Background: Significant developmental challenges in low-resource settings limit access to sustainable water, sanitation, and hygiene (WASH). However, in addition to reducing human agency and dignity, gendered WASH inequities can also increase disease burden among women and girls. In this systematic review, a range of challenges experienced by women relating to inadequate WASH resources are described and their intersection with health are explored. We further assess the effectiveness of interventions in alleviating inequalities related to the Sustainable Development Goals (SDGs) three (health), five (gender), and six (water). Methods: We searched the MEDLINE database to identify research articles related to water (i.e., WASH), gender, and sustainability. An analysis of both observational and interventional studies was undertaken. For each study, content analysis was performed to identify the relevant WASH, gender, and health related outcomes, and the main conclusions of the study. Results: Key themes from our search included that women and girls face barriers toward accessing basic sanitation and hygiene resources, including a lack of secure and private sanitation and of Menstrual Hygiene Management (MHM) resources. In total, 71% of identified studies reported a health outcome, suggesting an intersection of water and gender with health. Half of the research studies that included a health component reflected on the relationship between WASH, gender, and infantile diseases, including under-5 mortality, waterborne parasites, and stunting. In addition, we found that women and girls, as a result of their role as water purveyors, were at risk of exposure to contaminated water and of sustaining musculoskeletal trauma. A limited number of studies directly compared gender differences in accessing WASH resources, and an even smaller fraction (N = 5, 8.5%) reported sex-disaggregated outcomes. Educational, infrastructural, and programmatic interventions showed promise in reducing WASH and health outcomes. Indeed, infrastructural WASH interventions can be successful if long-term maintenance is ensured. Conclusions: Significant WASH inequities in women and girls further manifest as health burdens, providing strong evidence that the water-gender-nexus intersects with health. Thus, addressing gender and water inequities holds the potential to alleviate disease burden and have a significant impact on achieving the SDGs, including SDG three, five, and six.

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A Systematic Review of Water and Gender Interlinkages: Assessing the Intersection With Health

In low- and middle-income countries, a common component of water, sanitation, and hygiene (WASH) interventions is the goal of empowerment of beneficiaries, particularly poor households. Empowerment is viewed as an important development goal in itself, as well as a way to obtain improved WASH outcomes. However, empowerment is a complex and multi-dimensional concept, and it is often not clear how it is defined in WASH sector programming. This scoping review explores how concepts of empowerment have been used in the WASH sector and delineates relevant empowerment dimensions. Medline, Embase, and Global Health databases were searched for in the peer-reviewed literature published in English. A total of 13 studies were identified. Five major interrelated empowerment dimensions were identified: access to information, participation, capacity building, leadership and accountability, and decision-making. This review provides researchers and practitioners with a greater understanding of dimensions of empowerment that are relevant for strengthening WASH interventions, as well as tracking progress toward gender and social equality outcomes over time. This understanding can help ensure inclusive WASH service delivery to achieve gender-sensitive Sustainable Development Goal (SDG) targets for universal water and sanitation access.This article has been made Open Access thanks to the generous support of a global network of libraries as part of the Knowledge Unlatched Select initiative.

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Understanding empowerment in water, sanitation, and hygiene (WASH): a scoping review

The connections between gender and water, sanitation, and hygiene (WASH) are profound, and the sector is beginning to explore the integration of gender-transformative principles into WASH programming and research. Gender-transformative approaches challenge inequalities and move beyond an instrumentalist approach to gender in development interventions. Through a critical review of academic empirical studies, this paper explores the last decade of WASH-gender literature (2008–2018). Trends were visualised using an alluvial diagram. The reviewed literature was underpinned by a diversity of disciplines, yet was dominated by women-focused, water-focused studies. Although the studies addressed many important gender considerations, few studies engaged with transformational aspects of gender equality. The majority of the studies were based in rural sub-Saharan Africa and South Asia, indicating opportunity to explore contextual dynamics in other areas of the global south. Lastly, the studies primarily focus on women of productive age; only a few studies touched on gender dynamics relevant for a diversity of women, and men and boys were mostly absent. Insights from this analysis can inform future studies at the intersection of WASH and gender. Researchers and practitioners are encouraged to include a diversity of voices, reflect on the strengths and limitations of research disciplines, and incorporate gender-transformative concepts.

WASH and Gender: a critical review of the literature and implications for gender-transformative WASH research

This international literature review of the tourism–water nexus identifies a gender gap. Tourism development can affect water supply both quantitatively and qualitatively. Many regions will face considerable problems of water availability and quality, affecting their tourism sector and increasing competition with local residents, and other industries especially agriculture. This international review of literature explores the tourism–water nexus, comparing and contrasting literature published in English, Chinese, and Spanish. Securing access to safe water for continued tourism development is a common theme and the vast majority of work has focused on hotels including water pricing, water-saving practices and innovative management methods. In all continents, struggles are apparent, and the unsustainability of tourism is having impacts on water quantity and quality. This article identifies significant gaps in the literature including climate change, the energy-water nexus, and the links with the Sustainable Development Goals. Furthermore, studies from a gendered perspective are minimal and the potential for areas of further gendered studies within the tourism–water nexus are highlighted including intersectionality, water insecurity and sanitation, tourism and gender based violence, and additional unpaid care work.

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“Tourism, water, and gender”—An international review of an unexplored nexus

Background
Water and sanitation programs historically have focused on women9s instrumental value in improving effectiveness and impact of programs, though focus is shifting to consider how programming and conditions may contribute to women9s empowerment an gender equality. To date no systematic review has comprehensively assessed and synthesized evidence on water and sanitation and women9s and girls9 empowerment. The primary aims of this review were to: a) identify empirical water and sanitation research that engaged empowerment and/or empowerment-related domains from a pre-specified conceptual model; b) tabulate and report how empowerment-related terminology was 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.

Methods and Findings
The conceptual model of women9s and girls9 empowerment developed by van Eerdewijk et.al (2017) informed our search strategy and analysis. The model presents three interrelated domains (agency, resources, institutional structures) and 13 sub-domains of empowerment. We searched MEDLINE, EMBASE, CABI Global Health, PsycINFO, CINAHL and AGRICOLA for any peer-reviewed sources presenting research related to water and/or sanitation and either empowerment and/or related terms from the conceptual model (4 May 2020). Systematic and ancestry and decendency searching identified 12,616 publications, of which 257 were included following screening, representing 1,600,348 participants. We assessed all studies using the Mixed-Method Appraisal Tool (MMAT). We followed the 9best-fit framework synthesis9 approach for analysis, using the domains and sub-domains of the conceptual model as codes to assess all included sources. During coding, we inductively identified two additional sub-domains relevant to water and sanitation: privacy and freedom of movement. Thematic analysis guided synthesis of coded text by domain and sub-domain. The majority of research took place in Asia (46%; 117) or Africa (40%; 102), engaged adults (69%; 177), and were published since 2010; (82%; 211). A greater proportion of studies focused on water (45%; 115) than sanitation (22%; 57) or both (33%; 85). Over half of articles use the term empowerment yet only 7% (17) provided a clear definition or conceptualization. Agency was the least commonly engaged domain (47%; 122) while the Resources domain was dominant (94%; 241). Measures for assessing empowerment and related domains is limited. This review was limited by only including sources in English and only includes menstruation-focused research in the context of water and sanitation.

Conclusions
Water and sanitation research specifically engaging women9s and girls9 empowerment in a well-defined or conceptualized manner is limited. A substantial body of research examining domains and sub-domains of empowerment exists, as does research that illuminates myriad negative impacts of water and sanitation conditions and circumstances women9s and girl9s well-being. Available research should be used to develop and evaluate programs focused on improving the life outcomes of women and girls, which has only been minimally conducted to date. A more comprehensive 9transformative WASH9 that includes gender-transformative approaches to challenge and reduce systemic constraints on women9s and girls9 resources and agency is not only warranted but long overdue.

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Water, Sanitation, and Women's Empowerment: A systematic review and qualitative metasynthesis

This article presents the results of empirical research conducted in Central Vietnam in 2016 into water, sanitation, and hygiene (WASH) initiatives. It uncovered changes in gender relations and power dynamics at both household and community levels, aiming to explore the extent to which both practical and strategic interests of women can be influenced and changed by WASH policies and programming. In particular, we were interested in assessing the impact of a Gender and WASH Monitoring Tool (GWMT), developed by Plan International Australia and Plan Vietnam, on women’s strategic gender needs. In this article, we discuss the types of changes reported by women and men of different ages and ethnicities and the reasons for their occurrence. There were a wide range of reported reasons for change, with implications for our understanding of the relationship between changes in gender relations at the household and community levels. We also consider the relationship between wider shifts in social norms in the...

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John Kelleher

Papers

Transforming gender relations through water, sanitation, and hygiene programming and monitoring in Vietnam