Drivers of women's sanitation practices in informal settlements in sub-Saharan Africa: a qualitative study in Mathare Valley, Kenya

Shared sanitation in informal settlements: A systematic review and meta-analysis of prevalence, preferences, and quality

Shared sanitation facilities are not considered a type of basic sanitation by the WHO/UNICEF Joint Monitoring Programme (JMP), though they may be the only alternative to open defecation in urban informal settlements. Additionally, JMP indicators for sanitation do not cover aspects related to the quality of shared sanitation, such as those outlined in the Human Right to Water and Sanitation (HRTWS) framework. Data on the prevalence of shared sanitation within informal settlement areas is limited, and there is a need to understand user preferences, experiences, and barriers to the use of shared sanitation to inform effective policy and practice. This systematic review aims to summarize the prevalence and number of households sharing sanitation in informal settlements globally, as well as user experiences and barriers to successful implementation of shared sanitation. We included studies available in English and published after January 1, 2000. We retrieved 4741 articles from seven databases and included a total of 167 relevant publications. Among included studies, 54 reported the prevalence of shared sanitation in informal settlements, and 138 studies reported on user perceptions and experiences related to shared sanitation quality. A meta-analysis of studies reporting the prevalence of shared sanitation in informal settlements globally revealed an estimated overall prevalence of 67% [95% CI: 61%-73%]. Commonly reported user preferences included cleanliness to promote continued use of shared facilities, privacy with a lockable door, facilities for menstrual hygiene management, safety and protection against violence, 24/7 access, proper lighting, and shared responsibility for facility management - which align with the HRTWS framework and represent barriers to shared sanitation use. Based on the findings of this review, we recommend including the number of households or people sharing a sanitation facility in monitoring of shared sanitation quality, locating sanitation facilities within compounds, where applicable, and promoting safety, dignity, and privacy of all users in the development of shared sanitation quality indicators.

Socio-ecological impacts of extreme weather events in two informal settlements in Nairobi, Kenya

Climate change is expected to profoundly impact health and coping and widen social and environmental inequalities. People living in informal settlements are especially vulnerable to climate change as they are often located in ecologically sensitive areas more susceptible to extreme weather events (EWEs), such as floods, droughts, and heat waves. Women residing in informal settlements are especially vulnerable to climate change and related EWEs because they are more likely to experience worse health-related impacts than men but are less likely to have access to health-related services. Despite this inequality, there is a dearth of research that focuses on the impacts of EWEs on women in informal settlements. This study aims to explore the multidimensional impacts of EWEs on the daily lives of women in informal settlements through the lens of socio-ecological theory. Study data is from six monthly surveys (1 September 2022-28 February 2023) collected from a probability sample of 800 women living in two of the largest informal settlements in Nairobi, Kenya. This data is part of an ongoing longitudinal study that uses community participatory methods to investigate the effects of climate change on health and wellbeing in informal settlements by a team of 16 community health volunteers who lead data collection and provide expertise in ongoing analysis. Findings show profound impacts on women's health and wellbeing across individual, micro-, meso-, exo-, and macrosystems. These include physical and mental health, financial disruptions, property issues, social impacts, and impacts on their surrounding physical environment, such as disrupted food or water access, poor air quality, drainage issues, and safety concerns. In addition, findings highlight the critical importance of the chrono- and biosphere systems in research focused on the impacts of climate change and related EWEs among climate-vulnerable communities and marginalized populations within them.

Determinants of dietary diversity and drivers of food choice among low-income consumers in urban Kenya, Malawi and Zimbabwe

INTRODUCTION

Rapid urbanisation affects lifestyle and eating habits, predominantly causing a dietary shift that adds challenges to meet dietary recommendations within a complex food system. This research investigated dietary diversity and food choice drivers among low-income consumers in three urban settlements (Nairobi, Kenya; Bulawayo, Zimbabwe and Lilongwe, Malawi, representing rapid, moderate and slow urban growth patterns, respectively) as a first step towards improving diets across cultures and geographies.

METHODS

Mixed methods data collection was employed for this study. Qualitative methods such as rapid foodscape appraisal workshops and food stories in selected low-income settlements in Nairobi, Bulawayo and Lilongwe were utilised to collect information on the food environments (food balances, infrastructure, safety, policies and institutions). Quantitative data such as socio-demographic characteristics and dietary diversity were collected via structured questionnaires using Cognitive Edge's SenseMaker® (n = 890, 450 and 440 for Nairobi, Bulawayo and Lilongwe, respectively). The dietary intake of respondents was assessed using a 24-h recall, which was then converted to the food group diversity score (FGDS).

RESULTS

Different levels of compounded stress affected dietary diversity and quality, including high food prices, concerns about sanitation and hygiene and the role of food standards regulation bodies. The mean FGDS across all locations was lower than the recommended cut-off of 5 (4.5, 2.8 and 2.6 across Nairobi, Zimbabwe and Lilongwe, respectively). Additionally, in Nairobi, there were gender differences in diet diversity, with men having a higher dietary diversity score than women (4.6% vs. 4.3%; p = 0.004). The majority of respondents in Lilongwe (65%) reported price as the most important driver of food choice, compared to 38% in Nairobi and 42% in Bulawayo.

DISCUSSION/CONCLUSIONS

Our observation of poor-quality diets provides further evidence of the need for food policies that are cognisant of the nutrition and health of the growing population of the urban poor. Such policies would focus on lowering the costs of nutritious foods as well as ensuring food safety within the complex food system observed in the urban low-income environment.

Sanitation-related violence against women in informal settlements in Kenya: a quantitative analysis

Introduction

Approximately 3.6 billion people around the world do not have access to safe sanitation options. Those lacking access are not only at risk of diarrheal disease, other tropical diseases, and parasitic infections, they are at greater risk of experiencing violence, particularly women and girls. The burden of lack of access to safe sanitation is disproportionately experienced by women in informal settlements in lower- and middle-income countries, where violence rates tend to be higher and access to sanitation lower. Women lacking access to safe toilets often have to walk long distances to access a facility or open site or use shared toilet facilities, which increase their vulnerability to violence.

Methods

We explore the prevalence and multilevel factors associated with women's experiences, observations, and exposure to stories about past-year sanitation-related violence in a probability sample of 550 women in a large informal settlement in Nairobi, Kenya using chi-square tests and multivariate logistic regressions.

Results

Findings suggest that social/community engagement and social/cultural beliefs are important considerations for hearing about and observing sanitation-related violence, but less so experiences of sanitation-related violence. Alternatively, individual-level and technological factors may be critical factors in actual experiences of violence.

Discussion

Sanitation-related violence and creating an environment of safety in which women can take care of their sanitation-related needs in ways that also protect them, their families, and their communities is critical for meeting sanitation-related development agendas and goals such as Sustainable Development Goal 6.2 to achieve access to adequate and equitable sanitation and hygiene for all by 2030.

Environmental determinants of access to shared sanitation in informal settlements: a cross-sectional study in Abidjan and Nairobi

BACKGROUND

Universal access to basic sanitation remains a global challenge, particularly in low- and middle-income countries. Efforts are underway to improve access to sanitation in informal settlements, often through shared facilities. However, access to these facilities and their potential health gains-notably, the prevention of diarrheal diseases-may be hampered by contextual aspects related to the physical environment. This study explored associations between the built environment and perceived safety to access toilets, and associations between the latter and diarrheal infections.

METHODS

A cross-sectional study was carried out between July 2021 and February 2022, including 1714 households in two informal settlements in Abidjan (Côte d'Ivoire) and two in Nairobi (Kenya). We employed adjusted odds ratios (aORs) obtained from multiple logistic regressions (MLRs) to test whether the location of the most frequently used toilet was associated with a perceived lack of safety to use the facility at any time, and whether this perceived insecurity was associated with a higher risk of diarrhea. The MLRs included several exposure and control variables, being stratified by city and age groups. We employed bivariate logistic regressions to test whether the perceived insecurity was associated with settlement morphology indicators derived from the built environment.

RESULTS

Using a toilet outside the premises was associated with a perceived insecurity both in Abidjan [aOR = 3.14, 95% confidence interval (CI): 1.13-8.70] and in Nairobi (aOR = 57.97, 95% CI: 35.93-93.53). Perceived insecurity to access toilets was associated with diarrheal infections in the general population (aOR = 1.90, 95% CI: 1.29-2.79 in Abidjan, aOR = 1.69, 95% CI: 1.22-2.34 in Nairobi), but not in children below the age of 5 years. Several settlement morphology features were associated with perceived insecurity, namely, buildings' compactness, the proportion of occupied land, and angular deviation between neighboring structures.

CONCLUSIONS

Toilet location was a critical determinant of perceived security, and hence, must be adequately addressed when building new facilities. The sole availability of facilities may be insufficient to prevent diarrheal infections. People must also be safe to use them. Further attention should be directed toward how the built environment affects safety.

"Next, it will be you": Women's Fear of Victimization and Precautionary Safety Behaviors in Informal Settlement Communities in Nairobi, Kenya

Around one billion people live in informal settlements globally, including over half of Nairobi, Kenya's 3 million residents. The purpose of this study was to explore women's fear of victimization within Mathare, an informal settlement in Nairobi, Kenya and how fear of victimization influences women's behaviors. Fifty-five in-depth interviews were conducted with women in 2015-2016. A modified grounded theory approach guided data collection and analysis. Findings suggest fear of victimization is a serious concern in informal settlements, but women have found ways to adapt their behaviors to cope and to continue to function and protect their children despite fearing victimization.

Associations between WASH-related violence and depressive symptoms in adolescent girls and young women in South Africa (HPTN 068): a cross-sectional analysis

OBJECTIVE

There is a lack of research on experiences of WASH-related violence. This study aims to quantify the association between experience or worry of violence when using the toilet or collecting water and depressive symptoms among a cohort of young women in South Africa.

METHODS

Data are from visit 3 of the HPTN 068 cohort of adolescent girls in rural Mpumalanga Province, South Africa. Participants (n=1798) included in this analysis were aged 13-21 at baseline. Lifetime experience of violence or fear of violence when using the toilet and collecting water was collected by self-report; depressive symptoms in the past week were measured using the Center for Epidemiological Studies Depression Scale (CES-D). We used G-computation to calculate the prevalence difference (PD) and prevalence ratio of depression (CES-D score >15) associated with each domain of violence, controlling for baseline covariates.

FINDINGS

A total of 15.1% of respondents reported experiencing violence when using the toilet; 17.1% reported experiencing violence when collecting water and 26.7% reported depression. In adjusted models, those who reported experiencing violence when using the toilet had an 18.1% higher prevalence of depression (95% CI: 11.6% to 24.4%) than those who did not experience violence when using the toilet. Adjusted prevalence of depression was also higher among those who reported violence when collecting water (PD 11.9%, 95% CI: 6.7% to 17.2%), and who worried about violence when using the toilet (PD 12.8%, 95% CI: 7.9% to 19.8%), as compared with those who did not report these experiences. Worrying about violence when collecting water was not associated with depression after adjusting for covariates.

CONCLUSION

Experience of WASH-related violence is common among young women in rural South Africa, and experience or worry of experiencing violence is associated with higher prevalence of depressive symptoms.

TRIAL REGISTRATION NUMBER

NCT01233531; Post-results.

Shared but Clean Household Toilets: What Makes This Possible? Evidence from Ghana and Kenya

Shared sanitation facilities are not considered as basic sanitation owing to cleanliness and accessibility concerns. However, there is mounting evidence that some shared household toilets have a comparable level of service as private toilets. This study examined the factors that contribute to the quality of shared household toilets in low-income urban communities in Ghana and Kenya. The study design comprised household surveys and field inspections. Overall, 843 respondents were interviewed, and 838 household shared sanitation facilities were inspected. Cleanliness scores were computed from the facility inspections, while a total quality score was calculated based on 13 indicators comprising hygiene, privacy, and accessibility. Regression analyses were conducted to determine predictors of cleanliness and the overall quality of the shared sanitation facilities. More than four out of five (84%) shared toilets in Ghana (N = 404) were clean, while in Kenya (N = 434), nearly a third (32%) were clean. Flush/pour-flush toilets were six times (p < 0.01 aOR = 5.64) more likely to be clean. A functional outside door lock on a toilet facility and the presence of live-in landlords led to a threefold increase (p < 0.01 aOR = 2.71) and a twofold increase (p < 0.01 aOR = 1.92), respectively in the odds of shared sanitation cleanliness. Sanitation facilities shared by at most five households (95% CI: 6−7) were generally clean. High-quality shared toilets had live-in landlords, functional door locks, and were water-dependent. Further studies on innovative approaches to maintaining the quality of these high-quality shared toilets are needed to make them eligible for classification as basic sanitation considering the increasing reliance on the facilities.

Willingness to pay for improvements in rural sanitation: Evidence from a cross-sectional survey of three rural counties in Kenya

Poor sanitation worldwide leads to an annual loss of approximately $222.9 billion and is the second leading cause of Disability-Adjusted Life Years (DALY’s) lost due to diarrhoea. Yet in Kenya, the slow rate and levels at which the household’s access improved sanitation facilities remain a concern, and it is unknown if the cost of new technologies is a barrier to access. This study assessed the maximum willingness to pay (WTP) for SAFI and SATO sanitation products and identified those factors that affect the willingness to pay (WTP) valuation estimates by households in three counties in Kenya. It used quantitative economic evaluation research integrated within a cross-sectional survey. Contingent valuation method (CVM) was used to determine the maximum WTP for sanitation in households. We used the logistic regression model in data analysis. A total of 211 households were interviewed in each county, giving a total sample size of 633 households. The mean WTP for SAFI latrines was $153.39 per household, while the mean WTP for SATO pans and SATO stools was $11.49 and $14.77 respectively. For SAFI latrines, households in Kakamega were willing to pay $6.6 more than average while in Siaya, the households were willing to pay $5.1 less than the average. The main determinants of households WTP for the two sanitation products included household’s proximity to the toilet (p = 0.0001), household income (β = .2245741, p = 0.004), sanitation product (β = -2968.091; p = 0.004), socioeconomic status (β = -3305.728, p = 0.004) and a household’s satisfaction level with the current toilet (β = -4570.602; p = 0.0001). Increased proximity of households to the toilet, higher incomes, and providing loan facilities or subsidy to poor households could increase the demand for these sanitation technologies.

Household sanitation access and risk for non-marital sexual violence among a nationally representative sample of women in India, 2015-16

BACKGROUND

Lack of household sanitation, specifically toilet facilities, can adversely affect the safety of women and girls by requiring them to leave their households to defecate alone and at night, leaving them more vulnerable to non-marital sexual violence. This study analyzes the association between household sanitation access and past year victimization from non-marital sexual violence (NMSV) in India.

METHODS

We analyzed 74,698 women age 15-49 from whom information on NMSV was collected in India's National Family Health Survey 2015-16 (NFHS-4). We used multivariable logistic regression to test the relationship between women's household sanitation access and recent NMSV experience, controlling for socioeconomics (SES;e.g., age, marital status, caste, wealth, employment), for the total sample and stratified by rural/urban, given lower access to sanitation and lower NMSV in rural contexts.

RESULTS

We found that 46.2% of households in our sample lacked their own private sanitation facilities (58.0% rural; 24.5% urban) and were forced to openly defecate (37.3%) or walk to a shared sanitation facility (8.9%), and 0.45% of women report NMSV in the last 12 months (0.33% rural; 0.68% urban). Our multivariable model indicated no significant association between having private household sanitation facilities and NMSV for the total sample, but stratified analyses indicate a significant association for rural but not urban women. In rural India, those who lack private household sanitation, compared to those with a household toilet, have significantly greater odds of NMSV (AOR = 2.45; p < 0.05). These findings persist after accounting for demographics including age and marital status, socio-economic factors related to marginalization (e.g., caste, wealth), women's employment, and the overall climate of the state.

CONCLUSION

Findings from this study support prior research suggesting that poor access to sanitation is associated with women's risk for NMSV in rural India. This may be via increased exposure, and/or as a marker for greater vulnerability to NMSV beyond what is explained by other SES indicators. Solutions can include increased access to private household sanitation and more targeted NMSV prevention in rural India.

Understanding the Barriers and Opportunities for Effective Management of Shared Sanitation in Low-Income Settlements-The Case of Kumasi, Ghana

Improved sanitation for all is a daunting task for low-income countries, and shared toilets often provide an alternative to private household sanitation for most urban residents. This study sought to provide better understanding of the existing barriers and opportunities for improved management of shared sanitation. The study used focus group discussions and in-depth interviews with 70 users (landlords and tenants) of shared sanitation in Kumasi, Ghana to assess barriers and opportunities of "high-quality" shared sanitation. The commonly used toilet facilities were dry toilets-Kumasi Ventilated Improved Pit latrine and Ventilated Improved Pit latrines; and flush systems-water closet and pour flush connected to septic tanks. Between 2 and 21 households, or 4 and 84 people, shared one facility. Participants' description of "high-quality" (Ideal) shared sanitation was centred on cleanliness, user behaviour, smell, and user crowding. They also identified challenges of shared sanitation as overcrowded users, poor user behaviours, conflicts among users, and high cost associated with frequent desludging. However, opportunities for improvement included users' preference for shared toilets due to enjoyed benefits, existing facility management practices, and mutual understanding among users (tenants and landlords). Interventions and policy guidelines to influence behaviour change of shared sanitation users are proposed and are intended to be delivered by local government and users.

Intimate partner violence: A key correlate of women's physical and mental health in informal settlements in Nairobi, Kenya

Globally, one billion people live in informal settlements, and that number is expected to triple by 2050. Studies suggests that health in informal settlements is a serious and growing concern, yet there is a paucity of research focused on health outcomes and the correlates of health in these settlements. Studies cite individual, environmental and social correlates to health in informal settlements, but they often lack empirical evidence. In particular, research suggests that high rates of violence against women (VAW) in informal settlements may be associated with detrimental effects on women's health, but few studies have investigated this link. The purpose of this study was to fill this gap by empirically exploring associations between women's experiences of intimate partner violence (IPV) and their physical and mental health. Data for this study were collected in August 2018 in Mathare Valley Informal Settlement in Nairobi, Kenya. A total of 550 randomly-selected women participated in surveys; however, analyses for this study were run on a subpopulation of the women (n = 361). Multivariate logistic regressions were used to investigate the link between psychological, sexual, and emotional IPV and women's mental and physical health. Results suggest that while some socioeconomic, demographic, and environmental variables were significantly associated with women's mental and physical health outcomes, all types of IPV emerged key correlates in this context. In particular, women's experiences of IPV were associated with lower odds of normal-high physical health component scores (based on SF-36); higher odds of gynecological and reproductive health issues, psychological distress (based on K-10), depression, suicidality, and substance use. Findings from this study suggest that policies and interventions focused on prevention and response to VAW in informal settlements may make critical contributions to improving health for women in these rapidly growing settlements.

Environmental Correlates of Health-Related Quality of Life among Women Living in Informal Settlements in Kenya

Informal settlements (slums)—defined as residential areas lacking durable housing; sufficient living and public spaces; access to basic infrastructure, water, sanitation, and other services; and secure tenancy—are presumed to be poor health environments. Research in Kenya suggests that residents of these settlements have the worst health outcomes of any population, yet there is a paucity of research focused on the health and well-being of these residents. Even less attention is given to the role played by environment in health in these settings. The present study addresses these gaps by examining potential environmental correlates, specifically access to water and sanitation, of health-related quality of life (HRQOL) among 552 women in Mathare slum in Nairobi, Kenya. A Kiswahili version of the 36-Item Short Form Health Survey (SF-36) measured HRQOL. Results suggested that access to a toilet at all times was associated with every subscale of the mental health and general well-being domains of the SF-36. Primary water source was also associated with women’s HRQOL. Despite increasing efforts to expand sanitation and water access in informal settlements, more attention should be given to whether the interventions being introduced, which likely affect women’s psychosocial health, are appropriate for all residents, including women.

Household water insecurity may influence common mental disorders directly and indirectly through multiple pathways: Evidence from Haiti

Living in poverty significantly elevates risk of common mental disorders, but the underlying mechanisms are poorly specified. The stress of coping with household food insecurity is posed as one fundamental driver. While much less tested, the stress of failing to meet household water needs may also matter. We test (a) a hypothesized direct influence of household water insecurity (as household access to water sources and quality/quantity of water available in the household) on anxiety and depression symptoms. We also test (b) if there are indirect (mediated) effects of these aspects of water insecurity on common mental disorder symptom levels via household food insecurity, and (c) via their association with sanitation insecurity (lack of toilet). Data were collected in Haiti in June-July 2016 from 4,055 geographically-sampled households representing three distinct low-resource communities, purposefully differentiated as urban, town, and rural. We confirm that household water insecurity exerts a direct, strong independent effect on anxiety and depression levels, even once food insecurity and household assets are taken into account. Additionally, household water insecurity appears to have an indirect effect on anxiety and depression levels through its influence on household food insecurity. In the rural community sample, there is also support for the proposition of additional influence of household water on anxiety through its association with lack of sanitation. This Haitian case supports theories posing a central, influential role for household water insecurity as a potential driver of common mental illness in low-resource households via direct and indirect (food insecurity, sanitation) pathways.

Exploring the complex relationship between women's sanitation practices and household diarrhea in the slums of Nairobi: a cross-sectional study

BACKGROUND

Diarrheal disease kills over half a million people each year in sub-Saharan Africa; the majority are children under 5 years. About 58% of diarrhea cases are associated with poor water, sanitation, and hygiene-a critical issue for people living in informal settlements. In Kenya, 60% of Nairobi's population lives in informal settlements; yet, there is a paucity of research exploring the relationship between water, sanitation and hygiene (WASH) conditions in these settlements and associated health outcomes.

METHODS

The study examines characteristics of women's WASH behaviors and environments as potential factors associated with household diarrhea in Mathare Valley Informal Settlement in Nairobi using cross-sectional survey data collected from 550 women.

RESULTS

Approximately 17% of participants reported that at least one member of the household suffered from diarrhea in the previous 2 weeks-48% of the cases were children under five. Results from a logistic regression exploring factors associated with reports of household diarrhea suggest that women's sanitation management strategies are associated with recent household diarrhea. Women who use toilets for defecation during the day, but rely on bags, buckets, or open defecation (OD) for urination during the day and for urination and defecation at night have over five time the odds of recent household diarrhea than women who use a toilet for all their sanitation needs. The odds of diarrhea were also higher for participants who walk up to 2 min to reach their toilets/sites for defecation and those who rely on water from taps inside buildings and plots. Odds were 62% lower for participants with clean toilets.

CONCLUSIONS

Findings suggest that health targets to reduce the prevalence of diarrheal diseases in informal settlements may not be met unless particular attention is paid to the needs of women living in these environments.