In this re-review of 133 studies from two systematic reviews assessing effectiveness of water, sanitation, and/or handwashing with soap interventions on diarrheal disease1 and acute respiratory infections,2 we evaluated the reported engagement of individuals in the evaluation and delivery of WASH interventions.
We find that, in many instances, the interventions that were the subject of these studies relied entirely on women as the agents of delivery and as the source of study data. WASH interventions were overwhelmingly gender-unequal or gender-blind and, therefore, classified as gender exploitative under the GRAS framework (Fig. 1). Any costs to women’s own time or benefits to their own lives were rarely mentioned. Women appear to play a critical but purely instrumental role in advancing WASH. The often unacknowledged role of women in the evaluation and implementation of health-related WASH studies has several unintended, yet detrimental, consequences that require change for WASH to enable gender equality and not hinder it.
Perhaps the most insidious consequence of taking for free and for granted women’s time and cooperation in WASH is that it cements existing and unequal gender norms. Maintaining family health, which includes WASH tasks, is considered to be women’s work, and women’s labor is “understood” to be of low value. When WASH implementers and researchers not only avoid playing an equalizing role, but actively exploit gender-unequal roles, then existing inequalities are reproduced32 or even strengthened16. These observations—that women perform unpaid WASH labor and that this renders the research itself exploitative—are not new; this bias has been described since the early 1980s.33–35 Nonetheless, the exploitation of gender stereotypes and acceptance of numerous hours of unpaid labor by women has persisted. While occurring in both research and intervention delivery, the impact of engagement is likely quite different; the demand for women’s unpaid labor in intervention delivery, in particular, could be sustained indefinitely or even scaled up if deemed effective at improving child health. Moving forward, WASH programs and interventions should be evaluated using the GRAS tool before implementation so those classified as exploitative can be redesigned or abandoned. Exploitative interventions should not be funded for evaluation.
Regardless of the effectiveness of the WASH interventions assessed, the full implementation costs have not been transparently acknowledged in evaluations or reflected in subsequent recommendations. Many WASH approaches, especially household-based approaches, are touted as “low-cost” by depending on women’s “free” time and labor. These falsely low costs are routinely highlighted as a benefit for—and even a stipulation by—policy makers and donors, who often demand evidence of cost-effectiveness, put caps on the total costs allowed for an intervention, and restrict the types of allowable expenses (e.g., participant compensation). We acknowledge that the extent and nature of compensation must be context-specific so as not to place undue burdens on low-income communities and NGOs, and we recommend that WASH actors (i) budget appropriate compensation for those who shoulder the burdens of making these interventions “work,” (ii) transparently report who is engaged, and (iii) rigorously evaluate participant time and opportunity costs.
The gender-unequal or gender-blind interventions were largely among interventions that represent lower levels of service, illuminating how these allegedly low-cost interventions not only demand “free” labor, but extract this labor to provide services or promote approaches that are often inferior. Interventions at the lowest service levels often emphasize behavior change, and as we and others18 have shown, most target women’s behavior change. Yet, behavior change approaches are ‘generally the least effective type of intervention’.36 Furthermore, ‘the need to urge behavioral change is symptomatic of failure to establish contexts in which healthy choices are default actions.’36 As a result, the women conscripted to perform (or enforce) WASH behaviors are likely living in the least enabling environments and therefore may have little chance for impact despite their efforts. Failed behavior change interventions tend to be ascribed to poor “compliance”, which blames individuals—largely women—for intervention failure as opposed to the possible inappropriateness of the approach itself.37 Our data show that factors that shape individual ability to adopt interventions (e.g., time, finances) —which are useful to assess intervention appropriateness—were rarely documented. In contrast, the most common reported outcomes related to women were about their ‘compliance’ behaviors. Higher WASH service levels are critical for health3 and for establishing contexts that enable healthy choices including relieving women’s labor, saving energy costs and time, and lowering stress.
WASH provision at higher service levels does tend to require less household work, but cannot guarantee that women will not be burdened, or that their needs will be met. WASH approaches therefore need to be intentionally gender-sensitive, at a minimum. The JMP service ladders, which function as the benchmark by which to evaluate the quality of WASH services, are notably gender-blind38 and therefore insufficient as the only benchmark. As an example, toilets can be categorized to be at the highest service level (safely managed) even if they lack a superstructure or a door because the ladder does not assess privacy. The global WASH community is already calling for a paradigm shift in how WASH services are delivered and evaluated.39 Consistent with this call, we recommend that potential gender-related needs, burdens, and benefits are formally included when assessing the quality of WASH services, as well as in WASH evaluations when assessing their effectiveness in preventing disease.
A shift is also needed in how evaluations of WASH interventions are conceived, conducted and communicated to prevent further gender exploitation. As with intervention delivery, studies are not always explicit about who is engaged in research activities, women are routinely targeted, compensation is rare, and few report the time participation required. Women, in effect, act as unpaid research assistants. While there remain debates about research compensation40, researchers and donors should be deliberate about time required from research participants and justify compensation decisions transparently.
These conclusions are limited by the information reported in the papers assessed, did not consider studies that may have been published elsewhere, excluded evaluations in languages other than English or Spanish, and may have a restricted sample because of the sources from which included studies were identified. Our re-review nonetheless takes a gender lens to prominent studies used to determine intervention effectiveness on key health outcomes. This lens should be considered when assessing the health impacts of WASH interventions. Specifically, women have been critical to evaluation research and intervention delivery and yet are often invisible and undervalued in the public health literature. Greater awareness and reflexivity are needed within WASH research and practice to elevate and value gender equity alongside health impacts.