BackgroundResearch suggests that the lived experience of inadequate sanitation may contribute to poor health outcomes above and beyond pathogen exposure, particularly among women. The goal of this research was to understand women’s lived experiences of sanitation by documenting their urination-related, defecation-related and menstruation-related concerns, to use findings to develop a definition of sanitation insecurity among women in low-income settings and to develop a conceptual model to explain the factors that contribute to their experiences, including potential behavioural and health consequences.MethodsWe conducted 69 Free-List Interviews and eight focus group discussions in a rural population in Odisha, India to identify women’s sanitation concerns and to build an understanding of sanitation insecurity.FindingsWe found that women at different life stages in rural Odisha, India have a multitude of unaddressed urination, defecation and menstruation concerns. Concerns fell into four domains: the sociocultural context, the physical environment, the social environment and personal constraints. These varied by season, time of day, life stage and toilet ownership, and were linked with an array of adaptations (ie, suppression, withholding food and water) and consequences (ie, scolding, shame, fear). Our derived definition and conceptual model of sanitation insecurity reflect these four domains.DiscussionTo sincerely address women’s sanitation needs, our findings indicate that more is needed than facilities that change the physical environment alone. Efforts to enable urinating, defecating and managing menstruation independently, comfortably, safely, hygienically, privately, healthily, with dignity and as needed require transformative approaches that also address the gendered, sociocultural and social environments that impact women despite facility access. This research lays the groundwork for future sanitation studies to validate or refine the proposed definition and to assess women’s sanitation insecurity, even among those who have latrines, to determine what may be needed to improve women’s sanitation circumstances.

There has been growing recognition of menstrual hygiene management (MHM) as a significant public health issue. However, research has predominately focused on the experiences of adolescent girls in school settings. The purpose of this research is to examine detailed accounts of menstruation for women in rural Odisha, India at various life stages with a view toward improving international monitoring of MHM. Focus group discussions and in-depth interviews were conducted to understand women’s experiences of menstruation across four life stages (unmarried women, recently married women, married women, and older women). Thematic analysis was used to identify menstruation-related challenges and needs. We found women voiced needs that aligned with those captured by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) definition for MHM: access to clean materials, privacy for changing materials, soap and water for bathing, and disposal facilities for materials. However, we also found women require materials that are not only clean but comfortable and reliable; soap and water for more than bathing; privacy for the full spectrum of menstruation-related practices, not just when changing; and disposal facilities that are private and safe, not just accessible. Additionally, we identified needs that extend beyond the existing definition: pain management, social support, and an enabling sociocultural environment. Overall, women representing all life stages discussed menstruation challenges, including bathing, pain, and washing, drying, and storing cloth materials. Cloth management challenges were most acute for unmarried and recently married women, who were concerned that practices could reveal their menstrual status and harm their reputations, thus informing their preference for disposable materials, if attainable. We propose a revised definition of adequate MHM for this population that more comprehensively captures their needs. This definition may also prove useful for other populations, future research, creating measures of assessment, and guiding interventions and program priorities.

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.