Sanitation, stress, and life stage: A systematic data collection study among women in Odisha, India.
Open accessAbstract
Emerging evidence demonstrates how inadequate access to water and sanitation is linked to psychosocial stress, especially among women, forcing them to navigate social and physical barriers during their daily sanitation routines. We examine sanitation-related psychosocial stress (SRPS) across women's reproductive lives in three distinct geographic sites (urban slums, rural villages, and rural tribal villages) in Odisha, India. We explored daily sanitation practices of adolescent, newly married, pregnant, and established adult women (n = 60) and identified stressors encountered during sanitation. Responding to structured data collection methods, women ranked seven sanitation activities (defecation, urination, menstruation, bathing, post-defecation cleaning, carrying water, and changing clothes) based on stress (high to low) and level of freedom (associated with greatest freedom to having the most restrictions). Women then identified common stressors they encountered when practicing sanitation and sorted stressors in constrained piles based on frequency and severity of each issue. The constellation of factors influencing SRPS varies by life stage and location. Overall, sanitation behaviors that were most restricted (i.e., menstruation) were the most stressful. Women in different sites encountered different stressors, and the level of perceived severity varied based on site and life stage. Understanding the influence of place and life stage on SRPS provides a nuanced understanding of sanitation, and may help identify areas for intervention.
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Movement restrictions influenced women and girls' access to water and defecation, urination, and menstrual management locations, and are most widely reported in India.
“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][190][191].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [181]
General and sexual harassment are more frequently observed/documented in sanitation than water research.
“General harassment, including taunting, teasing, name calling, and throwing things at women or girls is more frequently observed in sanitation [138, 168, 174, 175, 181, 187, 190, 263] than water research [168,199] Sexual harassment, including verbal harassment, peeping, flashing, and male masturbation is also more frequently documented in sanitation [171-174, 189, 190, 214, 217, 226, 231, 233]”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [181]
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 [181]
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 [181]
Compromised water and sanitation environments have led to suppression of urination, defecation and menstrual hygiene needs.
“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.”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [181]
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 [18]
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 [44]
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 [44]
Religious restrictions, physical separation, and inability to touch food during menstruation were consistent with findings among other women in India and schoolgirls in Kenya.
“Religious restrictions, physical separation, and inability to touch food during menstruation were consistent with findings among other women in India and schoolgirls in Kenya [8, 26, 44].”
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 [44]
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 [44]
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 [53]
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References 35 · Cited by 152
- Authors
- Hulland, K. R. S., Chase, R. P., Caruso, B. A., Swain, R., Biswal, B., Sahoo, K. C., Panigrahi, P., & Dreibelbis, R.
- Affiliations
- University of Chicago (US)
- Johns Hopkins University (US)
- Emory University (US)
- Asian Institute of Public Health (IN)
- University of Nebraska Medical Center (US)
- University of Oklahoma (US)
- Corresponding author
- Dreibelbis, Robert
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2015-11-09
- Volume
- 10
- Issue
- 11
- Pages
- e0141883
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC4638353
- OpenAlex
- W2121303526
- Cited by
- 152
- References
- 35
- Citations by year
- 2026: 12 · 2025: 15 · 2024: 19 · 2023: 22 · 2022: 13 · 2021: 17 · 2020: 16 · 2019: 14 · 2018: 10 · 2017: 9 · 2016: 4 · 2014: 1
- FWCI
- 17.78
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- SHAREOK (University of Oklahoma; Oklahoma State University; Central Oklahoma University) (submittedVersion, cc-by)
- Knowledge@UChicago (University of Chicago) (submittedVersion, cc-by-nc-nd)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- University of Chicago (cc-by)
- 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
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Menstrual Health and Disorders
- Keywords
- menstrual hygiene, defecation, micturition, water carrying, bathing, life stages, urban slums, rural villages, tribal villages, Odisha, gender and sanitation, water access
- MeSH terms
- Adolescent, Adult, Female, Humans, Hygiene, India, Poverty Areas, Pregnancy, Surveys and Questionnaires, Rural Population, Sanitation, Stress, Psychological, Toilet Facilities, Urban Population, Young Adult, Drinking Water
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