PROTOCOL: What is the impact of complex WASH interventions on gender and social equality outcomes in low‐ and middle‐income countries? A mixed‐method systematic review protocol
2021; The Campbell Collaboration; Volume: 17; Issue: 2 Linguagem: Inglês
10.1002/cl2.1164
ISSN1891-1803
AutoresBiljana Macura, Laura Del Duca, Adriana Elizabeth Espinoza Soto, Naomi Carrard, Louisa Gosling, Karin Hannes, James Thomas, Lewnida Sara, Marni Sommer, Hugh Waddington, Sarah Dickin,
Tópico(s)Global Maternal and Child Health
ResumoSafely managed water, sanitation and hygiene (WASH) services are viewed as fundamental for human wellbeing, enabling a range of positive outcomes related to health, education, livelihoods, dignity, safety, and gender equality. Progress in providing WASH services and thus achieving these outcomes has not occurred equally, with a range of inequalities in who can access and benefit from WASH services across varying socio-cultural contexts, geographical areas and socioeconomic settings. For instance, among the 785 million people who lack a basic drinking-water service, and 2 billion who lack access to basic sanitation services, a greater proportion are poor and living in rural areas (WHO/UNICEF JMP, 2019). Further, unsafely managed water and sanitation disproportionately impacts a number of social groups, including women, girls, and sexual and gender minorities, people with disabilities, people marginalised due to ethnicity, caste, poverty or other factors, and those living in vulnerable situations such as displaced people or people who are experiencing homelessness. As the COVID-19 pandemic disproportionately affects particular groups of people, it has the potential to exacerbate many of these existing WASH inequalities (Howard et al., 2020). Gender inequalities related to WASH are particularly large, as women and girls have specific needs related to biological factors, and experience strongly gendered norms surrounding water and sanitation, such as expectations of carrying out water fetching, caregiving and hygiene roles within the household (Caruso et al., 2015). In many countries where women and girls are responsible for water fetching this contributes to a substantial burden of musculoskeletal disease (Geere & Cortobius, 2017). Additionally, women and girls are more negatively impacted by a lack of private and safe sanitation facilities, particularly for menstrual hygiene management which creates sanitation-related psychosocial stress and may cause urinary tract infections (Das et al., 2015; Torondel et al., 2018). Maternal and child health are also thought to be seriously affected by inadequate WASH—for example, sepsis, one of the biggest causes of neonatal mortality, due to unhygienic practices by mothers and birth attendants(Campbell et al., 2015). Additionally, a lack of a household toilet and the practice of open defecation has been linked to sexual violence (Jadhav et al., 2016). These inequalities extend beyond the household, with women and girls, and socially marginalised groups often under-represented in decision-making processes at all levels of WASH governance (Coulter et al., 2019; Shrestha & Clement, 2019). In particular, women have had limited access to skilled and higher-paid employment in the water sector such as within water utilities (World Bank, 2019). While the WASH sector has frequently focused on women and a binary understanding of gender, sexual, and gender minorities also experience a range of WASH-related inequalities (Boyce et al., 2018; Neves-Silva & Martins, 2018; Schmitt et al., 2017). Besides gender, there is a range of other social inequalities related to WASH. Caste relations have shown to facilitate or create barriers to sanitation interventions, related to cleaning, access to subsidies, latrine design, and purity issues (O'Reilly et al., 2017). People experiencing homelessness often face a denial of their rights to safe water and sanitation (Neves-Silva & Martins, 2018). For people with disability, WASH services often do not meet specific needs for hygiene and privacy, or eliminate discrimination and abuse (Banks et al., 2019). A multicountry study reported that 23%–80% people with disabilities were unable to fetch water on their own, and those with more severe impairments had problems accessing the sanitation facilities used by other household members (Mactaggart et al., 2018). In many cases gender intersects with other social identifies such as age, sexual orientation, ethnic group, caste, disability, and this may exacerbate disadvantage (or expand advantage) (Crenshaw, 1989). For instance, displaced women and girls face particular challenges in access to safe and private facilities for menstrual hygiene management (Schmitt et al., 2017). Awareness of these inequalities has resulted in implementation of WASH interventions that include mainstreaming of gender and social equality (GSE) considerations. While a large focus, in terms of both theoretical and empirical work, has been placed on gender inequalities, other forms of social exclusion related to WASH are also being increasingly addressed (WaterAid, 2010). WASH practitioners argue that such interventions will result in services that meet the needs of different groups, as well as challenge unequal power relations in society (Carrard et al., 2013). For example, adequate sanitation and hygiene facilities in schools are widely considered to facilitate girls' school participation and contribute positively to a sense of dignity and self-esteem (Sommer et al., 2016). Easily accessible water sources are thought to increase economic opportunities and economic empowerment, as people spend less time and energy on unpaid work and have more time for productive or leisure activities. The time-savings benefits of improved water access have long been recognised as reason alone to investment in improved water supply, even without demonstrable benefits on child survival health (Churchill et al., 1987). For example, Cairncross and Cliff (1987) demonstrated substantial opportunity costs of inadequate water supply for women, which affected time available for child-care, food preparation, household hygiene, rest, and income generation. Moreover, household sanitation facilities or water on premises are thought to decrease risks of violence associated with open defecation or water collection (Geere et al., 2018; Jadhav et al., 2016). Consideration of gender and power relations within WASH interventions has also been shown to improve women's self-confidence in intra-household relations (Leahy et al., 2017), and participation in society, such as community-level decision-making (Sam & Todd, 2020). Despite the wide range of GSE outcomes associated with WASH interventions, evidence has often been anecdotal, based on assumptions, or reported only in the grey literature. Funding agencies, governments, civil society organisations and academia alike have placed a greater emphasis on rigorous evaluation of technical and health outcomes of WASH interventions. This includes measuring provision or uptake of WASH-related technology or behaviours such as safe water storage, hand-washing with soap after using a toilet, toilet maintenance and similar (Parvez et al., 2018), or evaluating the relationships between access to inadequate WASH facilities and incidence of diarrhoeal diseases and other infectious diseases (Crocker & Bartram, 2016; Pickering et al., 2019). Limited efforts to evaluate GSE outcomes may be related to the challenges of measuring social change, often a complex, nonlinear, context-specific, and slow process (Hillenbrand et al., 2015). It can be difficult to trace clear causal pathways between intervention components and targeted outcomes. For instance, improvements in GSE outcomes may be cross-sectoral, with difficulties attributing change directly to particular WASH components. Despite these challenges it is important to understand what kind of interventions are most often associated with better or worse GSE outcomes. A lack of attention to monitoring and evaluating changes in GSE outcomes or development of validated methodological approaches for evaluating GSE outcomes (UNESCO, 2019) has translated into gaps in understanding which intervention components contribute to the greatest positive impacts on GSE outcomes, as well as which interventions may lead or contribute to negative impacts that reinforce inequalities. These gaps in understanding are evident in the global policy discourse. For example, Sustainable Development Goal 6 "Clean Water and Sanitation" refers to the sanitation needs of women and girls, but has been described as "gender blind" due to the lack of gender-sensitive targets (UN WOMEN, 2016). A comprehensive synthesis and greater availability of evidence of GSE outcomes resulting from WASH interventions is therefore needed to support WASH intervention design, implementation, and evaluation. In this review, we use gender to describe socially constructed identity and the related contextual and variable set of roles, behaviours, norms and responsibilities, while sex refers to a spectrum of biological differences. Although WASH interventions have often applied a female/male binary understanding of gender, there is a diverse spectrum of gender identities and gender expressions, including those who identify across or outside of the gender binary, and this group is described as gender minorities. Gender comprises part of a broader concept of social (in)equality and power hierarchies (Segnestam, 2018). Moreover, gender and other social identities such as age, sexual orientation, ethnic group, citizenship status, socio-economic status, caste, disability, marital status are interdependent, and may intersect to exacerbate exclusion (Crenshaw, 1989). For instance, there is a particularly large burden on young girls and adolescents for water-related responsibilities, while boys may be involved in water fetching for productive water uses (Thompson et al., 2011). It is important to note that local interpretations of what is meant by gender equality and other forms of social equality may be contested, adapted, and negotiated, which then influences engagement with the normative global discourse on gender equality. In a particular context, this may influence what components of a WASH intervention targeting GSE outcomes are culturally acceptable or relevant. In the WASH sector, addressing gender and social equality has often focused on meeting practical needs (Moser, 1989), such as interventions that address people's needs based on gender and other socially constructed roles. This frequently involves instrumental approaches, whereby the focus is on "engaging women" to achieve other ends (e.g., such as engaging women to promote child health or economic development) (MacArthur et al., 2020). Alone these approaches are not viewed as adequate to address inequalities without addressing power issues, the burden of work, or similar (Cornwall, 2016; Hillenbrand et al., 2015). More recently, gender transformative development that addresses unequal power relations, structures and norms is being more widely taken up by actors in the WASH sector (MacArthur et al., 2020; Oxfam, 2020). These approaches focus on power dynamics between different social groups in varied social contexts and seek to address how these relations produce inequalities. For instance, interventions that address these considerations may result in more equal sharing of unpaid domestic and care responsibilities or increased opportunities for marginalised groups to use their voice in decision-making. A key component of gender transformative approaches in the development sector is women's empowerment, which is understood as a complex process occurring at different levels, spaces and over time (Cornwall, 2016). However, gender transformative approaches aim to go beyond women's empowerment, emphasising working with both women and men to transform social relations towards more equitable arrangements. To measure and evaluate change, interventions have sometimes been described in terms of their level of responsiveness to gender (and less commonly, social equality) aims. While a range of terms may be used to categorise outcomes (e.g., gender-sensitive, gender-responsive, gender integration), they are generally placed along a continuum (Pederson et al., 2014). At one end, interventions are gender-blind and may exacerbate or exploit inequalities. In the middle, interventions may be inclusive of gender needs to varying extents, such as providing safe water supply or sanitation facilities, but may have a neutral impact on gender and social power relations. At the other end, interventions are aimed at transforming gender and social norms and relations. For instance, WaterAid developed a framework that categorises gender outcomes across the WASH system as ranging from harmful to inclusive, empowering and transformative (WaterAid, 2018). In this review, we use inclusive and transformative gender and social equality outcomes to capture two broadly defined categories of outcomes. Our theory of change for promoting gender and social equality through WASH interventions is that implementation of various WASH technologies and promotion of behaviours, combined with GSE mainstreaming components, can lead or contribute to better access to services that meet the specific needs of all users (Figure 1). If GSE considerations go beyond meeting the needs of individuals to challenge power relations, WASH interventions will lead to or contribute to transformative changes that reduce inequalities related to WASH challenges and broader society. Together these outcomes will result in or contribute to long term changes in outcomes related to gender and social equality more widely, across different levels of society. These could be increases in the participation of women, girls and marginalised groups in public and economic life, better opportunities for education and livelihoods, and decreased discrimination and violence. At the same time, we acknowledge that these types of changes are complex, slow-acting and nonlinear. Below, we describe WASH intervention components and resulting GSE outcomes illustrated in our theory of change in more detail. Water supply, sanitation or hygiene intervention components are sometimes grouped together (e.g., WASH) due to their inter-dependent nature, particularly in rural settings. WASH interventions can be described with four main components: "how," "what," "where" and "for whom" (Waddington et al., forthcoming). "How" describes how the intervention is delivered, such as behaviour change approaches (e.g., triggering campaigns to end open defecation and similar). "What" describes the targeted WASH technology or practice (e.g., toilet usage, construction of water supply or hand-washing stations). In the case of water supply, while a focus has been largely on safe drinking water, some interventions may go beyond meeting basic needs for drinking water and hygiene, to serve a range of uses including productive uses (e.g., livestock watering), known as Multiple Use of Water Services. In addition to supply driven approaches, WASH interventions can also involve the use of market-based approaches to strengthen supply and demand, such as through training of local vendors, or smart subsidies and loans to households to promote uptake of WASH services (USAID, 2018). "For whom" refers to the targeted participants. Most WASH interventions attempt to improve service provision for households, however interventions may target individuals, entire communities, service providers and authorities at national and subnational levels. Intervention components may be adapated to meet the needs of different groups, such as ensuring menstrual hygiene management in sanitation facilities. WASH interventions may also take place at the service-provider or regulator level (e.g., local government overseeing service provision and setting up policy and accountability mechanisms) level as part of WASH system strengthening. WASH systems refers to all the social, technical, institutional, environmental and financial elements, actors, relationships and interactions that impact service delivery (Huston & Moriarty, 2018). "Where" describes the targeted location of the intervention such as the household, community (e.g., marketplaces, religious buildings), school or health facilities. Many aspects of WASH service delivery are cross-sectoral, including housing, education, or health sectors, which can lead to complex arrangements with no clear governance structure. An example is WASH in-school interventions, which target WASH services in schools to improve health and education outcomes together, which generally involve stakeholders from both WASH and education sectors (Deroo et al., 2015). WASH interventions are increasingly using GSE mainstreaming components in their designs to ensure that they are inclusive of the needs of all users and contribute to GSE outcomes. Mainstreaming refers to addressing GSE considerations across development, planning, implementation, and evaluation of a WASH intervention (but it may be carried out to varying extents in different types of interventions). GSE mainstreaming is often viewed as having the dual purpose of improving the sustainability and effectiveness of the technical and health outcomes (e.g., such as uptake and sustained use of technologies or specific behaviours), as well as to promote positive change in GSE outcomes. Regardless of whether a WASH intervention includes intentional mainstreaming, it will still have social (and gendered) outcomes. Such an intervention may still lead to positive GSE outcomes, but no change in outcomes or regression with reinforced inequalities is also possible (Taukobong et al., 2016). This indicates the importance of intentional mainstreaming to influence these in the direction of inclusion and equality. In this review we define WASH interventions as complex interventions because they are comprised of multiple components (show intervention complexity) and have multiple causal pathways and feedback loops (pathway complexity) (see Figure 1). In addition, they also often target multiple participants, groups, and organisational levels (population complexity), require multifaceted implementation strategies to boost adoption and uptake (implementation complexity) and are implemented in multidimensional settings (contextual complexity) (Guise et al., 2017). We define GSE outcomes as inclusive and transformative. Inclusive WASH outcomes are those that relate to the specific WASH needs and barriers of different social groups (Hillenbrand et al., 2015). For instance, these interventions may involve female-friendly school toilets (e.g., modifications to ensure adequate menstrual hygiene management facilities) to meet girls' menstrual hygiene needs (Schmitt et al., 2018; UNICEF WaterAid & WSUP, 2018), toilets adapted to people with disabilities or toilets that are adapted to religious or cultural practices. Inclusive WASH outcomes may involve provision of water at more convenient locations, such as on premises (e.g., within the household property) to reduce women's time and physical burden spent collecting water, provision of water and sanitation at healthcare facilities to improve maternal outcomes, or provision of sanitation in public spaces such as schools and marketplaces. Beyond infrastructure design, such intervention components may include sharing of information, fair tariff structures, inclusive operating time, etc. To capture different types of transformative outcomes described in our theory of change we applied Rowland's framework of power (1997) (Table 1). Transformative approaches address social causes of being unable to access and benefit from WASH, and seek to transform harmful power dynamics, norms and relations such as unequal distribution of unpaid work in the household. For example, while provision of a safe water source on premises can reduce the amount of time someone needs to collect water, it does not change their status in the household or community. Any time savings may lead to expectations to conduct other unpaid work. In contrast, men assuming roles traditionally assigned to women may indirectly support women's participation and empowerment in other domains, such as having time to contribute to water governance. Transformative outcomes also relate to women or marginalised group gaining greater control of their lives, for example, obtaining expertise in managing a water source, acquiring land tenure documentation for a water source, or gaining financial autonomy through WASH entrepreneurship. In addition, there may be neutral, negative or other unexpected outcomes resulting from WASH interventions, as shown in Figure 1. In some cases, these may exacerbate inequalities related to WASH. For example, a sanitation intervention may lead to increased exposure to violence and discrimination if facilities are constructed without considering the needs of women and vulnerable groups, lead to backlash related to challenging social norms, or increase the burden of unpaid work (e.g., refilling handwashing stations). Other unintended harmful effects may include unpaid domestic labour shifted to the elderly or to a lower caste. Even when implementers consult with community leaders about socially acceptable ways of working with the community, WASH interventions may lead to increased resistance towards gender equality both at the household (e.g., (re)distribution of work) and community level (e.g., decision making in WASH governance). The process of social change is complex, nonlinear, and it can take a long time to observe change. These processes are highly contextual and dependent on social, gender, cultural, economic, ecological and institutional factors at individual, household, community, and institutional spheres (Carrard et al., 2013). Thus, no intervention leads to positive GSE outcomes in all contexts and outcomes. The outcomes of WASH interventions are also dependent on a set of assumptions, such as continuing investments and political will to support the kind of WASH interventions that lead to GSE outcomes. For instance, in some settings discriminatory policies or laws may be put in place which hinder progress, despite a well-designed intervention (especially at the level of service provision). There are also risks associated with addressing GSE due to possible backlash. For example, WASH interventions targeting increased decision-making opportunities in one setting, or reduction of gender-based violence, may lead to increase in another setting, or to women having less agency regarding their mobility both in and outside the household. There may also be unintended consequences of WASH technology provision as a result of interactions with social norms. For example, Rogers (2005) documented in Egypt that improved village water supplies were viewed suspiciously by villagers, who thought the taste of chlorine in the water was part of a government sterilisation programme. In addition, women preferred to collect surface water from canals where they could socialise with other women. Finally, each of the outcomes includes an intermediate step to reaching that outcome (such as capacity building for improving employment opportunities or similar) but this could not be represented in Figure 1. There is a growing interest in transformative WASH interventions because of their potential for delivering impact (Oxfam, 2020; WaterAid, 2018). A key message from the UN WOMEN Expert Group Meeting on Gender Equality and Water, Sanitation and Hygiene was as follows: "Taps and toilets are not enough. To realize transformational WASH outcomes, governments must enable women's voice, choice and agency" (UN WOMEN, 2017). In parallel, there is a growing emphasis on developing tools for collecting data on gender outcomes and disaggregating data by sex, age, ability status and other factors (Miletto et al., 2019). Despite the interest in these outcomes, evaluation practice in the WASH sector has placed more focus on technical and health outcomes, such as technical standards for water sources, or evaluating diarrhoea prevalence, leaving gaps relating to evaluating gender and social equality outcomes (Loevinsohn et al., 2015; Mackinnon et al., 2019). This gap can translate into a lack of budget line items and prioritisation by stakeholders. Most existing reviews on WASH have no explicit focus on gender, education or other social outcomes. Some reviews account for gender only as a contextual factor in the WASH intervention design (De Buck et al., 2017) or adoption (Hulland et al., 2015). The past and ongoing reviews that explicitly focus on social outcomes have a relatively narrow scope (only one WASH component such as menstrual hygiene management) or one specific group (e.g., girls in schools)) and some of them were conducted more than seven years ago (Birdthistle et al., 2011; DFID, 2013; Hennegan & Montgomery, 2016; Hennegan et al., 2019; Jasper et al., 2012; Munro et al., 2020; Sumpter & Torondel, 2013). An evidence-and-gap map (EGM) (Waddington et al., 2018) compiled systematic reviews and impact assessments and mapped outcomes such as psycho-social health, education, labour market outcomes, safety and income, consumption or poverty (see https://gapmaps.3ieimpact.org/evidence-maps/water-sanitation-and-hygiene-wash-evidence-gap-map-2018-update). The EGM did not include primary study evidence that used methods other than quantitative approaches, or undertake synthesis of findings from included impact evaluations. The impact studies included in the EGM, will be assessed for eligibility in the current review. Thus, this review will provide a much-needed synthesis of effectiveness of complex WASH interventions in contributing to GSE outcomes, facilitating better conceptualisation of GSE and WASH links as well as contributing to development of measurement tools to more accurately evaluate the GSE outcomes. The development of different measurement tools is already happening (e.g., Empowerment in WASH Index [EWI]: https://www.sei.org/projects-and-tools/projects/ewi-empowerment-in-wash-index/); or WASH Gender Equality Measure (WASH-GEM): https://waterforwomen.uts.edu.au/wash-gem-piloting-in-cambodia-and-nepal/) and the review can directly inform this ongoing work. This review aims to comprehensively and transparently synthesise evidence on gender and social equality outcomes in complex WASH interventions. We also aim to develop and test a set of hypotheses about causal relationships between WASH intervention components and outcomes and related to our theory of change. Our aim is to advance evaluation practices in the WASH sector by providing methodological advice on how to include, assess and measure GSE outcomes. Additionally, we will map definitions of different outcome measures and provide guidelines on this. The findings will be of use for decision makers in policy and practice allowing them to more effectively design and implement gender and social equality mainstreaming in WASH interventions and strategies and learn from best practices. By describing methodological deficiencies in relevant primary research (see section Assessment of risk of bias in included studies), we will provide guidance and best practice examples for future primary research on the subject. The review questions are: Review question 1: What are the impacts of complex WASH interventions on gender and social equality outcomes in low- and middle-income countries? Review question 2: What are barriers to or enablers of change in these outcomes? Review question 3: Under which conditions do WASH intervention (components) lead to a change in GSE outcomes? Review question 4: How are GSE outcomes measured in the literature? This review follows Campbell Collaboration policies and guidelines (The Campbell Collaboration, 2019). Principles of stakeholder engagement and co-design will be applied used throughout the review process to improve the rigour of research, maximise acceptance and legitimacy, provide a strong science-policy link (Land et al., 2017) and facilitate communication of findings (Haddaway & Crowe, 2018). We comprehensively mapped stakeholders that work in the WASH implementation and policy space, and closely linked stakeholders working on gender and social equality more broadly. A suite of complementary processes was used to identify and map stakeholders (e.g., snowballing and systematic searching). The resulting stakeholder map will also be used for the communication of review findings. Identified key stakeholders, such as representatives of funding agencies and civil society organisations engaged in WASH interventions, and researchers with expertise on a range of WASH outcomes, were engaged in the codesign of the systematic review protocol, review scope and questions, definitions and a theory of change to model the link between intervention components, the context and GSE outcomes (see Figure 1). The engagement occurred via two online workshops in May and June 2020. In addition and to obtain input of wider community, we invited stakeholders to comment on a previous version of the review protocol that was publicly available on the website of Stockholm Environment Institute and shared via Sustainable Sanitation Alliance network (https://www.susana.org), the Rural Water Supply Network and other online communities of WASH practitioners between 16 July and 3 August 2020. Stakeholders' inputs on the protocol and our responses are available here: https://www.sei.org/projects-and-tools/projects/advancing-evaluation-of-gender-equality-outcomes-in-wash/. Below we describe the eligibility criteria. For all the review questions we will apply the same eligibility criteria (except for Types of studies, see below for details). Randomised controlled trials, with assignment to intervention or "encouragement" to intervention at individual or cluster level. Quasi-experimental designs with nonrandom assignment, using methods such as naïve and statistical matching on baseline data, and double-difference analysis of data pre- and posttest data. Natural experiments using methods such as regression discontinuity design to construct comparison groups, where assignment is determined at pretest by a cut-off on an ordinal or continuous v
Referência(s)