Nome do Projeto
Basic and safely managed water, sanitation, and hygiene services in low- and middle-income countries: current state and inequalities Research project
Data inicial - Data final
24/10/2022 - 28/02/2025
Unidade de Origem
Coordenador Atual
Área CNPq
Ciências da Saúde
Women’s participation in water, sanitation and hygiene decision-making and governance has been called a priority area of research based on expert input and literature review 6 . It has been argued that improvement in WASH access may be achieved through women’s empowerment, via ownership and control of assets and resources, including income, land and credit 10,11; decision-making in household purchases and construction, including WASH infrastructure 12,13; group membership that allow women to discuss issues in their communities 10,11; intrinsic attitudes about WASH roles and responsibilities 14; personal agency and supportive environments 15; access and sharing of WASH information and other learning opportunities 14,15; available time 10; and leadership and participation in local WASH institutions and authorities 14 . It should be noted that evidence is still scarce, often anecdotal, and based on local studies. More robust studies that systematically compare the relationship between WASH indicators and women’s empowerment in different countries are still necessary. Demographic and Health Surveys (DHS) are household surveys that are highly comparable to MICS. They collect both information related to women’s economic autonomy and decision making and allow estimating access to basic WASH services, providing an opportunity to evaluate the association of women’s empowerment and those services. In fact, a 2021 report by the JMP states that “DHS does have several questions related to general household-decision making, which could be leveraged. [...] Exploratory analyses could investigate if there is any association with women’s household decision making power and household access to sanitation or water facilities” 16 . Finally, even though water and sanitation/hygiene are in separate targets, they do not operate separately in the household. Poor community sanitation coverage and lack of proper handwashing infrastructure can lead to faecal contamination of drinking water and are important risk factors to diarrhoea and infant mortality 3,17–19 . There is also evidence that water interventions combined with either hygiene education or improved sanitation can lead to an additional effect of reducing diarrhoeal disease in LMICs 20 . In 2012, an analysis of 59 countries showed that only half of their population had access to both improved water source and sanitation, while 75% had access to 9 improved water and 59% to sanitation 21 . In a 2017 study from Sub-Saharan Africa, only 4% of the population had access to combined basic WASH services, leaving almost a billion people lacking basic coverage 22 . With the new MICS’ water quality module and the extended version of the sanitation questionnaire applied in 34 countries, there is an opportunity to investigate the combined coverage of not only basic WASH, but also safely managed water and sanitation services.

Objetivo Geral

To identify published research articles that involve the association between a
water, sanitation, or hygiene (handwashing) household indicator and women’s


The world is not on track the achieve universal access to WASH services and
there are major regional inequalities. The Least Developed Countries 23 still have a
long way ahead, especially those in fragile contexts. Many more countries are facing
challenges to promote WASH services in rural, impoverished, and fragile communities
within their borders 1

. Girls and women have a double burden as the ones more
vulnerable to the absence of those services and as those with a larger role in WASH
activities 6

. On the other hand, data coverage is increasing. MICS and DHS surveys –
including extended WASH and women’s empowerment questionnaires, and water
quality testing – provide an opportunity to increase our understanding of who is being
left behind, where are they located, in which step are we failing and what mechanisms
can we use to change the situation.
In this project, we want to expand our knowledge in three topics:
1) what water sources are more likely to be contaminated and in which context
(urban/rural) is this more likely to happen;
2) what is the relationship between women’s empowerment – in particular their
economic autonomy and decision-making – and basic WASH services in the
household; and
3) what is the simultaneous coverage of safely managed water and sanitation
services and basic hygiene in LMICs and how unequal is that coverage between
different levels of wealth, rural and urban communities, and subnational regions.
The literature reviews presented in Section 4 show that there are gaps in
knowledge that our work will help to fill. In doing so, we will expand our knowledge on
the state of global inequality in WASH services and contribute to accomplish the goals
of SDG 5 – “Achieve gender equality and empower all women and girls”; SDG 6 –
“Ensure availability and sustainable management of water and sanitation for all”; and
SDG 10 – “Reduce inequality within and among countries” 24


8 Methods
8.1 Research article 1
8.1.1 Data source
The most recent MICS surveys that includes a water quality module will be
used. Currently, this includes 36 countries, presented in Table 5.

Table 5 – MICS surveys selected for article 1
Country Year
Algeria 2018
Bangladesh 2019
CAR 2018
Chad 2019
Congo Brazzaville 2014
Congo, Democratic Republic 2017
Côte d’Ivoire 2016
Dominican Republic 2019
Gambia 2018
Georgia 2018
Ghana 2017
Guinea Bissau 2018
Guyana 2019
Honduras 2019
Iraq 2018
Kiribati 2018
Kosovo 2019
Lao 2017
Lesotho 2018
Madagascar 2018
Malawi 2019
Mongolia 2018
Nepal 2019
Nigeria 2016
Paraguay 2016
Samoa 2019
São Tomé and Príncipe 2019
Sierra Leone 2017
State of Palestine 2019
Suriname 2018
Togo 2017
Tonga 2019
Tunisia 2018
Turks and Caicos 2019
Tuvalu 2019
Zimbabwe 2019


8.1.2 Indicators
Water contamination
Household drinking water contamination will be measured by the level of E. coli
contamination in water samples collected in the water quality module of MICS surveys.
Typically, the water quality module is designed to produce estimates that are
representative at the national and first subnational level (provinces, regions, or states)
and also for urban and rural areas of a country. A random subsample of all households
visited during a survey is selected in order to create a reliable estimate of water quality
while reducing costs and workload. A very common strategy used by MICS is to select
25 households in each survey cluster for the regular interview and 5 of these for water
quality testing, taking advantage of the fact that households from the same cluster
tend to have similar water sources 3,84

In most cases, the person responsible for collecting the water samples is also
responsible for anthropometric measurements of children under the age of 5. Those
field testers are trained by national specialists and should have practiced the water
sampling procedure at least 15 times 84. In the field, the collector requests permission
to collect water samples, asking for a “glass of drinking water” and to be shown the
location of the households regular drinking water source. 100 ml samples are collected
from the glass, known as “point of use” or PoU, and the source, known as “point of
collection” or PoC 3

Samples are analysed on site within 30 minutes. This consists of filtering the
sample through a 0.45 m paper membrane, which is added to growth media plates
rehydrated with 1 ml of sample water. The samples are then incubated overnight (24
to 48 hours) in electrical incubators or using “incubation belts” worn around the body
of interviewers during the day and underneath their pillow or under their bed covers
during the night 3,84

. The enzyme substrate on the growth media plates gives the E.
coli colonies a blue colour. The interviewer counts the number of blue colonies and
registers it on the water quality questionnaire 84

Indicadores, Metas e Resultados

7.1 Research article 1
• The prevalence of contamination varies substantially between and within
o Between countries, water contamination ranges from less than 10% to
more than 90% of households. The Pacific Islands and West and Central
Africa have the highest prevalence of water contamination globally
o Within the same country, distinct types of water sources have very
different prevalences of contamination
o In the worst contexts, almost all water is contaminated independently of

• The prevalence of contamination varies substantially between sources.
o Households with piped water sources are the least likely to have
contaminated water
o Improved sources have lower prevalence of contamination when
compared to unimproved sources
o Protected wells and protected springs are highly contaminated despite
being currently classified as improved water sources. Some improved
sources have higher contamination than some unimproved sources.
• In general, water sources from rural areas have higher prevalence of
contamination then those from urban areas
o The inequality between urban and rural settings varies significantly
according to water source
o Urban wells are as likely to be contaminated as rural wells
o Rural piped water is significantly more contaminated than urban piped
water, having one of the highest gaps among all sources

7.2 Research article 2
• The empowerment indicator (higher economic autonomy and decision making)
is lowest for women in countries from West and Central Africa
• More empowered women are more likely to live in households with basic WASH

o For the majority of countries (around 60%), there is a positive
association between women’s empowerment and WASH indicators. For
some (around 30%), there is no significant association between
women’s empowerment and WASH indicators. For only a few countries
(around 10%) this association is negative

• The strongest association is between women’s empowerment and basic
hygiene, followed by basic water. Basic sanitation has the weakest association
with women’s empowerment
• Women’s empowerment is generally more strongly associated with WASH
indicators in the urban environment than in the rural
7.3 Research article 3
• The coverage of the Full WASH indicator is generally low for most countries in
the sample (below 50%), with significant inequalities between those countries
o The Pacific Islands and West and Central Africa have the lowest
coverage of the Full WASH indicator
o Some countries, such as Chad, have a Full WASH coverage close to 0%
• The safely managed water services indicator is responsible for the low
coverage of the Full WASH indicator in most countries, followed by the safely
managed sanitation services indicator. The hygiene indicator is the component
with highest coverage.
• There are important inequalities regarding wealth, area of residence
(urban/rural), and subnational regions within most countries
o Subnational region is the stratifier with the highest level of inequality
o The poorest and rural populations have significantly lower coverage of
the Full WASH indicator

Equipe do Projeto

NomeCH SemanalData inicialData final

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