Abstract
Emerging qualitative research suggests women’s sanitation experiences may impact mental health. However, specific associations remain unclear. We aimed to determine if sanitation access and sanitation experiences were associated with mental health among women in rural Odisha, India. Using a cross-sectional design, we evaluated the association between sanitation access and sanitation experiences and selected mental health outcomes. Data were collected from 1347 randomly selected women across four life course stages in 60 rural communities (December 2014-February 2015). Our four primary outcomes included: mental well-being, and symptoms of anxiety, depression, and distress. The primary exposures were (1) access to a functional latrine within the household compound and (2) sanitation insecurity (SI), evaluated using a seven domain measure assessing women’s negative sanitation experiences and concerns. We used hierarchical linear modeling to determine associations between the exposures and mental health outcomes, adjusting for covariates (life stage, poverty, current health status, social support). Mean well-being scores were moderate and mean anxiety, depression, and distress scores were above a threshold indicating the potential presence of any of the three conditions. Access to a functional household latrine was associated with higher well-being scores, but not with anxiety, depression or distress. Women’s SI domains were associated with all four outcomes: four domains were significantly associated with lower well-being scores, two were significantly associated with higher anxiety scores, three were significantly associated with higher depression scores, and three were significantly associated with higher distress scores, all independent of functional household latrine access. Women in rural Odisha, India may suffer assaults to their well-being and have higher symptoms of anxiety, depression, and distress when urinating and defecating, even if they have an available facility. These findings suggest that sanitation-related interventions should consider how to accommodate women’s experiences beyond excreta management to comprehensively impact health.
Highlights
An estimated 2.3 billion people lack access to basic sanitation, an unshared household facility hygienically separating human excreta from human contact
The final analytic sample consisted of 1347 participants, including 328 unmarried women (25%), 301 recently married women (22%), 376 women married over three years (28%), and 342 women over age 49 (25%)
Almost all women were Hindu (99%); 45% belonged to the general caste, meaning they did not receive caste-based government support; 66% had a Below Poverty Line (BPL) card; 80% indicated they were not suffering from a current illness; 30% reported access to a primary water source within the household dwelling/compound, and 15% reported access to a bathing room (Table 1)
Summary
An estimated 2.3 billion people lack access to basic sanitation, an unshared household facility hygienically separating human excreta from human contact. An estimated 892 million lack access to any kind of sanitation facility and practice open defecation (JMP, 2017). Women may be at risk for non-infectious disease outcomes if they lack access to sanitation environments that accommodate their needs. Women have reported shame if seen by others, withholding food and water to limit urination or defecation, suppressing needs due to inhospitable physical or social environments, being unable to tend to needs due to obligations, fearing or experiencing physical or sexual violence when accessing locations or addressing needs, and feeling helplessness to change sanitation conditions (Caruso, Clasen, Hadley, et al, 2017; Joshi, Fawcett, & Mannan, 2011; Kulkarni, O’Reilly, & Bhat, 2017; O’Reilly, 2016; Routray, Torondel, Clasen, & Schmidt, 2017)
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