The association between women’s decision-making roles in sanitation and well-being in urban Bangladesh Open Access
Stephan, Nicole (Spring 2024)
Abstract
Objective: Research indicates that women and girls face gender-specific stressors related to sanitation that affect their mental health, and women’s decision-making agency may play a role in this relationship. This study aimed to quantitatively assess the association between women’s sanitation-related decision-making overall as well as at the household and community levels within two urban municipalities in Bangladesh.
Methods: This paper is a secondary analysis of cross-sectional survey data from 1,449 women collected in Meherpur and Saidpur, Bangladesh during March-April 2022. The primary exposures included women’s sanitation-related decision-making and access to a privately-owned latrine. Decision-making was measured using the Agency, Resources, and Institutional Structures for Sanitation-related Empowerment (ARISE) scale; the full-scale score was used in the first analysis and the five factor scores were used in the second. Linear regression models were used to assess the associations between the exposures and well-being scores (measured using the World Health Organization Well-being Index (WHO-5)), controlling for city, life stage, socioeconomic level, perceived social support and physical health.
Results: Mean well-being and decision-making scores were moderate in both cities, with approximately 20% of respondents reporting poor well-being. In the first analysis, the decision-making scale score (β=0.73, p=0.02) was positively associated with well-being. In the second analysis, factor scores related to the ability to influence community-level sanitation decisions (Factor 2) (β=1.10, p=0.0002) and make small household sanitation decisions (Factor 5) (β=1.07, p=0.006) were positively associated with well-being. Conversely, the ability to participate in community-level sanitation decisions (Factor 1) was negatively associated with well-being (β= -0.68, p=0.02). The ability to participate in household sanitation decisions (Factor 3) (β= -0.39, p=0.33) and make large household sanitation decisions (Factor 4) (β= -0.38, p=0.14) were not significantly associated with well-being. Access to a privately-owned latrine was not associated with well-being in full models.
Conclusion: Women's involvement in sanitation-related decision-making may influence mental health outcomes and warrants further research to explore its potential integration into sanitation-related interventions.
Table of Contents
Chapter 1: Introduction 1
Chapter 2: Literature Review 4
1. Introduction 4
2. Global Mental Health and Well-Being 4
3. Agency, Decision-Making, and Mental Health 6
Table 1: Definitions of women’s empowerment, agency, and decision-making used in this research study 8
4. Sanitation Experiences and Mental Health 11
Figure 1: Preliminary conceptual model demonstrating the relationship between inadequate sanitation and well-being 12
Figure 2: Conceptual model of sanitation-related psychosocial distress 14
5. Women’s Decision-Making Autonomy and Sanitation 15
6. Sanitation, Women’s Decision-Making, and Mental Well-Being in Bangladesh 18
Sanitation in Bangladesh 18
Women’s Decision-Making in Bangladesh 19
Mental Health in Bangladesh 21
7. Gaps in the Literature 23
Chapter 3: Manuscript 25
Abstract 25
1. Introduction 26
2. Methods 29
2.1 Study Design 29
2.2 Study population, setting, and sampling procedure 29
2.3 Data collection 30
2.4 Measures 31
2.5 Analysis 35
2.6 Ethics 36
3. Results 37
3.1 Sample size and demographic characteristics 37
Figure 1. Flow diagram of recruitment, eligibility, survey completion, and final analytic samples by city 38
Table 1. Demographic characteristics of participants, overall and by city (N = 1149) 39
3.2 Decision-making and well-being scores 41
Table 2. Decision-making and well-being scores, overall and by city (N=1448) 42
Figure 2. Box and whisker plot of decision-making scores by city 42
Figure 3. Box and whisker plot of well-being scores (WHO-5), overall and by city 43
3.3 Multivariate results 43
Table 3. Association between access to a privately-owned latrine, sanitation-related decision-making scale score (aggregate score), individual covariates and well-being scores (WHO5) in Meherpur and Saidpur, Bangladesh. Full models. (Participants=1448) 44
Table 4. Association between access to a privately-owned latrine, sanitation-related decision-making (factor scores), individual covariates and well-being scores (WHO5) in Meherpur and Saidpur, Bangladesh. Full models. (Participants=1448) 46
4. Discussion 47
4.1 Strengths and limitations 52
4.2 Conclusion 53
Chapter 4: Public Health Implications 54
References 58
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