasmayhaveinfluencedwomentosaywhatthefieldteamwantedtohear,basedonwhatwomenweretoldaboutthestudygoals.

InPart2,respondentsdidnotalwaysopenlyspeakaboutfearofbeingharassed,attacked,orembarrassed.Nordidwomenspeakdirectlytobeingstressedorexperiencingstressfulsituations.Astopicsofviolenceandharassmentaresensitive,andeventaboo,wedidnotexpectallwomentobeforthcomingontheseissues,butrather,toconveytheirknowledgeorexperiencesobliquely.Forexample,womenseldomreportedanywrongdoingperpetratedbysomeoneintheirownvillages;insteadtheseincidenceshappenedinotherplaces.Ourfindingsbelowusewomen'sdirectwordsoffearofharassment;embarrassment;andfearofattack,aswellasinterpretationsofthevariousresponsesgivenbywomenandgirlsthroughouttheGDs.

Fearofharassment:InmostGDs,womensaidthattheyhadnotexperiencedanyharassment/violencewhentheywentforOD,norhadtheyheardaboutsuchincidences.Inavillageofasinglecastegroup,womensaidthatsinceitisjustonecommunity,theydonotfearharassment.InotherGDs,thetypeofharassmentmentionedwasfieldownerschasingoffwomenseendefecatingintheirfields.Chamarwomenmentionedspecificallybeingharassedbyuppercastelandowners.Thistypeofharassmentis

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tiedbothtocaste,andtolandlessness,aswomenfromlandlessfamilies(whowereChamar)hadnowheretogoforODbutthelandsoftheirYadavneighbours.Embarrassment:Thewomenwere‘embarrassed’tobeseenbymen.Ifmenpassedthemby,theyhadtostandupandwaittilltheareawasclearagain.“Ifwedon’ttheywillsaywhatashamelesswomansheis!,”onewomansaidplainly.Womenwereblamedforbeingunashamedofbeingseenbymeniftheydidnotstandup,evenwhiledefecating.OnewomanfromtheYadavcommunitysaidthattheybuilttheirowntoilet,withsomefinancialhelpfromthelocalgovernment,becauseshehasyoungdaughters,"Ladkiyanbaharjatihain,tosharamaatihai,isliyebanvaliya"(Girlsgooutside,sotheyfeelshame.Forthisreason,webuiltalatrine).Moreover,mostofthewomenandgirlsdidnotcarrywaterforcleaningwhentheywentforOD.Theysaidtheywereembarrassedtocarryit.Theyperformedanalcleansingoncetheywerebackhome.ApartfromtheinconveniencecausedbycommutingtodistantODsites,womenalsoexpressedtheirembarrassmentintakingtheirguestsoutforOD,asoneofthemmentioned,“Ifyouhaveatoiletyouwon’thavetogofar;youwon’thavetotakeaguestout.”

FearofAttack:InoneoftheGDs,olderwomentalkedaboutfearofsnakes,scorpionsandotherinsectswhentheywentforOD.“Ifyougetbitbyakhide(centipede)thenthereisnocure”,saidoneChamarwoman.Womenconveyedfeelingsoffearfromanimalsandfrommaleattack.InonecasewherewomenwereusingthecemeteryforOD,theytalkedaboutbeingafraidofghosts.Womenalsospokeoffearasanelementofeverydaylifethattheyarehabituatedto.Younggirlsalsotalkedaboutfearofattack.Girlssaidthateventhoughnothinghashappenedyet,theywereafraidthatsomeonemightcomeandattackthemespeciallywhenitwasdark,andtherewerebushesaround.Girlswerealsoscaredofthieves,“Chorbadmashonsedarlagtahai.”(Weareafraidofthievesandbadbehavingmen/boys).InoneoftheGDswithaChamarcommunity,womensaidthattheyhadheardthatgirlsofneighbouringvillageswerekidnappedwhentheywentforOD,althoughthishadnothappenedintheirvillage.(Asmentionedabove,onewayofacceptablytalkingaboutactualviolencewastodiscusstheincidentashavingoccurredsomewhereelse.)"Somethingwillhappen”,expressedamotherfromoneoftheChamarcommunities.“Youcannottrustotherpeople”,mentionedanother,whileexpressingconcernfortheiryoungdaughtersanddaughters-in-law.Mothersworriedabouttheirdaughter’ssafety.

BehaviouralModificationThewomenadoptedseveralstrategiestomitigateSRPS.Theseweredailypractices,integratedintotheirnormaldailylives.Notallwomenspokeofthesehabitsorpracticesasintentionalwaystheymitigatedstress.Infact,the'normalization'ofbehaviouralmodificationwasmadeclearbythefrequent,buteasymanner,thatwomenandgirls'spokeoftheirbehavioursinresponsetoquestionsof"Whatareyourdailyhabit/practicesofdefecation(oropendefecation[iftheydidnothaveatoilet])?"Answersweregiveninmatter-of-factkindsofways.Evenwhenpressed,e.g.,"Isthatbehaviour/conditionaproblemforyou?",bothwomenandgirlsmoreoftenthannot,respondedthatitwasnot.Nevertheless,

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thespecificsthatwomenspokeaboutindicatedthattheymodifiedtheirbehaviourinresponsetoinadequatesanitation.

Opendefecationcompanions:RespondentsfromallGDgroupssaidthattheyounggirlsdonotgobythemselves.Theywereeitheraccompaniedbyolderwomenofthehouseholdortheywentingroups.Women’spreferencestogoforODaloneoringroupsvariedacrossallagegroups.SomewomenexpressedthattheycouldgotoODsitesalone,whileotherssaidtheyalwayswentingroups.Somesaidthattheycouldgoaloneinthemorning,butatnighttheypreferredtogoingroups.Unfortunatelywedidnotaskaboutthisbehaviourmoreclosely,asbothmorningandnightODtimesareinthedark,butwomenfeltthatthedangerordiscomfortweredifferentatnight.Wespeculatethatwomenwentingroupsatnightintheknowledge(andfear)thatmanymenwouldstillbeawake.AdjustthetimeforgoingforOD:WomenreportedthattheypreferredtogoforODwhentheywerenotseen,especiallybymen,butbyothersingeneral.Womenawokeearlyinordertoavoidthem.Itwasanormforthewomentomodifyandadjusttheirbody-cycletobehaviours,whichweresociallyacceptedas‘right’or‘wrong’.Thiswasbecauseinthesecommunities,womencouldnotallowthemselvestobeseenwhiledefecatingintheopen.Incaseofupsetstomach,womenreportedthattheyhadtogoduringtheday,despiteshame,"Weareseen,butwhatotheroptionisthere?".

OnlyinavillagecomprisingonlytheChamarcommunitydidwomenexpressthattheycouldgoatanytime,becausethey"wereallonefamily"(i.e.,asinglecastegroup).Itwasalsoonlyinthissamevillagethatanolderwomansaid,"Darneseekyaahoga,kapdementodhikarenge?"(Whatisfear,whenyoumightmess[shit]yourclothes?)Herresponsewasapracticalone,asshewasnotfearfulinherowncommunity.

Changeplaces/findalternateplaces:Dalitwomenthatwerechasedofffieldsofuppercastefarmersspokeofmovingtothefieldsofsomeotherfarmer.InDalithouseholdsthatwerelandless,womenhadtogotofieldsbelongingtouppercastefarmersorhuntforalternateplacestodefecate.Duringgrowingseasonswithsownfields,farmerswerevigilant."Theydonotallowandevenshoutatanyonewhoattemptstodefecateintheirfields",weweretold.

ItwasChamarwomenwhospokeofhavingtomakeachoicetowalklongdistancesbecausetheirownlandholdingsweretoosmallandtoonearthevillage,ortheyhadnolandatall.Thiscopingbehaviourwasaresponsetofearsofbeingchasedaway,ortherealthreatofviolenceiftheywerecaughtdefecatinginothersfields.Asonemiddleagedwomansaid,"Fightshappenifthey[women]goinsomeone'sfields."Onepregnantwomansaidthatshedoesn’tgototheODplaceotherwomenuse—itistoofar,butgoesinsteadtoanearbyplace.

Womenandgirlsalsotoldusthattheytriedtoreachplacesearlyenoughtofindaclean-ishspot,andthatsometimesitwassimplynecessarytosquatinadirtyplace.Forsomewomenwhowentearly,findingaclean-ishspotwaspartoftheirmotivation,e.g.,"Ifwegetupearly,thenthereisnotroublefindingaplace".

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Olderwomencontrolledyoungerwomen:Mostwomeninourdiscussionsspokeoflimitinggirls'mobilityandtimingforODsotheycouldaccompanythem(daughters-in-law,orpubescentgirls).Asonemothersaid,"Weareafraidforouryoungdaughters.Wedonotletthemgoalone."Motherswouldtelldaughterswhattodo,andwhentogo.Girlshadtoadjusttheirneedstothesedirectives,aswellastheavailabilityofotherwomentoaccompanythem.However,girlsspokeoftravelingtoODsitesinthecompanyoftheirfriends.Thewomeninasingle-castevillagespokeofthesecurity(forwomenandgirls)intheirvillage,becauseitwasonebigfamily.

MenstrualhygieneForgirlsinschoolswithtoiletstoodirtytobeused,neitherurination,defecation,norchangingofmenstrualclothswasthinkable.Girlswereembarrassedtouseatoiletthatwasalsousedbymen/boys,onegirltoldus,“Ladkonkekaransharmaatihai"(becauseofboys,Ifeelashamedtouseit).Althoughtellingtheteacherthattheyneedtoleaveschoolbecauseoftheirperiodistaboo,girlswillasktogohomebysayingthattheyhaveaheadacheorastomachache.Theyarenotalwaysgrantedleavefromschool,butgirlsindicatedthatmaleandfemaleteachersunderstoodthata'stomachache'meantshewashavingherperiod.

Duringmenstruationwomeneitherusedcottonclothsorsanitarynapkins/pads.Insomecasesyounggirlsusedpads,whilewomenusedcloth.Thehighcostofsanitarynapkinswasmentionedasareasontochooseclothovernapkins,inoneGDofDalitwomenandgirls.Onceusedtheclothwasdisposedof(i.e.,notwashedandreused)bythrowingitawayorburyingit.SomegirlspreferredpracticingMHMinsolitudeand/ordisposingofmenstrualclothsindistanthidingplaces.Afewspokeofgoingalonetothrowawaymenstrualcloths.

LimitationsWomenintheirmiddleagewerethemostvocalparticipantsinGDs,andmanywomenspokeatonce,soitwasoftenthatthemostassertivewomenwereheard.Wepurposelysingledoutwomenandgirlsoutsidethemiddle-agedcategorywhoindicatedthattheywishedtospeak,butcouldnotgetawordin.Nevertheless,thevoicesofolderwomenandgirlsareunder-representedinourdataduetothemethodofdatacollection.ItispossiblethatbecauseGDswereheldinpublic,womenandgirlswerereticent;however,informationlearnedinGDsdidnotvarywidelyfrominformationlearnedinSSIs.Also,thedataincludesonlywomenandgirlswhoself-selectedtoparticipateinthediscussions,butasinterviewsanddiscussionsdependonconsent,qualitativeresearchacceptsthispotentialbias.Triangulationofwomenandgirls'experiencesacrosstheGDsandSSIsgivesusconfidencethatwewereabletocapturethe'bigpicture'ofSRPSforourstudyarea.

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Phase2:QuantitativeSurvey

Methods

Sampling,samplesize,andrecruitmentSurveyswerecompletedin16villagesinthelargerstudyarea.Thisincluded5villageswhereGDdiscussionshadoccurred.Additionalvillageswererecruitedtoincreasethescopeofthesurvey.

Surveyinstrumentswithpre-codedresponsesweredevelopedandadministeredinasampleof303women.Becausethesurveywasexploratoryanddescriptive,standardsamplesizescalculationsforhypothesistestingwerenotused.Instead,asampleofapproximately300respondentswaspre-determinedasanappropriatebalancebetweenavailableresourcesandstatisticalprecision.

Thissamplewasdistributedproportionallyamongparticipatingvillagesaccordingtopopulationsizeasavailableinthe2011Indiancensusdata.Samplingintervalwithineachvillagewasdeterminedbydividingthetotalnumberofhouseholdsbythepopulation-adjustedsamplingtargetandproceedingtoeverykthhouseholdfromafixedstartingpoint.Toensurethattheentirevillagewassurveyedandspecificmarginalisedgroupswerenotexcluded,thefieldsupervisorestablishedmultiplestartingpointsthroughouteachcommunitybasedonclustersofhouseholds/habitations.

Ateachselectedhousehold,theenumeratorreadarecruitmentscriptandaskedtocompletearosterofallwomen14yearsorolderinthehouseholds.Fromthisroster,onewomanwasselectedatrandomforrecruitment,consented,andtheinterviewcompleted.

SurveyInstrumentSurveyinstrumentsreflectedkeypreliminaryfindingsfromthequalitativephase,including:variationinpatternsofsanitationuse,behaviouralregulationpractices,andkeysourcesofsanitation-relatedstress.Standarddemographicindicatorswerecollected,includingincome,lifestage,age,andhouseholdcomposition.Self-reporteduseofsanitationfacilitiesforavarietyofbehaviours–urination,defecation,menstrualhygienemanagement,bathing,etc.–werecollectedthroughthesurvey.Inaddition,avarietyofnovelmeasuresspecifictosanitationuseandsanitation-relatedstressandvulnerabilitieswereincludedinthesurveyinstrument.

Tocapturerespondentsexperiencesrelatedtosanitationaccess,asanitation-relatedpsychosocialstress(SRPS)anddistress,aseriesof25yes/noquestionswereincluded(Chase,R.P.etal.2015).Thesequestions,alsopilotedandvalidatedinOdisha,correspondtothreesub-scales:environmentalstressors,socialstressors,andgender-basedviolencestressors.Sub-scalesandthecompleteSRPSwereanalysedtogether.Forthescale,answerstoindividualquestionsaresummedforeachrespondent.Scorescanbegeneratedforeachsub-scale–EnvironmentalStressScore,SocialStressScore,andGender-basedViolenceStressScore–aswellasacompositeSanitation-RelatedPsychosocialStressScore(SRPS)reflectingthesumofeachsub-scale.HigherscoresareindicativeofhighermeasuredlevelsofSRPS.

Aseriesofquestionsconcerningexperienceswithdefecation,cleaningafterdefecation,bathing,andmenstrualcyclemanagementinthelast30dayswereaskedofrespondents,fromwhicha4-itembehaviouralmodificationindexwascreated.Theitemsincludedinthebehaviouralmodificationindex

15

wereif,inthelast30days,therespondenthad:1)withhelddefecationorurinationtotheextentthatitwasuncomfortableorhurt;2)takenlessfoodthanyouwantedinordertoavoidordelaydefecation;3)hadlesswaterthanyouwantedinordertoavoidordelayurinationand4)skippedwashingorbathingorbeenunabletowashtoyourownsatisfaction.Theindexwascreatedbysumming,givingasummaryscorerangingfrom0-4,with0indicatingtheleastbehaviouralmodificationand4themost.

AnalysisAnalysisofsurveyresultswascompletedinStatav13.1(CollegeStation,Texas,USA).Descriptivestatisticsofalldemographicvariablesandkeyoutcomes(SRPSscale,GeneralandExperientialScales,andbehaviouralmodificationscale)weredeveloped.Becauseallscalesutilisedinourstudywerebasedonbinaryvariables,scalescoresrepresentasimplesumofallresponsesfavourableofthetraitofinterest.Bivariateanalyses(analysesinwhichtherelationshipbetweentwovariablesarecomparedwithoutadjustingforothervariables)examiningtheassociationbetweenkeyoutcomes(SRPSscores,SRPSsub-scales,andbehaviouralmodificationindex)andselectedsocio-demographicandotherindicatorvariableswereconductedusingPoissonregression,withthescaleinquestionmodelledasthedependentvariableandoutcomespresentedasincidentrateratios.Waldtestswereusedtotestthesignificanceofcategoricalvariables.

QuantitativeResults

DemographicsAtotalof303householdswereincludedinthisstudywithonewoman14+interviewedfromeachhousehold.Agesrangedfrom14-75,withameanageof35.7years.Nearly80%(241/303)ofthewomenweremarriedand7%(20/303)werewidowed.Ofthosewhohadbeenmarried,themeannumberofchildrenwas3.38witharangeof0-9.Twowomenreportedbeingmarriedinthelastyearandsevenwerepregnantatthetimeoftheinterview.Morethanthree-quartersofthesamplewereHindu(237/303),15%(45/303)wereMuslimand7%(21/303)Buddhist.Overhalfofthewomeninterviewedreportedhavingnoformaleducation(178/303).Womencouldidentifyasmanyoccupationsastheywished.Themajorityofwomen-96%(291/303)-reportedthatbeingahousewifewasoneoftheiroccupations.Additionaloccupationsincluded:22%(67/303)reportedcultivators(self-employed–agriculture),9%(28/303)reportedagriculturallabourforsomeoneotherthanthemselves,13%(39/303)reportedotherdailywagelabouroutsidethehome,5%(15/303)students,4%(11/303)self-employed(ex.craftmaking),and1%(2/303)reported“Other”.18%(54/303)ofhouseholdreportedorhadaverifiedBPLcardatthetimeofdatacollection.SeeTables1&2forhouseholdandsocio-demographicdata.

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Table1:HouseholddataTotal#women14+inallhouseholds 760Total#households/womeninterviewed 303Percentofwomenfromeachcategoryselectedforinterview:14+,nevermarried14+,marriedlessthantwoyears14+,currentlypregnant14+,marriedmorethantwoyears;notpregnant45+,marriedorwidowedTotal:

%(N)21.43%(42/196)12.5%(2/16)30%(6/20)50.83%(183/360)41.67%(70/168)39.87%(303/760)

NumberofpeoplelivinginthehouseholdMean(SD)RangeOneormoremalesinthehousehold,under5yearsOneormoremalesinthehousehold,5–14yearsOneormoremalesinthehousehold,15–44yearsOneormoremalesinthehousehold,45+Oneormorefemalesinthehousehold,under5yearsOneormorefemalesinthehousehold,5–14yearsOneormorefemalesinthehousehold,15–44yearsOneormorefemalesinthehousehold,45+

7.62(3.88)1–35%(N)30.03%(91/303)60.07%(182/303)98.02%(297/303)45.54%(138/303)30.03%(91/303)53.79%(163/303)96.7%(293/303)51.81%(157/303)

Wholivesinthehousehold?OwnmotherMother-in-lawOwndaughterDaughter-in-lawSisterSister-in-law

%(N)14.19%(43/303)22.77%(69/303)57.09%(173/303)20.13%(61/303)8.58%(26/303)14.85%(45/303)

DoesthehouseholdhaveaBPLcard?NoYes

%(N)82.18%(249/303)17.82%(54/303)

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Table2:Socio-demographicsAgeMean(SD)Range14–2425–3435–4445+

35.75(12.77)14–7518.48%(56/303)26.73%(81/303)32.67%(99/303)22.11%(67/303)

MaritalstatusSingle,nevermarriedMarriedWidowedOfthosewhohavebeenmarried:Numberofchildren:Mean(SD)RangeMarriedinthelasttwoyears?Currentlypregnant?

13.86%(42/303)79.54%(241/303)6.6%(20/303)3.38(1.62)0–90.77%(2/261)2.68%(7/261)

Ageatfirstperiod:111213141516Don’tknow

0.66%(2/303)7.26%(22/303)19.14%(58/303)24.42%(74/303)16.83%(51/303)2.31%(7/303)29.37%(89/303)

ReligionHinduMuslimBuddhist

78.22%(237/303)14.85%(45/303)6.93%(21/303)

Caste/TribeGeneralScheduledcasteScheduledtribeOtherbackwardcaste

5.0%(15/303)48.18%(146/303)0.66%(2/303)46.2%(140/303)

HighesteducationcompletedNoformaleducationPrimary(1-5thyear)Secondary(6-10thyear)Completed+2yrsormore(12thyear–university)

58.75%(178/303)8.58%(26/303)17.16%(52/303)15.51%(47/303)

OccupationHousewifeonlyGeneratesincome(agriculture,self-employed,dailywagelabouretc.)StudentOther

47.85%(145/303)*47.19%(143/303)4.95%(15/303)0.66%(2/303)

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SanitationAccessandPracticesAquarterofwomen(77/303)respondedthattheyhadaccesstoatoiletfacilityiftheywantedit,allofwhichwereidentifiedaspour-flushlatrinesandallofwhichwerereportedtobelocatedinthehouseoryard.95%(73/77)ofthehouseholdswithalatrinereportedthattheydidn’tsharethetoiletfacilitywithanyotherhouseholds.Amongthosewithaccesstoafacility,77%(59/77)reportedusingthefacilityforurination,83%(64/77)reportedusingthefacilityfordefecation,35%(27/77)reportedusingthefacilityforbathing,31%(24/77)forchangingclothes,43%(33/77)reportedusingthefacilityformenstrualmanagementand3%(3/77)reportedusingthetoiletfacilityforstorage.Ofthosewithafacility,lessthanhalf(45%;35/77)reportedthattheyviewedthefacilityascompletelyconstructed.Opendefecationwasstillwidelypracticedamongrespondentswithaccesstoasanitationfacility.Ofthewomenreportingaccesstoatoiletfacility,79%(61/77)reportedgoingforopendefecationatsomepointinthepast7days.SeeTable3fordetailsontoiletfacilityaccessandpractices.

Table3:ToiletfacilityaccessandpracticesIsthereatoilettheycoulduseiftheywantedto? 25.41%(77/303)Reportedusingthetoiletfor:UrinationDefecationBathingChangingclothesMenstrualmanagementStorage

76.62%(59/77)83.12%(64/77)35.06%(27/77)31.17%(24/77)42.86%(33/77)3.9%(3/77)

Facilityislocatedinthehouseoryard 100%(77/77)Householdsotherthanownthatsharethefacility015

94.8%(73/77)2.6%(2/77)2.6%(2/77)

Thetoiletfacilityisfullyconstructed 45.45%(35/77)Defecatedintheopen(field,bush,roadside,sideofcanal,etc.)atleastonceinthepastsevendaysduringthefollowingtimes:MorningAfternoonEveningNightAnyofthesetimesinthepast7days

61.04%(47/77)11.69%(9/77)40.26%(31/77)23.38%(18/77)79.22%(61/77)

Sanitation-RelatedPsychosocialStressThemeanSRPSscorewas18.6(SD4.24)–womenrespondedintheaffirmativetoapproximately75%topre-identifiedstressorsexperiencedinthelast30daysrelatedtosanitationpracticesanduse.Althoughdirectcomparisonisdifficult,thesescoresaremuchhigherthanscoresfoundinpreviousstudieswheremeanvaluesonthesame25-itemscalewerebetween6and10.Themajorityofwomen-93%

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(281/303)answered“yes”tooverhalf(≥13items)ofthesurveyitems.Table4andFigure1summarisethe25itemscale.

Table4:Summaryscoreall25itemsMean(SD)RangeTabulationofsurveyitemsanswered“Yes”0-56-1011-1516-2021-25Answered“Yes”to≥13items

18.59(4.24)0–25%(N)2.97%(9/303)2.31%(7/303)9.90%(30/303)51.49%(156/303)33.33%(101/303)92.74%(281/303)

Figure1:DistributionofWASHscalescoresamongallwomen

TheSRPSscaleconsistedofthreeseparatesub-scales–environmentalstressors,socialstressors,andgender-basedviolencestressors.Tables5-10givedetailsoftheenvironmental,socialandgender-basedviolencescaleitemsusedinthe25itemscale.Wepresentdetailsofthesesub-scalesbelowaswellasdetailsontheindividualsub-scales.

Figure 1: Distribution of WASH scale scores among all women

05

1015

20P

erce

nt

0 5 10 15 20 25Score on 25-item scale about WASH practices among all women

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EnvironmentalStressors:TheEnvironmentalStressorsScoreweremeasureswith8itemsthatcharacterisedstressorsrelatedtotheirphysicalandbuiltenvironmentsuchascontactwithanimals,dirtywaterormud,with0indicatingthelowestdegreeofenvironmentalstressorsand8thehighest.EnvironmentalStressorsScoresrangedfrom0-8,withameanof6.58(SD1.3),with95%(287/303)ofwomenanswering“yes”to≥50%ofthe8items.Amongwomenthatreportedaccesstoatoiletfacility,EnvironmentalStressorsScoreswereonaverage9%lower(IRR0.91CI0.83–1.00,p=0.048).Accesstoasanitationfacilitywastheonlyvariablethathadasignificantassociationatthep<0.05level.SeeTables5and6fordetailsontheenvironmentalsubscale.

Table5:Environmentalfactors,scaleitemsHavebeenscaredtheywillgetsickfromrainordirtywaterwhengoingfordefecationorbathing

95.38%(289/303)

Havebeenstressedbythedistancetheyhavetogotofindaspottodefecate 85.48%(259/303)Havebeenirritatedbybugsinsectsorflieswhengoingtodefecateorbathe 95.38%(289/303)Havebeenworried/stressedtheywillgetsickorcatchaninfectionfromtheplacewheretheygofordefecation?

91.69%(276/301)*

Havefearedgoingfordefecationinthenighttimeorwhenitisdark 94.39%(286/303)Couldnotfindacleanspotfordefecationattheirpreferredplace? 52.98%(160/302)*Ithasbeentoowetormuddytousethesitetheypreferfordefecation 76.16%(230/302)*Havebeenscaredofanimals,suchassnakesandscorpions,whengoingfordefecation

95.05%(288/303)

Table6:Physicalsummaryscore(8items)Mean(SD)RangeTabulationofsocialsurveyitemsanswered“Yes”012345678Answered“Yes”to≥50%

6.58(1.3)0–8%(N)0.33%(1/303)0.33%(1/303)0.99%(3/303)0.99%(3/303)2.64%(8/303)6.93%(21/303)15.51%(47/303)36.30%(110/303)35.97%(109/303)94.72%(287/303)

SocialStressors:TheSocialStressorsScorecomprised10itemsrelatedtosocialstress,suchasfeelingshameorembarrassmentbecausepeoplecanseethemduringdefecationorbathing,orbeingworriedthatbehavioursrelatedtodefecationcouldlowerfamilyorpersonalprestige.SocialStressorsScore

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rangedfrom0-10,withameanof8.34(SD2.15)and92%ofwomenansweringyesto≥50%ofthe10items.Reportingaccesstoatoiletfacility(IRR0.84CI0.77–0.92,p<0.001),reportingusingthetoiletfacilityforurination(IRR0.74CI0.61–0.89,p=0.001)andreportingusingthefacilityfordefecation(IRR0.74CI0.61–0.89,p=0.003)wereeachsignificantlyassociatedwithreportinglowerSocialStressorsScores.SeeTables7and8fordetailsonthesocialsubscale.

Table7:SocialfactorscaleitemsWorriedthatbehavioursrelatedtodefecationandbathingwilllowerfamily’sprestige 92.08%(279/303)Feltshamebecausepeoplecanseetheirdefecation 91.09%(276/303)Feltashamedbecauseotherpeopleseethemchangepads/clothsduringmenstruation 63.7%(193/303)FeltangerorstressbecausetheywerenotallowedtogotodefecateorbatheWHEREtheywanted

91.75%(278/303)

Feltembarrassedbecausepeoplecanseethemwhenbathing 90.1%(273/303)Beenscoldedfordefecatingorcleaningafterdefecationataplacewheretheywerenotallowed

78.88%(239/303)

Feltstressabouthowdefecationandbathingpracticeswillinfluencetheirpersonalreputation

89.44%(271/303)

Worriedaboutthelackofprivacywheretheygofordefecationorbathing 91.09%(276/303)Ithasbeendifficulttofindsomeonetoaccompanythemwhengoingfordefecation 72.28%(219/303)Feltstressaboutthetimetheyhavetowaittousetheirpreferredspotfordefecation 73.6%(223/303)

Table8:Socialsummaryscore(10items)Mean(SD)RangeTabulationofsocialsurveyitemsanswered“Yes”012345678910Answered“Yes”to≥50%

8.34(2.15)0–10%(N)2.31%(7/303)0.66%(2/303)0.99%(3/303)0.99%(3/303)0.66%(2/303)2.64%(8/303)4.95%(15/303)9.24%(28/303)16.17%(49/303)25.41%(77/303)35.97%(109/303)91.75%(278/303)

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Sexual-violenceStressors:TheSexualViolenceStressorsScorescorewasmadeupof7itemsindicatingexperiencesorthefearofharassmentorviolencewhengoingtodefecateorbath.SexualViolenceStressorsScoresrangedfrom0-7,withameanof3.41(SD1.5),with56%(170/303)womenansweringyesto≥50%ofthe7items.Reportingaccesstoatoiletfacility(IRR0.82CI0.72–0.95,p=0.006)andreportingusingthetoiletfacilityforurination(IRR0.73CI0.55–0.97,p=0.03)werebothsignificantlyassociatedwithlowerSexualViolenceStressorsScore.LifestageandagewerealsosignificantlyassociatedwithSexualViolenceStressorsScores,withthegeneraltrendbeingthatcurrentlymarriedwomenaged25-44significantlymorelikelytohavehigherscoresthanadolescentwomen14-24(IRR1.23CI1.02–1.49)whilewomen45+orwidowedlowerscoresthancomparedtoadolescentwomen14-24.SeeTables9and10fordetailsonthesexual-violencesubscale.

Table9:Sexual-violencescaleitemsHavebeenafraidofencounteringmenwhohavebeendrinkingalcoholwhengoingfordefecation

91.09%(276/303)

Havehadboysthrowrocksorstoneswhentheywenttodefecateorbathe 10.6%(32/302)*Havefearedtheycouldberapedwhengoingtodefecateorbathe 66.01%(200/303)Havebeenharassedbyboyswhengoingtodefecateorbathe 23.18%(70/302)*Fearedtheycouldbesexuallyassaultedwhengoingtodefecateorbathe 61.39%(186/303)Havehadboysormenrevealthemselvestothemwhiletheirtryingtodefecate,cleanpost-defecation,orbathe

3.63%(11/303)

Havebeenangrywithboys/menwhowatchedthemdefecate,cleanpost-defecation,orbathe

84.49%(256/303)

Table10:Sexual-violencesummaryscore(7items)Mean(SD)RangeTabulationofsexualsurveyitemsanswered“Yes”01234567Answered“Yes”to≥4items

3.41(1.5)0–7%(N)3.63%(11/303)6.27%(19/303)21.45%(65/303)12.54%(38/303)34.65%(105/303)14.85%(45/303)5.61%(17/303)0.99%(3/303)56.12%(170/303)

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CompositeSanitation-RelatedPsychosocialStressScores(CompositeSRPSScore):ForthecombinedSRPSscale,thereweresignificantbivariateassociatesbetweentheSRPSsummaryscoreandsocio-demographicvariables,lifestage,age,religion,reportingaccesstoatoiletfacilityandusingthetoiletfacilityforurination,defecationandbathing.Womenwhoreportedaccesstoatoiletfacility(93/303)hadsignificantlylowerCompositeSRPSScoresthanthosewhodidnotreportaccesstoatoiletfacility(IRR0.86,CI0.81–0.91,p<0.001).WomenwhodidhaveaccesstoatoiletfacilityandreportedusingthatfacilityforurinationordefecationweremorelikelytohaveaCompositeSRPSScorethanthosewhodidnotusethefacilityforurination(p<0.001)ordefecation(p=0.001).Conversely,reportingusingthetoiletfacilityforbathingwasassociatedwithahigherSRPSscorecomparedtothosewhodidnotusethefacilityforbathing(IRR1.14;CI1.02–1.27,p=0.025).

WomenwhowerecurrentlymarriedweremorelikelytohaveahigherCompositeSRPSScorecomparedtoadolescentnevermarriedwomen(IRR1.07CI0.99–1.16,p=0.093),whereaswidowedwomenandwomen25+hadgenerallylowerCompositeSRPSScorethanadolescent,nevermarriedwomen(IRR0.95CI0.86–1.04,p=0.250).Overall,thelifestagevariablewasfoundtobesignificantlyassociatedwithCompositeSRPSScoreatp<0.001whenusingaWald-test.ReligionwasassociatedwiththeSRPSsummaryscoreusingaWaldtest(p=0.043),withMuslimwomenbeingmorelikelytoreportalowerscorethanHinduwomen(IRR0.92CI0.85–0.99,p=0.028),andBuddhistwomenmorelikelytoreportahigherscorethanHinduwomen(IRR1.05CI0.95–1.16,p=0.332).Table11showsthebivariateassociations.Figure2showsthe25-itemscalebylifestages.

Table11:Bivariateassociationsbetweensocio-demographicvariablesand25-itemSRPSscaleSocio-demographics

%(N) Environmental Social Sexualviolence SRPS p-value

Householdreportedaccesstoatoiletfacility 30.69%(93/303) 0.91(0.83–1.00)p=0.048*

0.84(0.77–0.92)p<0.001*

0.82(0.72–0.95)p=0.006*

0.86(0.81–091) <0.001*

Reportsusingtheirtoiletfacility(ofthosewhohadone,N=77)for:UrinationDefecationBathingChangingclothesMenstrualmanagementStorage

76.62%(59/77)83.12%(64/77)35.06%(27/77)31.17%(24/77)42.86%(33/77)3.90%(3/77)

0.86(0.70-1.05)0.87(0.69–1.09)1.09(0.91–1.31)1.10(0.91–1.32)0.99(0.83–1.19)1.17(0.76–1.80)

0.74(0.61-0.89)*0.74(0.60-0.90)*1.17(0.99–1.39)1.13(0.95–1.35)0.84(0.71–1.00)1.35(0.93–1.97)

0.73(0.55-0.97)*0.78(0.56–1.07)1.15(0.88–1.50)1.13(0.86–1.49)0.84(0.65–1.10)0.90(0.44–1.82)

0.78(0.69–0.88)0.79(0.69–0.91)1.14(1.02–1.27)1.12(0.97–1.26)0.90(0.80–1.01)1.21(0.93–1.56)

<0.001*0.001*0.025*0.0570.0620.166

LifestageAdolescent(14-24),nevermarriedCurrentlymarriedwomenWidowedwomenandwomen45+

-13.86%(42/303)63.04%(191/303)23.1%(70/303)

p=0.284Ref1.07(0.94–1.21)0.99(0.85–1.15)

P=0.142Ref1.01 (0.90–1.13)0.92(0.80–1.05)

*p=0.001Ref1.23(1.02–1.49)*0.94(0.75–1.18)

-Ref1.07(0.99–1.16)0.95(0.86–1.04)

<0.001*-0.0930.250

Numberofpeoplelivinginhousehold(Cont.)Mean(SD):7.62(3.88)Range:1–35

---

1.00(0.99-1.01) 0.99(0.98-1.00) 1.00(0.98-1.02) 0.99(0.99–1.00)--

0.230--

MenandwomenlivinginthehouseholdAnymalesinthehousehold1+malesinthehousehold,under5years1+malesinthehousehold,5–14years1+malesinthehousehold,15–44years1+malesinthehousehold,45+Anyotherfemalesinthehousehold1+femalesinthehousehold,under5years1+femalesinthehousehold,5–14years1+femalesinthehousehold,15–44years1+femalesinthehousehold,45+

99.67%(302/303)30.03%(91/303)60.07%(182/303)98.02%(297/303)45.54%(138/303)100%(303.303)30.03%(91/303)53.79%(163/303)96.7%(293/303)51.81%(157/303)

1.37(0.57–3.30)1.02(0.92–1.12)1.00(0.92–1.10)1.03(0.75–1.41)1.00(0.92–1.09)-1.01(0.92–1.11)0.97(0.89–1.06)1.01(0.79–1.28)0.98(0.90–1.07)

1.04(0.52–2.08)0.98(0.90–1.06)1.00(0.93–1.09)0.89(0.68–1.16)0.97(0.90–1.05)-1.04(0.95–1.13)0.97(0.89–1.04)0.92(0.75–1.14)0.95(0.88–1.02)

0.85(0.32–2.27)1.05(0.92–1.20)1.04(0.92–1.18)1.02(0.66–1.59)0.94(0.83–1.07)-1.07(0.94–1.22)1.04(0.92–1.18)1.00(0.71–1.41)0.92(0.82–1.04)

1.09(0.68–1.76)1.00(0.95–1.06)1.01(0.96–1.07)0.96(0.80–1.15)0.98(0.93–1.03)-1.03(0.98–1.10)0.98(0.93–1.03)0.97(0.84–1.12)0.95(0.91–1.00)

0.7110.8660.7060.6710.363-0.2230.5070.6510.082

Age(Cont.)Mean(SD):35.75(12.77)Range:14–75Age(Categorical)14–2425–3435–4445+

----18.48%(56/303)26.73%(81/303)32.67%(99/303)22.11%(67/303)

1.0 (0.99–1.00)P=0.483Ref1.05(0.92–1.20)1.07(0.94–1.21)0.98(0.85–1.13)

1.0 (0.99–1.00)P=0.258Ref1.0 (0.89–1.13)1.01(0.91–1.13)0.91(0.81–1.03)

1.0 (0.99–1.00)P=0.016*Ref1.19(0.99–1.43)1.17(0.97–1.40)0.93(0.76–1.14)

0.998(0.996–1.000)--Ref1.05(0.97–1.14)1.06(0.98–1.14)0.94(0.86–1.02)

0.122--0.006*0.1920.1340.155

MaritalstatusSingle,nevermarried

-13.86%(42/303)

P=0.761ref

P=0.853Ref

P=0.049*Ref

-Ref

0.268-

25

Table11:Bivariateassociationsbetweensocio-demographicvariablesand25-itemSRPSscaleMarriedWidowedOfthosewhohavebeenmarried:Numberofchildren(Cont.):Mean(SD):3.38(1.62)Range:0–9WasmarriedinthelasttwoyearsIscurrentlypregnant

79.54%(241/303)6.6%(20/303)--0.77%(2/261)2.68%(7/261)

1.05(0.92–1.19)1.02(0.83–1.26)1.00(0.97–1.02)--1.02(0.60–1.72)0.85(0.62–1.15)

0.99(0.88–1.11)0.95(0.79–1.14)0.99(0.96–1.01)--1.08(0.68–1.72)0.75(0.56–1.01)

1.18(0.98–1.42)0.90(0.65–1.24)0.98(0.94–1.02)--1.30(0.67–2.51)0.90(0.59–1.38)

1.04(0.96–1.12)0.97(0.85–1.10)0.99(0.97–1.01)--1.10(0.81–1.49)0.81(0.67–0.98)

0.2900.6170.198--0.5510.035*

Ageatfirstperiod:111213141516Don’tknow

-0.66%(2/303)7.26%(22/303)19.14%(58/303)24.42%(74/303)16.83%(51/303)2.31%(7/303)29.37%(89/303)

P=0.833Ref0.89(0.53–1.49)0.83(0.50–1.37)0.82(0.50–1.35)0.86(0.52–1.42)0.89(0.51–1.57)0.89(0.54–1.46)

P=0.175Ref0.91(0.57–1.44)0.87(0.55–1.35)0.79(0.50–1.23)0.77(0.49–1.20)0.91(0.55–1.51)0.86(0.55–1.34)

P=0.772Ref0.82(0.39–1.70)0.87(0.43–1.76)0.78(0.38–1.58)0.88(0.43–1.79)1.00(0.46–2.19)0.87(0.43–1.76)

-Ref0.89(0.65–1.21)0.85(0.63–1.15)0.80(0.59–1.08)0.82(0.61–1.11)0.92(0.66–1.29)0.87(0.65–1.18)

0.119-0.4460.3060.1410.2030.6380.371

ReligionHinduMuslimBuddhist

-78.22%(237/303)14.85%(45/303)6.93%(21/303)

P=0.091Ref0.94(0.83–1.07)1.16(0.99–1.36)

P=0.077Ref0.88(0.79–0.99)*0.92(0.78–1.08)

P=0.387Ref0.96(0.80–1.14)1.15(0.92–1.45)

-Ref0.92(0.85–0.99)1.05(0.95–1.16)

0.043*-0.0280.332

Caste/TribeGeneralScheduledcasteScheduledtribeOtherbackwardcaste

-5.0%(15/303)48.18%(146/303)0.66%(2/303)46.2%(140/303)

P=0.938Ref1.02 (0.83–1.25)1.03 (0.59–1.03)0.99(0.81–1.22)

P=0.821Ref1.06(0.88–1.28)1.13(0.68–1.85)1.03(0.85–1.24)

P=0.970Ref1.04 (0.78–1.41)0.92(0.39–2.14)1.04(0.77–1.39)

-Ref1.04(0.92–1.18)1.05(0.75–1.48)1.02(0.90–1.15)

0.738-0.4940.7710.803

HighesteducationcompletedNoformaleducationPrimary(1-5thyear)Secondary(6-10thyear)Completed+2yrsormore(12thyear–university)

-58.75%(178/303)8.58%(26/303)17.16%(52/303)15.51%(47/303)

P=0.849Ref1.05 (0.90–1.22)0.97(0.86–1.10)1.02(0.91–1.16)

P=0.851Ref0.99(0.85–1.14)0.96(0.86–1.07)1.01(0.91–1.13)

P=0.630Ref1.10(0.8801.36)0.93(0.79–1.11)1.03(0.86–1.22)

-Ref1.03(0.94–1.13)0.96(0.89–1.03)1.02(0.95–1.09)

0.504-0.5550.2660.590

HouseholdhasaBPLcardNoYes

82.18%(249/303)17.82%(54/303)

Ref1.04(0.93–1.16)

Ref0.99(0.90–1.10)

Ref1.03(0.88–1.20)

Ref1.01 (0.95–1.09)

-0.603

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Table11:Bivariateassociationsbetweensocio-demographicvariablesand25-itemSRPSscaleOccupationHousewifeonlyGeneratesincome(agriculture,self-employed,dailywagelabouretc.)StudentOther

47.85%(145/303)47.19%(143/303)4.95%(15/303)0.66%(2/303)

0.97(0.89–1.06)1.04(0.96–1.14)0.94(0.77–1.15)1.17(0.71–1.91)

0.98(0.90–1.06)1.01(0.93–1.09)1.06 (0.89–1.26)1.20(0.77–1.86)

0.97(0.87–1.11)1.03(0.91–1.16)0.92(0.68-1.23)1.33(0.69–2.55)

0.98(0.93–1.03)1.02(0.97–1.08)0.99(0.88–1.12)1.21(0.90–1.62)

0.3770.3360.8580.199

*P-value<0.05

Figure2:S25-itemSRPSscalebylifestagesAdolescent(14-24),nevermarriedwomen(N=42)Currentlymarriedwomen(N=191)

Widowedwomenandwomen45+(N=68)

BehaviouralModificationIndexThebehaviouralmodificationindexwascreatedfromfoursurveyitemsinwhichwomenwereaskedwhetherornottheyhadfelttheneedtochangetheireating,drinkingorbathinghabitsinthepast30daysinordertoavoidordelaydefecation,urinationorsatisfactorybathing.Responsesweresummedintoanindex,resultinginavaluerangingfrom0-4,with0indicatingtheleastbehaviouralmodificationand4themost.Scoresrangedfrom0-4,withameanscoreof2.76(SD1.37).80%(242/303)ofallwomenansweredaffirmativelyto≥50%ofthequestions,while13%(40/303)answered“no”toallfourbehaviouralmodificationquestions.

Thebehaviouralmodificationindexwasfoundtobesignificantlyassociatedwithreportingaccesstoatoiletfacility(IRR0.85CI0.73–0.99,p=0.037),withwomenhavingatoiletfacilityscoring15%lower

Distribution of scale scores among adolescent (14-24), never married women

05

1015

2025

3035

4045

50P

erce

nt

5 10 15 20 25Score (0-25) on a 25-item scale about WASH practices

Distribution of scale scores among married women (N=191)

010

2030

Per

cent

0 5 10 15 20 25Score (0-25) on a 25-item scale about WASH practices

Distribution of scores among widowed women or women 45+ (N=68)

05

1015

2025

3035

4045

50P

erce

nt

0 5 10 15 20 25Score (0-25) on a 25-item scale about WASH practices

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thanwomenwithout.CompositeSRPSScorewassignificantlyassociatedwithbehaviouralmodificationindex(IRR1.12CI1.09–1.14,p<0.001.ForeachadditionalpointontheSRPSscale,respondentsscored12%higheronthebehaviouralmodificationindex.Tables12detailsthebehaviouralmodificationindexanditsbivariateassociations.

LimitationsAsstatedabove,standardsamplesizescalculationsforhypothesistestingwerenotusedasthiswasanexploratoryanddescriptivestudy.Instead,asampleofapproximately300respondentswaspre-determinedtobalanceavailableresourcesandstatisticalprecision.Culturalpracticesinthelow-incomesettingofruralUPimpactsanitationbehavioursandthestressorsmeasuredinthisresearch.Forthisreason,someofthefindingsmaybelimitedtolow-income,ruralareasofIndiawithsimilar,genderedculturalnorms.

DiscussionFindingsfromthequalitativeandquantitativestagesofoursurveyfoundwhatappeartobeconflictingresults.WomenandthegirlsinGDsrarelyspokeopenlyaboutsocialandsexual-violencestressorsassociatedwithlackofaccesstosanitationfacilitiesintheirhouses,communitiesandschools.Incontrast,measuredsanitation-relatedstresswasveryhigh-themeanscorewas18.6(SD4.24)andthelargemajorityofwomen-93%(281/303)answered“yes”tooverhalf(≥13items)ofthesurveyitems.Tounderstandthisdiscrepancy,itisimportanttoexaminethevariousunderstandingsofstressandit’scomponentsemployedwithineachmethod.

Aswomenandgirlsspokeofgoingoutforavarietyofbodilyneeds,theywerespeakingofdailyaspectsoftheirlives,oftentakenforgranted.Theyfocusedontheenvironmentinwhichbodilyneedsaremanagedasnormalandroutine.Womendidnotdiscussdistance,time,cleanliness,orriskofinfectionasstressors(Sahooetal.2015)—thesewereconditionsthathadbeennormalisedamongrespondents.Inthequantitativecomponent,EnvironmentalStressorsScoreswerebasedonpre-identifiedenvironmentalstressorsfrompreviousstudies(Hullandetal.2015;Sahooetal.2015).Distantlocations,timeofday,health,etc.,wereincludedwithinthemeasurementsystem.Similarbehavioursareexaminedinthequalitativeandquantitativestudy,andtheroutinenaturewithwhichthese“stressors”weredescribedinthequalitativestudymayreflectthewaysinwhichdifficultenvironmentalconditionshavebecome“normal”forwomenwithinourstudypopulation.

Women'sgeneralsilencesubjectssuchasharassmentandsexualviolence(ataboosubject)inGDsstoodinstarkcontrastwithwomenshowingveryhighlevelsofsocialandsexual-violencestressorsinsurveys.WomenmayhavebeenreluctanttodiscusspersonalexperiencesofharassmentandviolenceinGDsandmorecomfortablesharingpersonalexperiencesinthemoreprivatesurveysetting.InGDs,womenwerefirstaskedtocommentontheirexperienceswiththeeverydayofopendefecation,urinationandMHM(i.e.,environmentalstressors).Inconveniencescausedduringmonsoonsandfloods(environmentalstressors)wereexpressedbywomenacrossagegroups.Withoutdirectprobingwomenandgirlsmayhavebeenreluctanttosharemoredisturbing,out-of-the-ordinaryexperiences.Survey

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questionselicitedresponsesthatmadeiteasyforwomentoanswerquestionsaboutsocialstressorsandfearsaboutsexualorgender-basedviolenceinastraightforwardmanner.Thisdemonstrateshowsurveymethods,intelligentlyinformedthroughqualitativeinquiry,cancollectkeyexperientialaspectsofsanitationthathavesignificantimpactonqualityoflife.Incorporatingtheseexperientialquestionsintothestandardindicatorsformeasuringsanitationinterventions'successandfailure,especiallyalonggenderedlines,couldprovidenecessarydataontheimpactofprogramsonwomenandgirlscurrentlymissingthroughstandardindicatorreportingalone.

BothqualitativeandquantitativefindingshelpedunderstandthevariousfactorsthatareassociatedwithSRPS.Sanitation-relatedstressdifferedacrossthelifecourseinboththequalitativeandquantitativestudies.Responsesfromwomenatdifferentstagesoflifeshowedthedifferentperceptionsofstressassociatedtopoorsanitation.Middle-agedwomenspokeoffearofanimalsandinsects.Girlsontheotherhandexpressedshameandshynessatsharingfacilitieswithmen/boysatschoolorhavingtobearoundthemwhentheneedtousetheschooltoiletarose.Mothersexpressedadesireforatoiletduetopubescentdaughters,andthesefearsseemtohavebeentransferredtogirlswhospokeofgeneralfearsofbeingattacked.Girlscouldnotremember(orchosenottotell)storiesofsexualviolence;oftenfearswerespokenofasfearofghosts.Inthequantitativesurvey,marriedwomenreportedthehighestlevelsofSRPSandthehighestlevelsofsexualviolencestressors–considerablyhigherthanadolescentgirls.Thismaybeenagenerationaldifference–youngergirlsmaynotviewteasingandharassmentbymenwiththesameleveloffearoranxietythatolderormarriedwomendo.Additionally,amongtight-knitcommunitiesyounggirlsmaybeseenasthe'daughters'ofallfamilies,andthereforearenottargetsforteasingandharassment.WhilecastebiasinruralUttarPradeshiswell-foundedintheliterature(Coffeyetal.2015)andwasspokenofbywomeninthequalitativeportionofthestudy,thesurveyinstrumentdidnotfindsignificantrelationshipsbetweencastegroupsrelativetotheSRPSscores.

Ofnote,havingaccessto–andusing–asanitationfacilitysignificantlyreducedsanitation-relatedpsychosocialstress.WomenwhoreportedaccesstoatoiletfacilityweresignificantlymorelikelytoreportalowerSRPSsummaryscorethanthosewhodidnotreportaccesstoatoiletfacility.Amongthosewomenwhodidhaveaccesstoatoiletfacility,reportingusingthatfacilityforurinationordefecationwassignificantlyassociatedwithalowerSRPSsummaryscorecomparedtothosewhodidnotreportusingthefacilityforurination(Sp<0.001)ordefecation(Sp=0.001),indicatingthathavingadesignatedlocationforurinatinganddefecatingmaysignificantlylowerpsychosocialstress.Itsuggeststhatdespitethedailynatureofurinationanddefecation,andwomen'shabitofusingageneralODlocation,women'sstressisnegativelyimpactedbythis'normalised'behaviour,comparedtolatrineusage.

However,wenotethatmanywomenhadfacilitiesthatwerenotusedandhavingasanitationfacilitydidnotentirelyeliminatesanitation-relatedstress.Althoughvillageshadallparticipatedinvarioussanitationschemes,fewtoiletsthatwerebuiltwereusableandmettheneedofwomenandgirls–overthreefourthsofrespondentswithafunctioninglatrinestillpracticedopendefecationatleastoneintheweekpriortodatacollection.Inthequalitativeportion,wefoundthatthemajorityoflatrinesthathadbeenbuiltinvillagesaspartofvarioussanitationschemeswereprimarilyforshowandthatadoptionof

30

alatrinewasmorecloselyafunctionoftheneedtoprovidefacilitiesforaspecificmemberofthehousehold.Womenandgirls,therefore,usedfacilitieslessthanthenumbersofunitswouldimply.MultiplestudiesinIndiahaveidentifiedlow-ratesofusefollowingsanitationinterventions(Patiletal.2015;Clasenetal.2014).Findingsfromthisstudyhelpexplainwhyusageratesremainlow–fewtoiletsthatwereconstructedunderguidelineswereconsideredcomplete,womenandgirlswerenotinvolvedintheplanningandplacementoffacilities,andfacilitiesdidnotmeetuserneeds.

Ourstudyhighlightsthehighprevalenceanddegreetowhichwomenregulatetheirbehavioursandeventheirbodyfunctionstoaccommodateinadequatesanitationfacilities.Adjustmentsnecessarytogooutinagrouporwaittobeaccompanied(inthecaseofyounggirls),weretakenasgiven.Risingearlyinthemorning,orwaitingtogoafterdarkintheeveningwerecommon,everydayoccurrences—avoidingbeingseenbymenwaspresentedbywomenastheonlysociallyacceptablechoiceforsanitationpractices.Notbeingseenbyanyonewasdesirable,andODwas'hidden'bynotcarryingwaterandperforminganalcleansinguponreturninghome.Thesebehaviourmodificationswereintegratedintotheirdailylives.Onlywithprobingdidwomendiscussthattheydisciplinedtheirbodiestoavoidshame,embarrassmentortheneedtostandupwhiledefecating.Thesefeelingswerealsopresentedasobvious,aswerethebehaviourmodificationsrequiredtoavoidthem.Thebehaviouralmodificationindexindicatedthat80%ofwomensurveyeddidmodifytheirbehaviourinsomeway.Women'sSRPSsummaryscoreswerepositivelycorrelatedwithabehaviourmodificationofsomekind,suggestingthateverydayhabitsofadjustingtheirbodiestoSRPSiscommon.Insum,womendidnotspeakofbodilydisciplineasstressfulinGDsandSSIs,butsurveyresultsindicatethatbodydisciplinewashighlycorrelatedwithSRPSandmoremodificationsweremadeathigherstresslevels.Importantly,accesstoatoiletseemstohavereducedwomen'sbehaviourregulation.

ConclusionsThisresearchshowsthatwomenfeelmeasurableamountsofSRPS,andthatthosestressorscanbemitigatedbyaccesstoanadequatesanitationfacility.Standardindicatorsforsanitationprogrammingsuccesshavefocusedonthepresenceanduseoffacilities.Ourfindingsindicatethattheexperientialaspectofbothopendefecationandsanitationfacilityuseshouldbeconsideredinunderstandingthemagnitudeofimpactlimitedsanitationaccesshasonthelivesofwomenandgirls,aswellashowaspecificinterventionhasorhasnotimprovedtheoverallprocessofsanitationuse.

Theresearchalsoindicatesthatitispossible,anddesirable,toincorporatequestionsrelatedtowomen'sSRPSintofuturestudiesofsanitationinterestedinthegenderedimpactsofsanitationinterventions.Itiswell-knownthatopendefecationcauseslossoflife,health,andimpactshouseholdeconomies.Itislessunderstoodtherelationshipbetweenmentalandphysicalstress,andtheirtollonthebodyovertime.AsitisclearfromthisresearchthatwomenexperienceSRPSaspartoftheireverydaylives—somuchapartoftheirexistencethatitisrecognisedas'inconvenient'andnot'stressful'—anditislikelythatthisstressnotonlyimpactstheirgeneralwell-being,butperhapstheirphysicalhealthoverthelong-term(Sahooetal.2015;Hullandetal.2015).

ThisstudyisinformedbytheearlierworkoftheSHAREresearchteams(Sahooetal.2015;Hullandetal.2015),buttakesthisworkforwardbycapturing:a)women'sdailyexperiencesofstressthattheymay

31

notinterpretassuch,e.g.,bodilydiscipline;b)theeverydayactivitiesassociatedwithurination,defecationandMHMthatrepresentthefullspectrumofwomen'sexperiencesthatmightleadtoSRPS;c)aframeworkthatenablessurveyquestionssuchasthosedevelopedherethat,informedbysituatedknowledgegainedethnographically,couldcontributetostandardindicatorsoftherelationshipofSRPSonwomenwhodonothaveaccesstoadequatesanitation,andwhatsanitationprovisionmightalleviateintermsofwomen'sSRPS.GenderedSRPSisunderstudied,butanimportantpartofsanitationprovisionandusage,andperhapsanentryforgreaterparticipationofwomeninthesanitationplanningandimplementationprocesses.

PolicyRecommendationsAsapartofimpactevaluationsandcost-benefitanalyses,measuresofwomen'sSRPSatbaselineandendlineareacriticalpartofmeasuringtheimpactthatsanitationishavingonthelivesofruralIndianwomen.SBMisinterestedinbuildingtoiletsforallandinitiatingbehaviourchangethatwillbringaboutusage.ThisresearchshowsthattheSustainableDevelopmentGoals(SDGs)andtheWHO-JMP(WorldHealthOrganization-JointMonitoringProgramme)couldincorporatemeasuresofwomenandgirls'SRPSanditsrelationshiptogenderedsocialnormsinmeaningfulways,leadingtobetterinterventionsandbetteroutcomes,bothforlatrineusesustainability,andcommunityhealth.

SDGs#5and#6pertaintogenderequalityempowermentandtotalcoverageofsanitationandwaterforall,respectively.Under#6,whichstatesensuringofsanitationandwaterforallby2030,#6.2statesatargetto:achieveaccesstoadequateandequitablesanitationandhygieneforall;andendopendefecation,payingspecialattentiontotheneedsofwomenandgirlsandthoseinvulnerablesituations.

TheSBMGuidelinesarealsocommittedtoequityandinclusion,andspecificallyfocusonthequestionsofwomen,differently-abledpeopleandothervulnerablepopulations.ThestatedintentofSDGsandtheSBMallowsforsuggestionsintermsofdevelopingassessmentcriteriathatareinclusiveandgender-aware(SwachhBharatMission(Rural)Division2015).

OurrecommendationsforSBMspecificallyfallunderthefollowingareas:

MonitoringandEvaluationThebroadframeworkformonitoringSBMisasfollows:

• WhetheradequateInformationEducationCommunication/InterpersonalCommunication/Triggeringactivitieshavebeencarriedoutforbehaviourchange

• Whethertoiletshavebeenconstructedasreported;• Whetherconstructedtoiletsarebeingused;• WhetherODFinsinglecommunitiesandlargervillageclustershavebeencreated

Theguidelinesstatethat“independentagenciesshalltakeupsuchmonitoringwhichshallconformtonationalandinternationalrequirementsliketheJointMonitoringProgramme(JMP)”.However,theJMPitselfdoesnothavegender-disaggregateddataanddoesnotfocusonpsychosocialwell-beingindicators.Thesewillhavetobeincludedatalllevelsofmonitoring.

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Theguidelinesstatethatbothannualandconcurrentmonitoringwillneedtobedonebyindependentthirdpartiesandcommunities,respectively.Thisguidelineneedsgreaterdetail,specifically,itmustbeensuredthat'independentthirdparties'includeagencies/persons/organisationssensitivetoissuesofgenderandsocialvulnerabilities.Representativesfromwomen’smovementsandsimilarcivilsocietyorganisationswillneedtoparticipateinmonitoring.Concurrentmonitoringactivitiesatthecommunitylevelrequiredefiningwhat'community'means(i.e.,nottaking'community'forgrantedasall-inclusiveorequal).Forthisreason,women’sgroupsandotherdiscriminatedgroups'participationisnecessaryforsocially-inclusivemonitoringactivities.

Werecommendthatpsychosocialhealthofwomenandothervulnerablepopulationsneedstobeincludedasanindicatorformonitoring,andgroupsrepresentingtheseinterestsbeincludedinmonitoringactivities.

VerificationofODFSBMhasissuedasetofguidelinesforverificationofODFandtheseguidelinesdonotmentiongender.ODFhasbeendefinedastheterminationoftheoralfaecaltransmissionwithnovisibletracesoffaecesfoundintheopenenvironmentandsafeoptionsfordisposal.Currently,ODFverification—boththehouseholdsurveytoolandcommunitysurveytool—doesnotincludegenderortheimpactsofsanitation/lackofsanitationonwomen’slives.However,Indianstateshavethefreedomtoincludedifferentindicators.

WerecommendthattheseODFverificationquestionnairesbemodifiedtoincludespecificquestionsonthepsychosocialwell-beingofwomenandothervulnerablegroups.

Disbursementlinkedindicators-WorldBanksupporttoSBMTheWorldBankhasprovidedUSD1.5billiontosupportSBMbyrewardingIndianstatesfortheirperformanceinmeetingSBMtargets.Stateperformanceismeasuredbydisbursement-linkedIndicators(DLIs).Theseindicatorsare:reductionintheprevalenceofopendefecation;sustainingODFstatusinvillages;andincreasingthepercentageofruralpopulationsservedbysolidandliquidwastemanagement.TheDLIshavenogendercomponentwhatsoever(GovernmentofIndia2016).

TheDLIsshouldbeusedasapowerfulincentivetomotivatesanitationprogrammingthatincorporateswomenandvulnerablegroups'psychosocialwell-beingintostate-levelgoalsforattainingandsustainingODFstatus.

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Hulland,KristynaR.S.,RachelP.Chase,BethanyA.Caruso,RojalinSwain,BismitaBiswal,KrushnaChandraSahoo,PinakiPanigrahi,andRobertDreibelbis.2015.“Sanitation,Stress,andLifeStage:ASystematicDataCollectionStudyamongWomeninOdisha,India.”PloSOne10(11).PublicLibraryofScience:e0141883.doi:10.1371/journal.pone.0141883.

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