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Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis [1]

['Bethany A. Caruso', 'Hubert Department Of Global Health', 'Rollins School Of Public Health', 'Emory University', 'Atlanta', 'Georgia', 'United States Of America', 'Gangarosa Department Of Environmental Health', 'Departmentof Behavioral', 'Social']

Date: 2022-08 

Abstract Historically, water and sanitation programs have focused on women’s instrumental value in improving conditions and behaviors. No reviews have synthesized evidence on water and sanitation and women’s and girls’ empowerment. This review a) identified empirical water and sanitation research that engaged empowerment and/or empowerment-related domains; b) reported empowerment-related terminology used, research locations, methods leveraged, if water and/or sanitation was the focus; and c) synthesized evidence. A conceptual model of women’s and girls’ empowerment, which includes three interrelated domains (agency, resources, institutional structures), informed the search and analysis. We searched MEDLINE, EMBASE, CABI Global Health, PsycINFO, CINAHL and AGRICOLA for peer-reviewed sources presenting research on water and/or sanitation and either empowerment and/or related terms from the model (4 May 2020). We identified 12,616 publications; 257 were included, representing over 1,600,000 participants. We used the Mixed-Methods Appraisal Tool (MMAT) and followed the ‘best-fit framework synthesis’ analysis approach, using the model domains and sub-domains as codes. We inductively identified two additional sub-domains relevant to water and sanitation: privacy and freedom of movement. Thematic analysis guided synthesis of coded text. The majority of research took place in Asia (46%; 117) or Africa (40%; 102), engaged adults (69%; 177), and was published since 2010; (82%; 211). The greatest proportion of studies focused on water (45%; 115). Over half of studies used the term empowerment, yet only 7% (17) provided a clear definition or conceptualization. Agency was the least commonly engaged domain (47%; 122); the Resources domain was dominant (94%; 241). Measures for assessing empowerment are limited. Inclusion of only peer-reviewed sources in English is a main limitation. Well-conceptualized water and sanitation research that engages women’s and girls’ empowerment is limited. A more comprehensive ‘transformative WASH’ that includes gender-transformative approaches to challenge and reduce systemic constraints on women’s and girls’ resources and agency is long overdue.

Citation: Caruso BA, Conrad A, Patrick M, Owens A, Kviten K, Zarella O, et al. (2022) Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis. PLOS Water 1(6): e0000026. https://doi.org/10.1371/journal.pwat.0000026 Editor: Inga T. Winkler, Central European University, AUSTRIA Received: November 4, 2021; Accepted: May 16, 2022; Published: June 7, 2022 Copyright: © 2022 Caruso et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials. Funding: This work was supported by the Bill & Melinda Gates Foundation (OPP1191625). Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. Authors BAC and SSS were recipients of the grant. Conversations with the funder informed our selection of the conceptual model that guided our analysis, however had no bearing on the adaptations of that model that we as authors undertook in the process of the review. The funder did not influence the study design, analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist.

Introduction Water, sanitation, and hygiene (WASH) access, behaviors, experiences, and physical and social environments have been shown to influence multiple outcomes, including diarrheal disease, soil transmitted helminth and protozoa infection, active trachoma and schistosomiasis, pneumonia, anemia, mental health and general well-being, economic productivity, school absence, and child growth and cognitive development [1–14]. This demonstrated importance of WASH underlies Sustainable Development Goal (SDG) 6, which aims to “Ensure availability and sustainable management of water and sanitation for all” [15]. Still, water and sanitation access remain out of reach for large proportions of the global population: 26% of the global population lacks access to water that is available when needed and free from chemical and fecal contamination, and 46% lacks access to household sanitation facilities that safely manage excreta [16]. Furthermore, while SDG Target 6.2 emphasizes “paying special attention to the needs of women and girls,” who are recognized as WASH duty-bearers globally, [17–20] data often fail to reflect the gender-specific benefits and harms of WASH conditions, behaviors, and interventions. Despite recognition of WASH ‘as a pathway to gender equality’, [21] a full understanding of the gendered effects of WASH remains limited, prompting calls for improved gender measurement, data, and learning [19, 22–25]. While historically WASH programs focused on women’s contributions to improving effectiveness and impact of programs, this focus has been evolving to consider how WASH programming may contribute to positive gender outcomes [26] and, more specifically, to women’s empowerment [27–30]. Research on women’s empowerment has flourished across multiple disciplines in the past two decades, argued to be propelled by the foundational work of Naila Kabeer (1999), who defined empowerment as ‘the expansion in people’s ability to make strategic life choices in a context where this ability was previously denied to them’ [31]. Kabeer further conceptualized empowerment as having three dimensions: resources, or the human, material, and social pre-conditions to exercising choice; agency, which is “the ability to define one’s goals and act upon them,” and achievements, which are the possible outcomes of exercising agency [31]. While several other definitions, frameworks, and measures exist, women’s empowerment is widely recognized to be multi-dimensional and a process that is valuable both intrinsically for its own sake and instrumentally for its link to varied life outcomes, including nutrition, access to care, contraception use, vaccination, and exposure to violence [32–36]. Global recognition of the importance of women’s empowerment is evidenced by its prominent role in SDG 5, which seeks to ‘empower all women and girls’[37]. Recent reviews have examined WASH and gender, with variable explicit engagement with empowerment [38–42]. In their scoping review, Dery et al. (2020) explored how empowerment was used in WASH. Among the 13 included articles, of which four focused on women’s access to WASH and empowerment, five interrelated dimensions of empowerment were identified: access to information, participation, capacity building, leadership and accountability, and decision-making [38]. MacArthur and colleagues (2020) conducted a critical review of WASH-gender literature from 2008–2018 and sought to understand how WASH studies engaged gender equality. Their distant-reading analysis of the 155 included articles, which focused only on assessment of titles and abstracts, revealed that few engaged with gender transformational-aspects of gender equality [39]. A mixed-method systematic review protocol outlines another study’s planned aim and approach to synthesize evidence on gender and social equality outcomes that are specific to complex WASH interventions [43]. However, the two reviews that have been completed (Dery et al. and MacArthur et al.) have used methods that are limited in their scope and rigor, [44] and a need has remained for a more comprehensive synthesis of the evidence. To date there have been no rigorous systematic reviews to assess and synthesize evidence on WASH and women and girls’ empowerment. Such a comprehensive review could benefit various actors, including researchers, by determining which domains of empowerment are well-studied and which require further attention; practitioners and policy makers, by identifying programs, interventions, and approaches that have contributed to (or hampered) women’s empowerment; and donors, by distinguishing what facets of WASH-related empowerment may require further investment. To that end, the primary aims of this literature review were to: a) identify empirical water and sanitation research that engaged empowerment and/or empowerment-related domains; b) tabulate and report how empowerment-related terms were used, where and when research was conducted, what methods were leveraged, and if water and/or sanitation was the primary focus; c) synthesize findings by empowerment domain and water and/or sanitation focus.

1. Agency Women reported exercising water and sanitation-related agency, including engagement in decision-making inside and outside the household, formal and informal leadership, and collective action. Women experienced constraints on their movement, which impacted their access to water and sanitation resources and to public water and sanitation related activities. 1.a Decision-making Women have varied roles related to intra- and extra- household water and sanitation making, though seem to have the greatest power related to decisions within the household related to water. Women in Guatemalan savings groups reported having at least equal participation in household WASH decisions, with many reporting greater decision-making power than their husbands [73]. Women in Bangladesh, [110] Ethiopia, [108] and India [60] reported decision-making power over water collection and allocation, though some studies from India found men to make water collection decisions that did not account for women’s priorities [101, 119]. A water security study from Nepal reported that some women found individual decision-making stressful and that seeking support from in-laws and husbands was culturally valued [59]. With respect to sanitation, in India, the odds of having a latrine was significantly higher in households where women were the main decision makers [136] and in Kenya, the likelihood of a household owning an improved sanitation facility was significantly higher when women had at least some input on decisions about major household purchases [134]. Women have both participated in and been prevented from a range of extra-household water and sanitation decision-making situations. In Indonesia, women exercised independent choice in selecting WASH-related jobs [66]. In India, women became a part of decision-making processes in village-level sanitation meetings, [139] water user committees, [89] and other sanitation projects, [127] and men believed women could speak up in meetings and expressed happiness that they could make joint decisions [145]. Women have voiced opinions about proposed activities and offered suggestions during informal water and sanitation meetings (Egypt), [78] and both men and women noted that women are likely to speak out in public settings and take action on water-related issues given their role as household water managers (Mexico) [93]. Both men and women in Hmong communities in Vietnam agreed that women were likely to be listened to when they participated in water management meetings [97]. In Bolivia, although women were rarely able to contribute in water-focused meetings, their contributions often shifted community conversations in important ways and women often had strong influence over water-related decisions, even when men had formal decision-making authority [114]. Conversely, women also have been barred from extra-household water and sanitation decision-making. Women reported being listed as water management group members, but never attending meetings (Bangladesh [109]), instructing husbands to relay water concerns to committees (Sri Lanka [56]), having husbands or sons attend meetings and make decisions in their place (India [106]), and deferring to men to speak during water-related meetings even though they bore water collection responsibility (Kenya [76]). In northern Kenya–where women primarily collect water for domestic use and men for livestock–women were not actively involved in decision-making around water source utilization and their needs were not prioritized [61]. Women play increasingly greater roles in water committees in rural Malawi, but they remain dominated by men in urban areas [86]. Factors that have influenced women’s involvement in intra- and extra-household water and sanitation decision-making are described in the S1 Text (SX). WASH programs have both promoted and discouraged women’s voices in WASH-related decision-making processes. Nongovernmental organizations (NGOs) have encouraged women to speak up in culturally appropriate ways [26, 126]. Trainings, information, and technical knowledge provided to women have contributed to the improvement of communication between men and women and led to women having a voice in household and community decision-making [26, 58, 75, 129]. WASH programs have increased trust, acceptance, and respect for women as community decision-makers (India [129] and Sri Lanka [56]), increased women’s roles in household decision-making (India [139] and Vietnam [58]), and improved women’s reported ability to express themselves (Costa Rica [63]). WASH programs also have inhibited women’s decision-making participation by targeting men [102, 124] or reinforcing gender norms [71, 126]. In India, women were included in public forums because they are responsible for children’s health, while men were involved because they could demand improvements and travel outside the village [126]. Additionally, women in India reported being provided water and sanitation, without consultation, resulting in services not meeting their needs [122]. In Timor Leste, women’s participation in water and sanitation projects has been limited to activities like cleaning or preparing food [71]. 1.b.Leadership Women have served as formal and informal leaders in water and sanitation initiatives, resulting in both programmatic benefits and to the women themselves. Formal positions include leadership on water and sanitation committees; leadership or management of WASH businesses, value chain companies, and organizations; leading community-level projects; and fundraising for and monitoring community-based water and sanitation initiatives [59, 66, 83, 85, 89, 93, 112, 120, 126, 133, 139, 149, 154]. Women’s formal leadership has led to increased confidence among and toward women leaders [26, 56, 73, 126, 146, 157]. In rural Vanuatu, water user committees with women in key posts met more regularly, functioned better, and collected more revenue than those with only men in these roles [150]. Still, while quotas have resulted in more women in leadership positions, [151] women remained underrepresented in committees and leadership [83, 102, 137]. Documented informal leadership activities included arbitrating local disputes, [69] disseminating water and sanitation information, [154, 160] motivating family members to use latrines, [155] and leading protests, like those during the “water wars” in Bolivia [148]. Select water and sanitation programs in Costa Rica, [63] Guatemala, [73] India, [126, 145] Sri Lanka, [56] and Vietnam [58] positively influenced the growth of women’s leadership and support for women leaders. In India, women’s participation in a community-led total sanitation campaign led to the emergence of female leaders who expanded their influence to other villages and activities [145]. Social and demographic factors have influenced women’s engagement and acceptance in water and sanitation leadership positions and are summarized in the S1 Text (SX). 1.c. Collective action Women have engaged in varied forms of collective action that has positively influenced water and sanitation access, conditions, experiences, and opportunities. Women’s collective action has led to funding, demand, construction, repair, and maintenance of water services [56, 61, 73, 78, 89, 91, 125, 129, 163, 165, 168, 169, 193, 296] and latrines [129, 139, 147, 168, 170, 174, 175]. Women have organized to form lending groups to support women-led WASH businesses, [66] provide community education about water safety, [56, 61, 73, 78, 89, 91, 125, 129, 163, 165, 168, 169, 193, 296] monitor open defecation, [145] and respond to sanitation-related harassment. [174] Indigenous women in Bolivia and the U.S. have collectively defended water access. [148, 167] Women’s involvement in WASH-related collective action has led to sustained involvement in water and sanitation issues [89, 163] as well as collective action around non-WASH issues, [56, 126, 145] and also has encouraged respect from community members, including men [26, 56, 89, 166]. Social and demographic factors facilitated or barred women’s involvement in collective action, which are detailed in the S1 Text (SX). 1.d. Freedom of movement Women have described benefits of and preference for water and sanitation activities that require leaving the home, yet many also reported restrictions on movement and therefore their access to basic water and sanitation needs. In Bangladesh, younger women enjoyed fetching water from distant water sources, providing opportunities to leave home and socialize [110]. In rural India, some women who owned latrines preferred going for open defecation to visit friends and escape their home, mothers-in-law, and chores [182]. Movement restrictions influenced women and girls’ access to water [101, 110, 178] and defecation, urination, and menstrual management locations, and are most widely reported in India [62, 135, 174, 181, 182, 184, 187], [101, 110, 187, 189–191]. Research in India found that family members (often husbands, fathers, and in-laws) restricted water fetching and sanitation-related movements, most intensely for unmarried daughters [174, 182, 190] and recently married and pregnant women, [178, 182, 189] (less intensely for women of lower castes [135] and widows [174]). Families have built latrines specifically to restrict movement, [62, 174] though women do not always have access when needed if situated in spaces controlled by men [62]. In India and Bangladesh, where women’s freedom of movement is restricted or being seen in public is considered shameful, women reported difficulty navigating public spaces for water or sanitation needs, experiencing stress, harm to reputations, or risked beatings [101, 110, 187, 189]. To prevent shaming family members (Bangladesh [110]) or suffering beatings by men (India [101]), women collected water from closer, polluted sources rather than cleaner sources in male-dominated public spaces. Women’s freedom of movement influenced participation in community-level water and sanitation activities. Women in India, [89, 101] Nepal, [59] and Kenya [76] reported needing permission from men or elders to participate in meetings outside the home, [76, 89, 101] which limited their involvement in water and sanitation committees and access to information, [89, 101] impacted their knowledge about water sources, [101] and constrained water access and decision-making. [59, 101] Restricted movement has limited women’s access to training opportunities and therefore engagement in piped water enterprises (Cambodia [30]), and has posed barriers to women’s WASH businesses (Indonesia [66]). Women in India experienced in development projects reported more spatial mobility and were more likely to participate in water committees. [89] One program (India) intentionally aimed to enhance mobility by engaging women in sanitation promotion outside the home; yet, the very latrines promoted were found to increase women’s confinement [62].

3. Institutional structures As outlined below, institutional structures—including formal laws and policies, norms, and relations—influence women’s agency and resources related to water and sanitation. 3.a Formal laws and policies Women have participated in WASH governance to varying extents. In Bangladesh, [177] Ghana, [83] India, [80, 106, 145, 180] Kenya, [61] and Uganda, [102] governments and organizations that set up community water and sanitation committees have required the inclusion of women [61, 80, 83, 102, 106, 180] or encouraged and supported women’s participation [145, 177]. In one project in India, rules mandated women be on water committees, but women did not always know they were on them [80]. Yet, inclusion does not guarantee participation, voice, or decision-making power. Women’s participation in WASH-related governance has been constrained by a lack of awareness about the rules (Uganda [102]), a lack of transparency or distrust in political institutions (Kenya [87]), husbands or sons attending meetings in their place (India [106]), and being ignored by men (Kenya [61]). Committees with women have divided roles along gendered lines, with men in powerful positions, like president, and women in less powerful positions, like cleaner [83, 153]. Research in Uganda found women constituted less than a third of members and were rarely in leadership positions on water user committees despite guidelines to have women comprise 50% of membership and serve in influential positions [102]. WASH policies, and uneven policy awareness, implementation, and enforcement, have posed barriers to women. Female entrepreneurs in Cambodia found certain policies made it hard to run water enterprises [30]. Even when policies exist to address women’s and girls’ needs, they are not always known or enforced. In India, both men and women lacked awareness of policies, acts, and regulations that prioritized gender equitable access to resources and participation in a watershed intervention [103]. A comparative study in Tanzania, Ghana, Cambodia, and Ethiopia, found some countries mandated sex-segregated school toilets, but adherence was inconsistent [253]. Lack of clear responsibility and accountability has resulted in policy or guidance failure. Women Sanitary Complexes in India were reportedly not maintained according to guidelines due to disagreements over responsibility [139]. In refugee camps in Lebanon and Myanmar, a lack of detailed guidelines and clarity about responsibility affected government actors’ ability to provide sufficient water and sanitation for female refugees, particularly to support menstruation-related needs [228]. 3.b. Norms Research described the social norms that govern men’s and women’s gendered water- and sanitation-related roles, focusing largely on gendered division of labor and roles in public life (_((((xxx))))_)[18, 20, 26, 59, 61, 62, 66, 76, 83, 88, 89, 97, 101–103, 110, 111, 123–126, 131, 132, 135, 140, 143, 153, 165, 179, 184–187, 190, 193, 198, 201, 209, 214, 220, 229, 243, 245, 258, 261, 273, 279, 282, 296, 301, 302, 304–306]. Women and girls are largely responsible for household water collection (_((((xxx))))_)[18, 20, 26, 62, 76, 88, 89, 102, 103, 110, 111, 123, 131, 153, 165, 179, 187, 193, 198, 201, 209, 229, 245, 261, 273, 282, 296, 301, 302, 304, 305]. Providing sufficient water for the household was described as important to being a good wife; failure to do so has resulted in shame and violence [153, 179, 273]. Normative roles extended beyond the home; girls at school in Swaziland were expected to fetch water rather than boys [220]. Gender intersected with other social identities to result in further marginalization or disadvantage related to roles and expectations. In India, lower caste women were expected to give priority water access to women from upper castes, particularly when water was scarce, [279] and were reported to lack access to handpumps constructed within upper caste areas, even when tasked with repairing them [106, 152]. In Malawi, women with disabilities experienced difficulty collecting water, though they are often still expected to fulfill this role [282]. Norms have influenced the extent that men engage in water collection and how they are perceived [110, 198, 258, 279, 296]. Men in Uganda who assisted with water collection were deemed emotionally unstable or bewitched, [165, 258] and boys in India were reportedly embarrassed to be seen helping girls carry water [187]. In Rwanda, men preferred water collection over other traditionally female tasks, though still viewed it as a woman’s task [305]. Norms of femininity and masculinity were found to be more fluid among lower castes in northwest India, enabling men to help women with water collection more easily than men in upper caste households [279]. When men or boys do collect water, it has been more acceptable when they consider it ‘helping’ women [261] or use technology–like bicycles, wheelbarrows, or motorcycles–while women and girls are expected to carry water [123, 165, 229, 258, 261]. Exceptionally, in Inuit communities, men are primary water collectors. They carry guns for protection against polar bears near water sources–something unacceptable for women to do; women experienced anxiety accessing water when men migrate for work [201]. Normative expectations affect women’s and girls’ sanitation-related practices. Rural Indian women reportedly suppressed urination and defecation urges when caregiving and household obligations were pressing [184] and were often responsible for assisting others, including children, adolescent girls, and elderly family members, with sanitation needs [62, 131, 135, 184, 190]. Women assumed more responsibilities for latrine cleaning than men because cleaning is typically considered women’s work.[186, 306] Norms govern public water and sanitation participation. In several countries, it was more acceptable for men to participate in the public sphere and serve in leadership roles, [66, 76, 103, 111, 123, 125, 126, 132, 140, 143] and to have technological jobs, like as handpump mechanics, while women were discouraged [66, 83, 261]. These normative beliefs are sometimes supported by men, women, and NGOs. In Thailand, women believed men were better suited for public leadership roles, and men questioned women’s participation and problem-solving capacities related to village water resources [193]. In sanitation planning initiatives in Kenya, a man justified women’s exclusion from participation in the sanitation initiatives stating, women’s brains were “like that of a child.” [143] NGOs have targeted men as household heads and ignored women in decision-making and public participation [124]. In rare cases, cultural beliefs facilitated women’s public participation; women were described as more trustworthy on water user committees in Uganda and Ghana [83, 102]. Normative societal and familial rules and restrictions have defined the boundaries of acceptable water and sanitation-related behaviors for women, including their engagement in the public sphere [61, 62, 66, 87, 89, 101–103, 110, 111, 124–126, 130, 140, 174, 177–179, 181, 182, 187–190, 197, 218, 234, 261]. Further details are provided in S1 Text. The S1 Text also describes women and girls’ reported experiences of shame, specifically related to menstruation and sanitation, as well as how norms related to shame and honor have been leveraged to change water and sanitation conditions and behaviors. Shifting norms. Water and sanitation-related norms, including roles, responsibilities, and restrictions, have shifted, but impacts are variable. Water initiatives have increased expectations and work for women: the introduction of piped water resulted in women having to fetch water for their husband’s bathing needs (India) [279] and doing all the clothes washing, instead of sharing responsibility (Vietnam) [58]. Some water and sanitation initiatives have shifted norms and expectations in women’s favor [26, 56, 125, 126]. WASH projects in Vanuatu resulted in men increasingly assisting with responsibilities like cooking and hygiene [26]. In Sri Lanka, a women’s group’s successful water project demonstrated women’s capacity to conduct public WASH projects [56]. In India, NGOs used facilitators to challenge norms that limited women’s ability to speak in village health committees that address WASH issues [125, 126]. However, initiatives that diverged from normative roles have faced resistance. When a project attempted to put household water connections in women’s names, women objected (India) [89]. Men with new homestead water access did not like their increased involvement in what they perceived as women’s work (Kenya) [88]. Norm change has emerged from changing circumstances; some displaced Syrian refugee girls did not face the same menstrual restrictions they did back home, though female refugees from Myanmar did not experience any shift [228]. 3.c Relations Relations have both facilitated and hindered water and sanitation-related behaviors and experiences. In India, social networks played an important role in women’s decision to purchase new water filters [204] and aided women’s water collection when queues were long [168]. In Bangladesh, [110] India, [279] and Uganda [165] women relied on social networks to access water, but noted that relationships could be strained or unreliable when water was scarce. Women avoided quarrels at collection sites in Kenya by waking early to get water [76]. Regarding sanitation, women frequently accompanied one another or asked men to accompany them for safety when open defecating, [135, 173–175, 182, 187, 189, 251] and to avoid harassment from community members when going to latrines and open defecation sites after dark [135, 143, 168, 182, 190, 228, 238]. Additionally, women in Kenya reported quarrels over contributions toward sanitation activities and maintenance of shared toilets, [170] and female toilet attendants in Europe reported poor treatment by patrons who refused payment [263]. Relations also influenced sanitation-related school experiences; girls reported bullying from boys if they were known to have defecated in the school toilet (Sweden [223]) and if boys knew girls were menstruating because of which toilets they used (India [247]). Research identified both change agents, those who deviate from the status quo and enhance women and girls’ empowerment, and gatekeepers, those who maintain the status quo and constrain women and girls’ choice and voice, related to water and sanitation. Specific examples of change agents and gatekeepers are provided in the S1 Text (SX). Water and sanitation conditions have strained both intra- and inter-household relations. In some cases, water collection responsibilities and having insufficient water to meet all household members’ needs have created tension and led to intra-household violence; further details are provided in S1 Text. Household sanitation-related conflicts were reported specifically in India. Adolescent girls were scolded by parents for taking too long or talking to boys when going for urination/defecation; newly married women were scolded for not following household sanitation rules; [189] women with children were scolded for abandoning children to meet sanitation needs; and women across life stages worried about upsetting others if they asked for assistance meeting sanitation needs [238]. Regarding inter-household relations, disputes with neighbors at water collection locations were widely reported [61, 108, 144, 165, 168, 179, 189, 198, 209, 258]. Water collection sites could be places of tension and danger, including sexual exploitation, for women and girls in Zimbabwe [123] and Uganda [165, 179]. In Kenya, disputes arose among women competing for water access, and verbal and physical fights erupted when women collecting payments favored women in the queue [61]. In India, women reported that their participation in a water project led to intrahousehold conflict; some women reported experiencing beatings when they spoke up at meetings (cite) [89]. Inter-household sanitation-related conflicts were reported related to shared toilets, [187] where women practice open defecation,[189, 190] and accessing sanitation facilities [175]. Finally, water and sanitation initiatives have both negatively and positively affected relations. Negative effects in India included increased expectations of wives to bring water home, quarrels, and conflicts at water points.[279] Positive effects included increased respect and support for women by men, changed division of labor, and increased ability of women to negotiate with husbands (Vanuatu [26]); reduced conflict between husbands and wives (Mozambique [153], Kenya, [88] and Vanuatu [26]); improved relationships between men and women (India [105]) and in families (Kenya [210] and Vietnam [58]); heightened status of women in and outside the home and positive attitudes and support for women’s collective work (India [56]); and greater acceptance of women performing WASH roles outside the home (India [129]).

Discussion We synthesized evidence on water, sanitation, and women and girls’ empowerment from 257 peer-reviewed empirical research articles, resulting in the most comprehensive synthesis of gender-focused water and sanitation research to date. Our review is more expansive and rigorous than recent WASH and gender or empowerment-focused reviews that restricted inclusion based on publication date, [39] only extracted data from titles and abstracts, [39] or focused more narrowly on the intersection of gender, water, and health [40] or on identifying the dimensions of empowerment used in WASH research [38]. The majority (86%) of included research was from Africa and Asia and focused on adults (69%). No studies focused primarily on men or boys, or on transgender or non-binary individuals, revealing patterns of research inequities that should be addressed to include more diverse geographies and populations. Our search and synthesis was grounded in an existing model of empowerment [45] which we iteratively expanded based on our review to include ‘freedom of movement’ within the Agency domain and ‘privacy’ within the Resources domain. Agency was the least commonly engaged domain among included articles (122; 47%); the Resources domains was dominant (241; 94%). This review not only contributes insights to those working in the WASH sector, it also augments understanding of the role of water and sanitation in discourse on empowerment more broadly. Water and sanitation research that engages empowerment and related domains is extensive and growing, yet clear conceptualization of empowerment remains limited. We found that 82% (211) of included articles were published since 2010, providing evidence that aligns with previous anecdotal observations that empowerment is increasingly a focus in water and sanitation research [28, 39]. Both the large body of work identified and its growth, which is consistent with growth in the broader field of women’s empowerment, [307] further justify the need to assess learning to date. Importantly, 124 (48%) included articles did not use ‘empowerment’ or related words (e.g. “empower”) in their text, but were included because they specifically reported on empowerment sub-domains (e.g safety, decision-making) aligned with our guiding model. Of the 133 (52%) articles that did use empowerment or related terms in their text, only 17 (13%; or 7% of total) provided a definition or conceptualization of women’s empowerment to inform their work. Our assessment aligns with a reflection by Dery et al. (2019) that the definition of empowerment in WASH research lacks clarity [38]. As this line of research continues, it is essential that researchers use empowerment-related terminology deliberately. Without solid conceptualization, whether by articulating a clear guiding definition or framework a priori, or by eliciting a local understanding of empowerment via the research (See Bisung and Dickin (2019) [64]), terms may be misused or become devoid of meaning [33]. The tool we created and used (Fig 1) can be adopted to assess engagement of empowerment concepts in future research. We identified only one article that used a quantitative tool to assess women’s empowerment related to WASH, the Empowerment in WASH Index, [308] highlighting an opportunity for future work. Additional tools are under development, such as the Agency, Resources, and Institutional Structures for Sanitation-related Empowerment (ARISE) Scales, [309] and Kayser et al. (2019) propose four priority areas for assessing gender equality and empowerment related to WASH [24] Adjacently related, another tool is under development focusing specifically on gender equality: the Water, Sanitation, and Hygiene Gender Equality Measure (WASH-GEM) [310]. The momentum around measuring empowerment and WASH, while exciting, merits caution. In her critical review of current practices for measuring women’s empowerment, Richardson (2018) provides three recommendations to ensure sound measurement: measures should draw on theory; analytic methods should be used to minimize implicit judgement and bias; and comprehensive information should be collected (like data from men or complementary qualitative data) [33]. Yount et al. (2018) note that empowerment measures should rigorously assess validity and reliability [311]. Furthermore, research on empowerment from other sectors teaches that a multitude of measures can also hinder learning by limiting comparability between studies, [32] and that tools should be selected intentionally based on context and need [35]. If WASH-related empowerment is to be monitored at scale, a consensus on indicators and associated measures will be needed eventually. As tools emerge, there will be a need to review and assess the similarities, differences, strengths, weaknesses, specific uses, and gaps to continue strengthening this line of research. Although existing measurement is limited, this review illuminates how water and sanitation circumstances and conditions have resulted in myriad negative impacts related to various sub-domains of women’s empowerment that remain unmonitored and under-evaluated. Illustratively, considerable research shows how compromised water and sanitation environments have contributed to women’s risk or experience of harassment or physical and sexual violence; (_((((xxx))))_)[61, 62, 70, 76, 86, 89, 101, 108, 110, 111, 123, 135, 138, 143, 144, 153, 168, 171–175, 177, 179, 181–184, 186–191, 198, 199, 201, 214, 217, 226, 231, 233, 238–240, 243, 251, 255, 257–266, 268–270] compromised mental well-being; [2, 76, 90, 96, 100, 108, 123, 139, 163, 165, 168, 170, 172, 173, 175, 177, 178, 185, 188, 189, 192, 198, 201, 202, 205, 209, 229, 271, 274, 275, 280, 283, 289] resulted in illness, infirmity, and bodily harm (_((((xxx))))_)[62, 63, 65, 70, 76, 78, 81, 86, 90, 101, 111, 118, 122, 123, 135, 141, 143, 144, 154, 158, 168–170, 172–174, 177–179, 181, 182, 184, 186–191, 195, 197–199, 201, 202, 208, 214, 220, 223, 225, 226, 231, 239–241, 244, 247, 256–259, 261, 272, 273, 276–278, 284, 285, 287, 288, 290, 296] or limiting of hygiene, food, and water; [76, 86, 98, 100, 123, 135, 144, 165, 168, 174, 179, 184, 192, 197, 198, 200, 202, 212, 224, 229, 232, 281] and suppression of urination, defecation and menstrual hygiene needs, [2, 62, 181, 184, 188, 190, 191, 214, 217, 224, 229, 235, 236, 238, 240, 241, 247, 248, 250, 270] among other impacts. However, estimates of the burden of inadequate WASH remain focused on disease outcomes [8]. Our review shows that the true burden of inadequate WASH is likely far greater, supporting calls to collect and report sex-disaggregated and gender-specific data that also considers intersectionalities, [312, 313] and to not discount or ignore impacts predominantly or only experienced by women and girls [314]. Specifically, the bodily integrity, health, and safety and security sub-domains are particularly relevant when assessing the health-related burdens of inadequate WASH. Finally, this review confirms the need to set goals for measuring, monitoring, and reporting the specific impacts of WASH on women and girls, including impacts that extend beyond health (e.g. time, freedom of movement, privacy) [22]. Despite the numerous studies that have documented impacts of water and sanitation conditions on sub-domains of women and girls’ empowerment, there has been scant action in response, warranting greater investment in programs and evaluations to create and assess change. For example, the Safety and Security domain is well-researched; 82 (32%) articles document links between WASH and safety and security, yet only one study evaluated a program that improved perceived safety [257]. Furthermore, WASH programs have the potential to catalyze change across domains of empowerment and to be transformative in the lives of women and girls, but only a few studies have documented these linkages and transformative change. Research in Ghana showed how a water project resulted in time savings, which further benefited well-being among women [194]. A water intervention in Kenya also enabled time savings, which led to improved intra-familial relationships [210]. WASH programming in Vietnam provided knowledge and skills, which women reported improved their decision-making, public participation, and relations [58]. Programs aiming to achieve transformative change should be evaluated to deepen the knowledge base on WASH and empowerment. To start, more research on Agency is warranted. Agency, which includes decision-making, leadership, collective action, and freedom of movement, is “the heart of empowerment” and transformation, [45] yet is the domain least studied. Research should aim to further understand Agesncy, including all sub-domains, in the context of WASH, including its relationship with other domains. Finally, political will and investment are necessary to ensure women and girls are prioritized in WASH initiatives. At a minimum, WASH initiatives should engage women meaningfully and not cause harm by bypassing them [102, 122, 124]. We summarize research and practice opportunities in text box 1. Box 1. Research and practice opportunities related to women’s and girls’ empowerment Acknowledge importance of empowerment in water and sanitation research and practice. This review elevates a substantial body of research that should be leveraged to inform research and practice moving forward.

This review elevates a substantial body of research that should be leveraged to inform research and practice moving forward. Measure, monitor, and report. Negative impacts on women and girls related to water, sanitation, and the sub-domains of empowerment are extensive, yet underassessed, rendering them invisible. Further work to improve measurement, monitoring, and reporting is needed to assess and enable change via programmes and policies.

Negative impacts on women and girls related to water, sanitation, and the sub-domains of empowerment are extensive, yet underassessed, rendering them invisible. Further work to improve measurement, monitoring, and reporting is needed to assess and enable change via programmes and policies. Act and Evaluate. Initiatives are needed to address, challenge, and transform systemic constraints related to women’s and girls’ resources and agency. Relevant existing evidence should be considered from the design phase. Investment is needed to fund and evaluate such initiatives to assess impact and enable further learning.

Initiatives are needed to address, challenge, and transform systemic constraints related to women’s and girls’ resources and agency. Relevant existing evidence should be considered from the design phase. Investment is needed to fund and evaluate such initiatives to assess impact and enable further learning. Use empowerment terminology deliberately. There is a need to deliberately define the term empowerment when used in research and practice, by leveraging an existing definition, model, or framework, or by eliciting a local understanding via research itself.

There is a need to deliberately define the term empowerment when used in research and practice, by leveraging an existing definition, model, or framework, or by eliciting a local understanding via research itself. Expand populations engaged in research and programming. The majority of research to date is in Asia and Africa and among adult women. There is an opportunity to learn from men, boys, transgender, and non-binary individuals, to do so across varied life stages and geographies, and to engage them in relevant programming.

The majority of research to date is in Asia and Africa and among adult women. There is an opportunity to learn from men, boys, transgender, and non-binary individuals, to do so across varied life stages and geographies, and to engage them in relevant programming. Expand research focus. The Resources domain in water and sanitation research is dominant. Further research across and between the other domains is warranted, specifically Agency, which is least represented, yet central to transformation. Research investigating the relationships between domains is also warranted. Strengths and limitations This review has leveraged an existing model of empowerment to analyze full texts of an extensive volume of research, resulting in the most comprehensive and rigorous synthesis on women’s and girls’ empowerment and water and sanitation to date. This review only captures studies available in English, does not include grey literature, could have engaged additional databases—particularly those that engage disciplines beyond public health—and broadened search terms to capture more relevant work, and research has continued to emerge since the search—all factors that may limit this review’s comprehensiveness. Further, other models of empowerment exist that could have framed the review. Still, this review provides a valuable base and resource from which to develop programming and further research, and does capture literature beyond public health because of our inclusion of ancestry and descendancy search methodologies. While this review captures research on menstruation, it only does so in the context of water and sanitation research and cannot be considered a comprehensive review of menstruation and empowerment. Hygiene was not a focus and should be considered in future reviews. Finally, while we intended to register the review, we began extraction to inform other work prior to registering and recent revisions to guidelines now stipulate extraction should not have started prior to registration and thus we were no longer eligible.

Conclusion Water and sanitation research specifically engaging women’s and girls’ empowerment in a well-defined or conceptualized manner is limited. However, a substantial body of research examining domains and sub-domains of empowerment exists that should be leveraged to develop and evaluate programs focused on improving the life outcomes of women and girls. Importantly, the integration of a gender lens into WASH research, and program and policy planning and evaluation, can enable the identification of inequities and potential harms and benefits, [312] and should be mainstreamed across the WASH sector [23]. Emergent discussions about ‘transformative WASH’ call for interventions that radically reduce fecal contamination [315] and chemicals [316] to impact health. However, our findings underscore the need for a more comprehensive ‘transformative WASH,’ which extends beyond reductions in contamination, to impact health and well-being more inclusively. Specifically, WASH researchers and practitioners should also integrate gender-transformative approaches that challenge and reduce systemic constraints on women’s and girls’ resources and agency, which is not only warranted but long overdue.

Acknowledgments We are grateful for the artistic contributions of Fernanda Kuri who assisted the authors in adapting the empowerment conceptual model by Van Eerdewijk et al. (2017) to be specific to this work (Fig 2).

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