Sanitation-related psychosocial stress: a grounded theory study of women across the life-course in Odisha, India.
Open accessAbstract
While sanitation interventions have focused primarily on child health, women's unique health risks from inadequate sanitation are gaining recognition as a priority issue. This study examines the range of sanitation-related psychosocial stressors during routine sanitation practices in Odisha, India. Between August 2013 and March 2014, we conducted in-depth interviews with 56 women in four life stages: adolescent, newly married, pregnant and established adult women in three settings: urban slums, rural villages and indigenous villages. Using a grounded theory approach, the study team transcribed, translated, coded and discussed interviews using detailed analytic memos to identify and characterize stressors at each life stage and study site. We found that sanitation practices encompassed more than defecation and urination and included carrying water, washing, bathing, menstrual management, and changing clothes. During the course of these activities, women encountered three broad types of stressors-environmental, social, and sexual-the intensity of which were modified by the woman's life stage, living environment, and access to sanitation facilities. Environmental barriers, social factors and fears of sexual violence all contributed to sanitation-related psychosocial stress. Though women responded with small changes to sanitation practices, they were unable to significantly modify their circumstances, notably by achieving adequate privacy for sanitation-related behaviors. A better understanding of the range of causes of stress and adaptive behaviors is needed to inform context-specific, gender-sensitive sanitation interventions.
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Lack of knowledge about MHM was a source of anxiety among the girls in this study, and this can lead to inadequate menstrual hygiene management (e.g. to predict onset of next period).
“Lack of knowledge about MHM was a source of anxiety among the girls in this study, and this can lead to inadequate menstrual hygiene management (e.g. to predict onset of next period) [19, 27, 28].”
From Menstrual health and school absenteeism among adolescent girls in Uganda (MENISCUS): a feasibility study (2018) · cites this paper as [27]
The Discussion (page unavailable) reports that lack of menstrual hygiene management knowledge is common in low-income settings and discusses it among sanitation-related stressors. It does not say that this lack of knowledge causes anxiety or inadequate management through difficulty predicting the next period. (LLM, conf=0.82)
Experimental — accuracy not yet measuredFamily members (often husbands, fathers, and in-laws) restricted water fetching and sanitation-related movements, most intensely for unmarried daughters and recently married and pregnant women, less intensely for women of lower castes and widows.
“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]).”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Fear of sexual assault was reported to be greatest at night, leading some women to use bags and buckets for sanitation needs; in India, urban settings reported greater fear than rural settings.
“Fear of sexual assault was reported to be greatest at night, [123, 186, 238, 239, 255] leading some women to use bags and buckets for sanitation needs [175, 255, 270].In India, those in urban settings reported greater fear of sexual assault when accessing sanitation than those in rural settings [181,189].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Women reported different health concerns, mostly negative, based on life stage and circumstance, including pregnant women's fears related to sanitation-related superstitions, stress about accessing sanitation sites for women with trouble controlling urination or defecation, lower odds of good health for women reliant on bags, buckets, or open defecation, and difficulty/pain defecating and urin
“Women reported different health concerns, mostly negative, based on life stage and circumstance.Notably, pregnant women expressed health fears related to sanitationrelated superstitions (India [184, 189]), women with trouble controlling urination or defecation stressed about accessing sanitation sites (India [2]), women reliant on bags, buckets, or open defecation had substantially lower odds of”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Women reported myriad sanitation-related stressors, including fear of being attacked by men or ghosts, being shamed for using open defecation sites, suppressing urination or defecation, withholding food and water, needing help to meet sanitation needs, being hurried while using shared facilities, sanitation-related costs, and lacking privacy or being seen by others, especially men, while openly
“Women reported myriad sanitation-related stressors, including fear of being attacked by men or ghosts, [177, 181, 184, 189, 229, 238] being shamed for using open defecation sites, [172] suppressing urination or defecation, [184] withholding food and water, [184] needing help to meet sanitation needs, [184] being hurried while using shared facilities, [168, 185, 188] sanitation-related costs, [170,”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Women reported challenges related to privacy and water, specifically concerning hygiene, including challenges obtaining privacy at water sources used for bathing, post-defecation cleansing, and washing, particularly during menstruation.
“Women reported challenges related to privacy and water, specifically concerning hygiene.Women and girls in Bangladesh, [199] India, [184, 189, 226] Indonesia, [115] and Mozambique [175, 261] described challenges obtaining privacy at water sources used for bathing, post-defecation cleansing, and washing, particularly during menstruation.”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Privacy of household and shared latrines is compromised by broken or missing doors, missing locks, and poor construction; women worried about being seen walking to latrines, waiting in queues, having others hear or smell their activity, or the proximity of latrines to houses, main roads, or public spaces.
“Privacy of household and shared latrines is compromised by broken [189] or missing doors, [184, 248] missing locks, [175,191,248,251] and poor construction [175,191,240,251].Furthermore, women worried about being seen walking to latrines; [189, 227] waiting in queues; [130] having others hear or smell their activity; [175] or the proximity of latrines to houses, main roads, or public spaces [69,1”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Women coped with sanitation stressors by seeking social support, withholding food or drink, or changing the timing of sanitation behaviors, though adaptations could also cause stress.
“Women coped with sanitation stressors by seeking social support, withholding food or drink, or changing the timing of sanitation behaviors, though adaptations could also cause stress [168, 177, 184, 189].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Social capital has facilitated sanitation access; women and girls have formed and maintained social connections when accessing sanitation locations, and sought social support to ensure privacy and safety and to protect reputations when urinating or defecating.
“Social capital has facilitated sanitation access.Women and girls have formed and maintained social connections when accessing sanitation locations, [130, 182, 189] and sought social support to ensure privacy and safety and to protect reputations when urinating or defecating [173, 182, 184, 187-190, 223, 226].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Inter-household sanitation-related conflicts were reported related to shared toilets, where women practice open defecation, and accessing sanitation facilities.
“Inter-household sanitation-related conflicts were reported related to shared toilets, [187] where women practice open defecation, [189,190] and accessing sanitation facilities [175].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Adolescent girls in India were scolded by parents for taking too long or talking to boys when going for urination/defecation.
“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]”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
Newly married women in India were scolded for not following household sanitation rules.
“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]”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [189]
The finding that higher levels of sanitation according to existing criteria were not strongly associated with more positive perceptions of the menstrual management environment is consistent with studies of girls in schools reporting that girls may avoid using sanitation facilities due to stigma around menstruation and fears for privacy, and with women's sanitation-related stress.
“However, this finding is consistent with studies of girls’ in schools, which have reported that girls may avoid using sanitation facilities due to stigma around menstruation and fears for privacy [2,12,13], and women’s sanitation-related stress [16,17].”
From The relationship between household sanitation and women’s experience of menstrual hygiene: Findings from a cross-sectional survey in Kaduna State, Nigeria. (2018) · cites this paper as [16]
These findings seem inconsistent with high reports of stress associated with menstrual management in studies amongst school girls in sub-Saharan Africa and among adult women in India.
“These findings seem inconsistent with high reports of stress associated with menstrual management in studies amongst school girls in sub-Saharan Africa [2,5,13,34], and among adult women in India [16,18,35].”
From The relationship between household sanitation and women’s experience of menstrual hygiene: Findings from a cross-sectional survey in Kaduna State, Nigeria. (2018) · cites this paper as [16]
Menstruation concerns extend beyond adolescence and WASH.
“Yet, menstruation concerns extend beyond adolescence and WASH.”
From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [45]
Studies in India, and Odisha specifically, have explored women's MHM challenges beyond adolescence, but have focused primarily on issues related to WASH conditions.
“Studies in India, and Odisha specifically, have explored women’s MHM challenges beyond adolescence, but have focused primarily on issues related to water, sanitation, and hygiene (WASH) conditions, including sanitation insecurity, experiences with sanitation-related psychosocial stress, and reproductive tract infections [19, 28, 44–46].”
From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [45]
The need for privacy beyond changing and inclusive of bathing, urination and defecation while menstruating, and washing, drying, and storing cloth, has been noted by other studies in India and Odisha specifically.
“The need for privacy beyond changing and inclusive of bathing, urination and defecation while menstruating, and washing, drying, and storing cloth, has been noted by other studies in India and Odisha specifically [8, 44, 45].”
From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [45]
Several of these needs and concerns have been noted elsewhere, suggesting applicability to other populations and contexts.
“Several of these needs and concerns have been noted elsewhere, suggesting applicability to other populations and contexts:”
From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [45]
Concerns connected to psychosocial support, agency, gendered environments, the role of men and boys, and social norms persist even if menstrual management needs are met.
“Concerns connected to psychosocial support, agency, gendered environments, the role of men and boys, and social norms persist even if menstrual management needs are met [44, 45, 71].”
From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [45]
While episodes of vaginal bleeding beyond menstruation are not noted, menstruation-related behaviours were considered the most stressful for women.
“While episodes of vaginal bleeding beyond menstruation are not noted, menstruation-related behaviours were considered the most stressful for women.52”
From Beyond menstrual hygiene: addressing vaginal bleeding throughout the life course in low and middle-income countries (2017) · cites this paper as [52]
Recent studies in India highlighted the 'sanitation-related psychosocial stress' girls and women experience around their sanitation needs, including urination, defecation and menstruation.
“More specifically, recent studies in India highlighted the ‘sanitation-related psychosocial stress’ girls and women experience around their sanitation needs (ie, urination, defecation, menstruation).52 53”
From Beyond menstrual hygiene: addressing vaginal bleeding throughout the life course in low and middle-income countries (2017) · cites this paper as [52]
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- Authors
- Sahoo, K. C., Hulland, K. R. S., Caruso, B. A., Swain, R., Freeman, M. C., Panigrahi, P., & Dreibelbis, R.
- Affiliations
- Asian Institute of Public Health (IN)
- University of Chicago (US)
- Emory University (US)
- University of Nebraska Medical Center (US)
- University of Oklahoma (US)
- Corresponding author
- Dreibelbis, Robert
- Venue
- Social Science & Medicine
- Publisher
- Elsevier BV
- Published
- 2015-08
- Volume
- 139
- Pages
- 80-89
- ISSN
- 0277-9536 (ISSN-L)
- OpenAlex
- W1758310571
- Cited by
- 300
- References
- 39
- Citations by year
- 2026: 18 · 2025: 26 · 2024: 26 · 2023: 30 · 2022: 40 · 2021: 29 · 2020: 31 · 2019: 34 · 2018: 26 · 2017: 24 · 2016: 12 · 2015: 3 · 2014: 1
- FWCI
- 50.25
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Social Science & Medicine (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- Funders
- Department for International Development
- Topics
- Social Sciences › Gender Studies › Gender Studies and Social Issues
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Social Sciences › Health › Public Health and Social Inequalities
- Keywords
- sanitation, psychosocial stress, women's health, life course, menstrual management, sexual violence, privacy, urban slums, rural villages, indigenous peoples, water carrying, Odisha
- MeSH terms
- Adolescent, Adult, Environment, Female, Health Services Needs and Demand, Humans, India, Pregnancy, Psychology, Rural Population, Sanitation, Stress, Psychological, Toilet Facilities, Public Health Practice, Grounded Theory
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