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International Journal of
Environmental Research
and Public Health
Article
The Inclusion of Rights of People with Disabilities and Women
and Girls in Water, Sanitation, and Hygiene Policy Documents
and Programs of Bangladesh and Cambodia: Content Analysis
Using EquiFrame
Nathaniel Scherer 1, *, Islay Mactaggart 1, Chelsea Huggett 2, Pharozin Pheng 3, Mahfuj-ur Rahman 4, Adam Biran 5
and Jane Wilbur 1
Citation: Scherer, N.; Mactaggart, I.;
Huggett, C.; Pheng, P.; Rahman,
M.-u.; Biran, A.; Wilbur, J. The
Inclusion of Rights of People with
Disabilities and Women and Girls in
Water, Sanitation, and Hygiene Policy
Documents and Programs of
Bangladesh and Cambodia: Content
Analysis Using EquiFrame. Int. J.
Environ. Res. Public Health 2021,18,
5087. https://doi.org/10.3390/
ijerph18105087
Academic Editor: Paul B. Tchounwou
Received: 31 March 2021
Accepted: 6 May 2021
Published: 11 May 2021
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
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iations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine,
London WC1E 7HT, UK; islay.mactaggart@lshtm.ac.uk (I.M.); jane.wilbur@lshtm.ac.uk (J.W.)
2WaterAid Australia, Melbourne, VIC 3002, Australia; chelsea.huggett@wateraid.org.au
3WaterAid Cambodia, Phnom Penh 12207, Cambodia; pharozin.pheng@wateraid.org.au
4WaterAid Bangladesh, Dhaka 1213, Bangladesh; mahfujurrahman@wateraid.org
5Environmental Health Group, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
adam.biran@lshtm.ac.uk
*Correspondence: nathaniel.scherer@lshtm.ac.uk
Abstract:
People with disabilities and as women and girls face barriers to accessing water, sanitation,
and hygiene (WASH) services and facilities that fully meet their needs, especially in low- and middle-
income countries. Women and girls with disabilities experience double discrimination. WASH
policies should support and uphold the concepts of disability and gender inclusion, and they should
also act as a guide to inform WASH programs and service delivery. Using a modified version of the
EquiFrame content analysis tool, this study investigated the inclusion of 21 core concepts of human
rights of people with disabilities and women and girls in 16 WASH policy documents and seven
end-line program reports from Bangladesh and Cambodia. Included documents typically focused
on issues of accessibility and neglected wider issues, including empowerment and support for
caregivers. The rights of children and women with disabilities were scarcely focused on specifically,
despite their individual needs, and there was a disconnect in the translation of certain rights from
policy to practice. Qualitative research is needed with stakeholders in Bangladesh and Cambodia
to investigate the inclusion and omission of core rights of people with disabilities, and women and
girls, as well as the factors contributing to the translation of rights from policy to practice.
Keywords:
people with disabilities; women and girls; water; sanitation and hygiene; WASH; policy;
rights; Bangladesh; Cambodia; low- and middle-income countries
1. Introduction
1.1. Inequitable WASH
Access to water, sanitation, and hygiene (WASH) is a fundamental human right,
as recognized in the 2010 United Nations General Assembly Resolution 64/292 and the
Sustainable Development Goals (SDGs) [
1
,
2
]. Despite global progress over the last 30 years,
estimates indicate that 2.1 billion people do not have access to safe drinking water, and
4.5 billion lack safe sanitation services [
3
,
4
]. As with all SDGs, Goal 6: Clean water and
sanitation, follows the guiding principle of “leave no one behind” [
5
]. However, barriers
to accessing WASH services disproportionately affect certain groups, especially in low-
and middle-income countries (LMICs), including people with disabilities, and women and
girls [
4
,
6
]. This inequitable access to WASH impacts their health, livelihood, and education
opportunities [4].
Int. J. Environ. Res. Public Health 2021,18, 5087. https://doi.org/10.3390/ijerph18105087 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021,18, 5087 2 of 19
Recent multi-country analyses reported that the majority of people with disabilities
could access the same WASH facilities as other household members, but they frequently
required assistance to do so and often faced difficulties [
7
]. One survey of 20,000 house-
holds in Bangladesh found that 47% of people with disabilities found it difficult to access
sanitation facilities without coming into contact with feces, whilst 79% were unable to
collect water. Furthermore, people with disabilities experience stigma and discrimination
when accessing WASH [
8
]. In Uganda, people with disabilities were not allowed to use
communal water points as they were seen to be dirty, and their impairment was thought to
be contagious [
9
]. Such stigma and discrimination can result in people with disabilities
being excluded from participating in WASH decision processes as well as the planning,
development, and implementation of services and programs [
10
]. People with disabilities
also report instances of physical, verbal, and sexual abuse when accessing public WASH
facilities [11].
Inequitable WASH is a gendered issue, and women and girls are disproportionally
affected by lack of access due to biological and cultural issues [
4
]. Limited access to WASH
resources and facilities leads to poorer physical and psychological health outcomes in
women and children, including infection and disease (such as soil-transmitted helminth
infections and schistosomiasis), which are associated with maternal and newborn mor-
tality [
12
]. Moreover, women and girls bear the brunt of unpaid WASH responsibilities
in households and communities. In a systematic review of 59 studies from 30 countries,
estimates of women as primary carriers of water ranged from 61% to 79%, and it is a role
associated with poorer health, pain, and musculoskeletal disorders [
13
]. In a systematic
review of 76 studies, women and girls in LMICs also reported restrictions on menstrual
hygiene management, resulting from inadequate infrastructure and the economic envi-
ronment, as well as cultural expectations and stigma [
14
]. As a result, women and girls
reported feelings of shame and distress when menstruating. Women and girls are also at
risk of abuse and violence when using WASH facilities and services [
15
]. Evidence from
Kenya found that women and girls were at risk of physical and sexual violence when
fetching water or when using WASH facilities, especially at night [16].
These barriers and challenges to disability and gender inclusive WASH intersect,
and women and girls with disabilities experience double discrimination, placing them at
higher risk of violence, exclusion, and exploitation. For instance, in Cambodia, women
with disabilities have reported exclusion from community meetings, making it difficult
for them to learn about WASH and health management [
17
]. In a systematic review of
22 studies from 14 countries, women with disabilities and caregivers reported challenges
and difficulties in menstrual hygiene management, including limited training and informa-
tion, and a lack of appropriate menstrual hygiene materials for individuals with a physical
impairment [
18
]. Through qualitative research in Malawi, menstruation was found to be
a source of shame, discomfort, and worry for women with disabilities, and adolescents
with disabilities were reported to drop out of school when beginning menstruation [
19
]. In
Nepal, information on menstrual hygiene management was often withheld from women
with intellectual disabilities because of perceived limitations in understanding [
20
]. As
a result, some showed their menstrual blood and hygiene products to others and were
abused for doing so, whilst others became frightened and withdrawn during menstruation.
1.2. Disability Inclusive Development
A definition of ‘inclusive WASH’ does not exist in peer-reviewed literature, although
a number of non-governmental organizations (NGOs) have formulated their own. An
inclusive approach addresses barriers to accessing and using WASH services and facilities.
Key pillars of inclusive WASH include participation of users in decision-making and access
for all.
International frameworks and collaborations exist to support investment in disability
and gender-inclusive WASH projects, programs and policies, including a directive from
the United Nations Children’s Fund (UNICEF) for investment in accessible and inclusive
Int. J. Environ. Res. Public Health 2021,18, 5087 3 of 19
WASH, which focused on the SDGs principle of “leave no one behind” [
21
]. Furthermore,
the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD)
provides evidence and guidance for new policy frameworks that aim to promote disability-
inclusive societies [22].
Whilst the Overseas Development Institute (ODI) has reported global progress in
tackling discriminatory legal and policy frameworks, the implementation of disability-
inclusive programs has been slow in LMICs, especially with regard to women and girls with
disabilities, suggesting a disconnect between policy and practice [
23
]. Reasons reported for
this include: a lack of coordination to enable cross-sectoral programing and accountability;
limited trained service providers; and few evaluations to provide evidence of what works.
In 2015, the Rural Water Supply Network recognized that “water user committee mem-
bers, government health educators, and village heads need simple and clear guidance or
manuals on how to promote inclusive WASH” [
24
]. Responding to this need, we aim to
develop evidence-based guidance for governments in LMICs on implementing disability-
inclusive WASH at scale. This guidance will provide information on including disability
within WASH policy and recommendations on translating policy commitments into practice.
With inequalities in WASH disproportionately affecting women and girls, and women and
girls with disabilities, the guidance will offer direction on support for this population.
To formulate this guidance, we are conducting research in Bangladesh and Cambodia,
evaluating contributing factors to implementing inclusive WASH in LMICs. As a first step
in guidance development, we have examined the inclusion of people with disabilities, and
women and girls, in WASH policy documents and programs in Bangladesh and Cambodia.
Bangladesh and Cambodia were chosen as research sites because of government commit-
ment to the rights of people with disabilities in WASH service provision. Assessments
in these countries have highlighted positive steps taken by each government toward a
disability-inclusive approach in WASH, but reported gaps remain [
25
,
26
]. For example,
in Cambodia, the Disability Action Council developed the ‘National Disability Strategic
Plan 2014–2018’, after ratifying the UNCRPD. Although this has helped improve the policy
framework on the rights of people with disabilities and provides guidance on accessible
public health infrastructure, it does not make mention of inclusive WASH specifically. It
has been some time since each country review, and this study provides further opportunity
to assess advances in disability-inclusive development and inclusive WASH. Both countries
operate a decentralized system, in which the national government is responsible for policy
formation and local government implementation.
1.3. Aims and Objectives
This study aimed to examine the extent to which WASH policy documentation in
Bangladesh and Cambodia include information on the rights of people with disabilities,
and women and girls, and the degree to which policy commitments have been translated
into program implementation.
The objectives of the study were as follows: (i) identify the information on the rights
of people with disabilities, and women and girls, included in WASH policy documents of
Bangladesh and Cambodia; and (ii) understand the extent to which implemented WASH
programs integrate these rights into practice.
2. Materials and Methods
We conducted a content analysis of WASH policy documents and program reports
from Bangladesh and Cambodia.
2.1. Selection of Documents
2.1.1. Policy Documents
Policy documents were identified through an online literature search and through
interaction with key actors involved in influencing national WASH policy and practice in
Bangladesh, Cambodia, and Australia. We also reviewed research articles in which the
Int. J. Environ. Res. Public Health 2021,18, 5087 4 of 19
WASH policies of each country were analyzed, in search of additional policy documents,
for example, ‘An analysis of Water Policies and Strategies of Bangladesh in the Context of
Climate Change’, from Hadi in 2019 [
27
]. WASH documents were included if they were
specific to WASH or its component parts (water, sanitation, and hygiene) and developed
by the governments of Bangladesh or Cambodia, for national use. Eligible document types
included policies, action plans, strategic objectives, and national guidelines, which were
either strategic or operational in nature. Legislative documentation was not included nor
were documents provided by regional or local authorities.
2.1.2. Program Reports
Information on implemented WASH programs was sought through an online review
and search of national and international NGOs and other entities working on WASH in each
country, as well as searches by teams in Bangladesh and Cambodia. In order to apply an
assessment of realized WASH implementation and outcomes, rather than those intended,
we included only end-line program reports produced by the implementing organization or
an external party. Protocols, inception reports, or mid-line reviews were not included. To be
eligible, end-line reports must have included information on the program components and
realized outputs. The program could have focused on implementing services or facilities
for any aspect of WASH, for any population, at either a national, regional, or local level.
All policy and program documents were required in English. Where documents were
not available in English, local partners translated documents from the local language. There
was no date restriction applied, although policies needed to be the most current version in
use by the national government.
2.2. Content Analysis
We adapted and used the EquiFrame content analysis tool to evaluate the rights of
people with disabilities, and women and girls, included in the WASH policy documents
and programs of Bangladesh and Cambodia. EquiFrame is a policy analysis framework
that has been designed to assess a policy against its inclusion of 21 core concepts of human
rights deemed essential for universal, equitable, and accessible health services [
28
,
29
]. This
tool is not typically used to examine program reports, but we have applied the same logic.
In addition to evaluating the inclusion of 21 core concepts of human rights, the tool is
designed to assess the inclusion of 12 vulnerable groups, including people with disabilities,
female-headed households, and mothers of young children (<5). With our focus being on
the rights of people with disabilities, and women and girls in WASH, we adapted the tool
to evaluate inclusion of the 21 core concepts for these two target groups only (people with
disabilities, and women and girls) each potentially vulnerable to exclusion from WASH.
EquiFrame provides key language and key questions for each of the 21 core concepts.
We refined these to reflect the rights of people with disabilities, and women and girls, in the
context of WASH (Table 1), by mapping each concept against the ‘human right to water and
sanitation’, which was adopted by the United Nations General Assembly in 2010 [
1
]. During
adaptation, we sought advice and feedback from the EquiFrame development team [29].
Int. J. Environ. Res. Public Health 2021,18, 5087 5 of 19
Table 1.
The 21 core concepts of EquiFrame, adapted to the rights of people with disabilities, and women and girls, in the
context of WASH.
No. Core Concept Key Question Key Language
1. Non-
discrimination
Does the policy support the rights of people
with disabilities and women/girls with equal
opportunity in receiving WASH services?
People with disabilities and women/girls are
not directly or indirectly discriminated
against within the WASH system
2. Individualized
services
Does the policy support the rights of people
with disabilities and women/girls with
individually tailored WASH services to meet
their needs, choices, and impairments?
People with disabilities and women/girls
receive specific, appropriate, and effective
WASH services. For people with disabilities,
this includes reasonable adjustments
made/supported, when necessary. For
women/girls, this may include services
specific to menstrual health and hygiene
3. Entitlement
Does the policy indicate entitlements for
people with disabilities and women/girls
(e.g., respite grant or reduced user fee), and
how they may qualify for specific benefits
relevant to them?
People with disabilities and women/girls
who have limited resources are entitled to
some services free of charge or at a sliding
scale tariff, especially if in unpaid work
4. Capability-based
services
Does the policy recognize the capabilities of
people with disabilities and women/girls?
For instance, programs including peer
support, mentoring, and group advocacy.
People with disabilities and women/girls are
meaningfully represented in WASH
committees. For people with disabilities,
programs may be implemented by
Organizations of Persons with Disabilities
(OPDs)
5. Participation
Does the policy support the right of people
with disabilities and women/girls to
participate in the decisions that affect their
lives and enhance their empowerment?
People with disabilities and women/girls
can exercise choices and influence decisions
affecting their life. Consultation may include
planning, development, implementation, and
evaluation
6. Coordination of
services
Does the policy support assistance of people
with disabilities and women/girls in
accessing services from within a single
provider system (inter-agency) or more than
one provider system (intra-agency) or more
than one sector (inter-sectoral)?
People with disabilities and women/girls
know how services should interact where
inter-agency, intra-agency, and inter-sectoral
collaboration is required. This includes
coordination between health services,
schools, households, and public places, with
regard to WASH. Additional coordination
opportunities include the WASH sector with
the private sector, civil society, and rights
groups
7. Protection from
harm
Does the policy outline that people with
disabilities and women/girls are to be
protected from harm during their interaction
with WASH and related services?
People with disabilities and women/girls are
protected from harm during their interaction
with WASH services and health-related
systems, as well as from families and the
community who may have negative attitudes
about WASH for people with disabilities and
women/girls (e.g., topics such as menstrual
hygiene)
8. Liberty
Does the policy support the right of people
with disabilities and women/girls to be free
from unwarranted physical or other
confinement?
People with disabilities and women/girls are
protected from unwarranted physical or
other confinement while in the custody of the
service system/provider. This includes at
home and a healthcare service
Int. J. Environ. Res. Public Health 2021,18, 5087 6 of 19
Table 1. Cont.
No. Core Concept Key Question Key Language
9. Autonomy
Does the policy support the right of people
with disabilities and women/girls to consent,
refuse to consent, withdraw consent, or
otherwise control or exercise choice or
control over what happens to them?
People with disabilities and women/girls
can express “independence” or
“self-determination”. For instance, a person
with an intellectual disability will have
recourse to an independent third party
regarding issues of consent and choice. Or, as
another example, a husband is not to make
decisions for his wife
10. Privacy
Does the policy address the need for
information regarding people with
disabilities and women/girls to be kept
private and confidential?
Information regarding people with
disabilities and women/girls need not be
shared among others
11. Integration
Does the policy promote the use of
mainstream services by people with
disabilities and women/girls?
People with disabilities and women/girls are
supported to use the WASH services that are
provided for the general population
12. Contribution
Does the policy recognize that people with
disabilities and women/girls can be
productive contributors to society?
People with disabilities and women/girls
make a meaningful contribution to society
and the WASH sector
13. Family resource
Does the policy recognize the value of the
family members of people with disabilities
and women/girls in addressing
WASH needs?
The document recognizes the value of family
members of people with disabilities and
women/girls as a resource for addressing
WASH needs
14. Family support
Does the policy recognize individual
members of people with disabilities and
women/girls may have an impact on the
family members requiring additional
support from WASH services?
Caring for persons with disabilities and
women/girls may impact other family
members (e.g., mental health), such that
these family members themselves
require support
15. Cultural
responsiveness
Does the policy ensure that services respond
to the beliefs, values, gender, interpersonal
styles, attitudes, cultural, ethnic or linguistic,
aspects of the person, as well as personal
safety and dignity?
(i) People with disabilities and women/girls
are consulted on the acceptability of the
service provided; (ii) Hygiene facilities,
goods, and services are respectful of ethical
principles and culturally appropriate, i.e.,
respectful of the culture of people with
disabilities
16. Accountability Does the policy specify to whom, and for
what, services providers are accountable?
People with disabilities and women/girls
have access to internal and independent
professional evaluation or procedural
safeguard. Law/regulations provide
mechanisms that ensure complaints are
effectively heard and there are clear systems
for people to lodge these complaints. Judicial
bodies are available to resolve conflicts, for
both public and private institutions
17. Prevention
Does the policy support people with
disabilities and women/girls in seeking
primary, secondary, and tertiary prevention
of health conditions associated with WASH?
Includes WASH-related illnesses and details
on how people with disabilities and
women/girls can seek primary, secondary,
and tertiary prevention of health conditions.
For example, Trachoma, Soil-Transmitted
Helminths—intestinal worms, Lymphatic
Flariasis, Leprosy, urinary tract infections
18. Capacity building
Does the policy support the capacity
building of health workers and of the system
that they work in addressing WASH needs of
people with disabilities and women/girls?
Includes awareness raising among
communities and families on disability and
on the specific issues/barriers facing people
with disabilities and women/girls
Int. J. Environ. Res. Public Health 2021,18, 5087 7 of 19
Table 1. Cont.
No. Core Concept Key Question Key Language
19. Access
Does the policy support people with
disabilities and/or women/girls—physical,
economic, and information access to
WASH services?
People with disabilities and women/girls
have accessible and safe WASH services
within, or in the immediate vicinity, of
household, health, and educational
institution, public institutions, and
workplace. All information must be
understandable and in an appropriate format
20. Quality
Does the policy support quality services to
people with disabilities and women/girls
through evidence-based and professionally
skilled practice? Does the policy promote
innovation in WASH services for people with
disabilities and women/girls
(e.g., technology)?
People with disabilities and women/girls are
assured that services are based on best
practice/evidence and support innovative
strategies/technology
21. Efficiency
Does the policy support efficiency by
providing a structured way of matching
WASH system resources with service
demands in addressing WASH needs of
people with disabilities and women/girls?
WASH services are sustainable for people
with disabilities and women/girls. Services
will be available at times of financial crisis
and will ensure appropriate technology
choices. Contracts with providers take into
account operation and maintenance, and
funds from donors are sustainable
2.3. Equiframe Scoring
Reference to a core concept, in relation to the rights of people with disabilities, or
women and girls, received a score of 1 to 4:
1. The concept was mentioned;
2. The concept was mentioned and explained;
3. Specific policy actions were identified to address the concept;
4. Intention to monitor the concept was expressed.
In end-line program reports, the scoring of 1 and 2 remained the same, with criteria
altered slightly for scores of 3 and 4:
3. Specific actions were taken in the program to address the concept;
4. Steps to monitor the concept were taken in the program.
Scores of 3 and 4 indicate a reference to the core concept is operational and actionable,
and the reference is deemed ‘high quality’.
For each document, two independent reviewers (NS and JW) coded each reference to
a core concept against the scoring criteria. References, in this context, typically refer to a
single sentence or short paragraph. For example, the following sentence taken from the
Cambodian policy document ‘National Guidelines on WASH for Persons with Disabilities
and Older People’ would be included as a single reference and scored 3 under the concept
of Participation: “Programs should include persons with disabilities and older people in the
planning, implementation, and evaluation of activities where possible, including the partic-
ipation of DPO [Disabled People’s Organization] and OPA [Older People’s Association]
representatives, and representatives from NGOs that already have expertise in working
with these groups”.
Scores were applied separately to references of rights of people with disabilities, and
women and girls. Overlapping references (i.e., with regard to women and girls with
disabilities) were scored twice, under each group. Any discrepancy in score was discussed
by the reviewers until a consensus was reached.
Summary statistics were generated for each document individually and then combined
across both countries under policy and program documentation. Statistics relevant to the
Int. J. Environ. Res. Public Health 2021,18, 5087 8 of 19
rights of people with disabilities, and women and girls, are presented separately. Data
were aggregated across the two countries to help us learn lessons on commonly endorsed
and neglected concepts, to take forward into guideline development, rather than focus on
the strengths and limitations of each individual country approach. To derive these data,
the following statistics were calculated.
2.3.1. Scoring across All Documents
1. Core concept reference:
the proportion (%) of all references to a core concept across
policy and program documents, split by disability and gender. This was calculated
for Bangladesh and Cambodia individually, and aggregated together;
2. Average score:
the average score across all references to a concept, providing insight
into the commitment of included information.
2.3.2. Scoring per Document
1. Core concept coverage:
Each document was examined with respect to the proportion
of the 21 core concepts referenced at least once;
2. Core concept quality:
The proportion of references to all 21 core concepts scored 3 or
4 (i.e., stating a specific action or an intention to monitor that action).
2.3.3. Document Excerpts
Excerpts from included documents were extracted and are presented as an illustrative
example of a single reference, in the context of total scoring. The concept scored is presented
with the excerpt.
2.3.4. Ethical Approval
The study was approved by the Ethics Committee of the London School of Hygiene &
Tropical Medicine (17679), the National Ethics Committee for Health Research in Cambodia
(042), and the Bangladesh Medical Research Council (BMRC/NREC/2019–2022/608).
3. Results
For clarity and ease of interpretation, we have presented the results and summary
statistics under two thematic areas: disability and gender inclusion.
3.1. Policy Documents
A total of 16 WASH policy documents, 10 from Bangladesh and six from Cambodia,
were included in the analysis. Table 2presents the proportion of references (across all policy
documents) and average score attributed to each of the 21 core concepts. Table S1 details
the core concept coverage (i.e., the proportion of core concepts referenced at least once)
and the proportion of references that are scored 3 or 4 for each included policy document.
3.1.1. Core Concept Reference and Coverage: Disability Inclusion
Information related to disability inclusion was most commonly provided with regard
to the rights of Access (21% of all references) and Individualized services (17%).
“Include sanitation businesses in disability awareness raising and encourage universal
accessible design principles—emphasizing the benefits and usability of the whole commu-
nity throughout a persons’ life cycle” (National Guidelines on WASH for Persons with
Disabilities and Older People: Cambodia; Scored Access)
The concepts of Contribution and Accountability were not referenced in any policy doc-
umentation from either country. The concepts of Liberty,Autonomy,Privacy,Family resource,
Family support,Prevention, and Efficiency were referenced relatively infrequently (
≤
1%) com-
pared with other concepts. Most (62%) of the references were scored 3 or 4 (‘high quality’).
Int. J. Environ. Res. Public Health 2021,18, 5087 9 of 19
Table 2. Proportion of total references and average score across concept, in the policy documents of Bangladesh and Cambodia (“-“ denotes no reference to a core concept).
Bangladesh Cambodia Total
Disability (n= 122) Gender (n= 247) Disability (n= 211) Gender (n= 99) Disability (n= 333) Gender (n= 346)
% Refs. Av. Score % Refs. Av. Score % Refs. Av. Score % Refs. Av. Score % Refs. Av. Score % Refs. Av. Score
1. Non-
discrimination 7% 1.6 6% 1.6 8% 2.9 8% 2.0 8% 2.4 7% 1.2
2. Individualized
services 31% 2.1 23% 2.3 10% 2.6 20% 3.1 17% 1.9 23% 2.2
3. Entitlement 7% 2.3 2% 2.3 4% 2.6 4% 2.3 5% 2.4 3% 2.3
4. Capability-based
services 2% 3.0 7% 2.6 9% 2.7 7% 2.6 6% 2.8 8% 2.6
5. Participation 6% 2.4 11% 2.6 13% 2.8 9% 3.0 11% 2.7 11% 2.7
6. Coordination of
services 2% 2.7 4% 2.5 6% 2.7 - - 5% 2.7 3% 2.5
7. Protection from
harm 7% 2.6 12% 2.7 1% 3.0 10% 2.9 3% 2.6 12% 2.0
8. Liberty 1% 2.0 - - - - - - <1% 2.0 0% 0.0
9. Autonomy 1% 1.0 1% 1.7 - - - - <1% 1.0 1% 1.3
10. Privacy 1% 3.0 1% 3.0 - - - - <1% 3.0 1% 3.0
11. Integration 4% 1.6 3% 1.6 4% 2.5 10% 2.4 4% 2.2 5% 1.9
12. Contribution - - 3% 1.9 - - 3% 2.0 - - 3% 1.9
13. Family resource - - - - 1% 2.5 - - 1% 2.5 0% 0.0
14. Family support - - - - 1% 2.0 - - 1% 2.0 0% 0.0
15. Cultural
responsiveness 5% 2.3 4% 2.6 1% 2.0 - - 3% 2.2 3% 2.4
16. Accountability - - 1% 1.5 - - 2% 2.0 - - 1% 1.3
17. Prevention 1% 1.0 3% 1.8 - - - - <1% 1.0 2% 0.4
18. Capacity building 2% 1.7 2% 1.8 12% 2.8 5% 3.0 9% 2.7 3% 2.4
19. Access 15% 2.7 6% 2.8 24% 3.0 10% 3.1 21% 2.7 8% 1.9
20. Quality 7% 2.5 6% 2.5 6% 3.0 10% 3.1 6% 2.7 7% 2.1
21. Efficiency 1% 1.0 2% 1.8 1% 3.5 1% 4.0 1% 2.7 2% 1.9
Total 100% 100% 100% 100% 100% 100%
Int. J. Environ. Res. Public Health 2021,18, 5087 10 of 19
Of the 333 core concept references, 90% regarded people with disabilities as a broad
group, with 4% made in relation to adults with disabilities only, 4% to children with
disabilities, and 2% to the needs of adults and children with disabilities as individual
groups. Only 7% of references referred to women with disabilities.
Across both countries, WASH policy documents referenced 21% of core concepts, on
average, in relation to the rights of people with disabilities (Table S1). Five policies (three
in Bangladesh, two in Cambodia) did not reference a single core concept in relation to
disability inclusion, and the overarching national WASH policy of neither country included
reference to any core concept.
3.1.2. Core Concept Reference and Coverage: Gender Inclusion
Under gender inclusion, Individualized services (23%) was the most commonly ref-
erenced concept. The concepts of Liberty,Family resource, and Family support were not
included in any policy document, whilst Autonomy,Privacy, and Accountability were refer-
enced relatively infrequently (
≤
1%). Half (50%) of the concept references were scored 3 or
4 (‘high quality’).
“Ensure hand pumps and water containers are women- and girl-friendly, and are designed
in ways that minimize the time spent collecting water” (Operational Guidelines for
WASH in Emergencies: Bangladesh; scored Individualized services).
More than one-third (37%) of the 346 references provided information relevant to females
broadly, with no mention of age group, whilst 35% focused on women only and 10% on girls.
Meanwhile, 18% of references referred to women and girls as individual groups.
In contrast to disability inclusion, all policy documents referenced at least one core concept
in regard to gender inclusion. On average, each document referenced 34% of core concepts.
3.2. Program Documents
Seven end-line program reports were included, of which five were implemented
in Bangladesh.
3.2.1. Core Concept Reference and Coverage: Disability Inclusion
Capacity building (27%) was the most frequently referenced concept in relation to
disability inclusion (Table 3).
“The disability-friendly latrines installed by the project were used as a demonstration
to the local government and service providers, such as the municipal and sub-district
governments, Department of Public Health and Engineering, and other NGOs.” (ADD
International—Improved Sanitation for Women and Children with Disabilities living in
extreme poverty in Bangladesh; scored Capacity building)
The concepts of Protection from harm,Liberty,Autonomy,Privacy,Contribution,Family support,
Cultural responsiveness,Accountability, and Prevention were not mentioned in any program report.
Most (90%) of references to the core concepts were scored at 3 or 4 (‘high quality’).
Of the 91 references, 66% were made in relation to people with disabilities broadly, 4%
were focused on adults with disabilities, 12% were focused on children with disabilities
only, and 18% were focused on both adults and children with disabilities as individual
groups. Meanwhile, 19% of references were made in relation to women with disabilities.
Program reports from Bangladesh and Cambodia referenced 14% of core concepts, on
average, in relation to disability inclusion (Table S2). Of the seven reports included, three
did not reference a single concept in relation to disability inclusion.
Int. J. Environ. Res. Public Health 2021,18, 5087 11 of 19
Table 3. Proportion of total references and average score across concept, in the program documents of Bangladesh and Cambodia; (“-“ denotes no reference to the core concept).
Bangladesh Cambodia Total
Disability (n= 89) Gender (n= 176) Disability (n= 2) Gender (n= 14) Disability (n= 91) Gender (n= 190)
% Refs. Av. Score % Refs. Av. Score % Refs. Av. Score % Refs. Av. Score % Refs. Av. Score % Refs. Av. Score
1. Non-
discrimination 1% 4.0 13% 3.3 - - 36% 3.0 1% 4.0 14% 3.2
2. Individualized
services 18% 3.7 14% 3.6 - - - - 18% 3.7 13% 3.6
3. Entitlement 2% 3.0 3% 3.4 - - - - 2% 3.0 3% 3.4
4. Capability-based
services 17% 3.9 10% 3.8 - - - - 16% 3.9 9% 3.8
5. Participation 4% 3.5 11% 3.7 - - 7% 4.0 4% 3.5 11% 3.7
6. Coordination of
services 7% 3.7 - - - - - - 7% 3.7 - -
7. Protection from
harm - - 3% 3.8 - - - - - - 3% -
8. Liberty - - - - - - - - - - - -
9. Autonomy - - 1% 3.0 - - - - - - 1% 3.0
10. Privacy - - - - - - - - - - - -
11. Integration 2% 4.0 5% 2.6 50 4.0 14% 3.5 3% 4.0 6% 2.7
12. Contribution - - 1% 3.0 - - - - - - 1% 3.0
13. Family resource 2% 2.5 1% 2.0 - - - - 2% 2.5 1% 2.0
14. Family support - - - - - - - - - - - -
15. Cultural
responsiveness - - 3% 3.6 - - - - - - 3% 3.6
16. Accountability - - - - - - - - - - - -
17. Prevention - - 1% 4.0 - - - - - - 1% 4.0
18. Capacity building 28% 3.6 19% 3.8 - - - - 27% 3.6 18% 3.8
19. Access 6% 3.2 10% 3.5 - - 7% 3.0 5% 3.2 9% 3.4
20. Quality 8% 4.0 6% 3.6 50% 3.0 36% 3.0 9% 3.9 8% 3.4
21. Efficiency 4% 3.3 2% 4.0 - - - - 4% 3.3 2% 4.0
Total 100% 100% 100% 100% 100% 100%
Int. J. Environ. Res. Public Health 2021,18, 5087 12 of 19
3.2.2. Core Concept Reference and Coverage: Gender Inclusion
Under the theme of gender inclusion, Capacity building (18%) was again most com-
monly referenced, with Non-discrimination (14%), Individualized services (13%), and Par-
ticipation (11%) referenced relatively frequently (
≥
10%), compared with other concepts.
Coordination of services,Liberty,Privacy,Family support, and Accountability were not ref-
erenced in any program document, whilst Autonomy,Contribution,Family resource, and
Prevention were referenced relatively infrequently (
≤
1%). Most (85%) references scored 3
or 4 (‘high quality’).
Of 190 references, 26% were made with respect to females broadly, while 38% were
made in relation to women only, and 24% were made with respect to girls. 12% recognized
women and girls as individual groups.
“Include a detailed gender baseline in relation to WASH at communities and schools for
being able to identify gender related needs, actions and indicators” (Child Rights Founda-
tion: Improving Hygiene and Sanitation of Cambodia Rural Schools and Communities;
scored Non-discrimination and Quality)
With so few references in the program reports of Cambodia, the summary indices
shown in Table 3are predominantly driven by the findings from Bangladesh.
All core concepts were referenced at least once, in relation to gender inclusion. On
average, program reports referenced 33% of concepts, with regard to the rights of women
and girls.
3.3. Mapping Policy to Program
In Cambodia, there was disparity in the inclusion of rights of people with disabilities
between policy and program documents, with program reports referencing just two con-
cepts. The program reports of Bangladesh demonstrated commitment to a greater breadth
of rights of people with disabilities, although these did not always correspond to policy
documents. For example, Capacity building (28%), the most commonly referenced concept
in program documentation, is referenced infrequently (2%) in policy.
This trend is seen again under concepts related to gender inclusion. In Cambodia,
the program documents reference few of the 21 core concepts and do not once reference
Individualized services, which is the most commonly referenced concept (20%) in the coun-
try’s WASH policy documents. Programs in Bangladesh demonstrated a greater breadth
of core concepts with regard to the rights of women and girls, with a number receiving
similar proportional representation in policy and program documents—Participation (11%),
for example. As with the theme of disability inclusion, Capacity building (19%) was more
commonly included in programs, compared to policy documents (2%).
4. Discussion
As a first step in developing guidance on inclusive WASH policy and practice in
LMICs, this study examined the inclusion of 21 core concepts of human rights of people
with disabilities, and women and girls, in WASH policy documents and programs from
Bangladesh and Cambodia.
When analyzed using EquiFrame, the UNCRPD included 95% of core concepts, high-
lighting the suitability of the tool and the core concepts to an assessment of disability
inclusion [
30
]. In relation to the rights of people with disabilities, the WASH policy doc-
uments examined included only 21% of EquiFrame’s 21 core concepts, on average. Both
Bangladesh and Cambodia have committed to the SDGs, and the guiding principle of
“leave no one behind”, and WASH policy documents should be including information
relevant to a greater breadth of rights of people with disabilities, in order to support
disability-inclusive development. The proportion of concepts included in relation to the
rights of women and girls was higher: 34% on average. This trend is also seen in the
program reports: 14% (disability inclusion) vs. 33% (gender inclusion). This may reflect a
better understanding of WASH for women and girls or a greater commitment of support
Int. J. Environ. Res. Public Health 2021,18, 5087 13 of 19
to this group, given their larger demographic representation and contributions to WASH
at the household level. It may also reflect the longer history of gender inclusion in policy,
compared to disability; the UNCRPD was adopted in 2006, whereas the Convention on
the Elimination of All Forms of Discrimination against Women (CEDAW) was adopted in
1979 [
22
,
31
]. Two-thirds of the core concepts were still typically not included in the policy
documents with regard to gender inclusion, which is an omission that should be addressed.
4.1. Accessible and Appropriate WASH Services and Facilities
In realizing disability-inclusive WASH, barriers to accessing services and facilities
must be alleviated, whether they be physical, attitudinal, or institutional [
10
]. Reflecting
this, Access is the most commonly referenced concept in the UNCRPD, and this is observed
in the WASH policy documents of Bangladesh and Cambodia (21%) reviewed in this
study [
29
]. However, Access is not frequently referenced in program reports (5%), despite
its stated value in policy documents and the UNCRPD. The reasons for this are unclear and
will be important to explore in future qualitative research. As well as Access, information
on Individualized services is frequently included in policy and program documentation,
in recognition of the specific WASH needs of people with disabilities (17% and 18%,
respectively), and women and girls (23% and 13%, respectively). Although relatively few
references are made to women with disabilities overall, when done so, Individualized services
is recognized most frequently (18% in policies and 35% in programs).
However, there are a number of factors that contribute to accessibility and individual-
ized services, which have been neglected. For example, Entitlement is rarely included in
either policy (5%) or program (2%) documentation, despite financial burden and poverty be-
ing major barriers to WASH access for people with disabilities in LMICs [
32
]. EquiFrame’s
core concepts do not exist in isolation of one another, and this highlights the need to
recognize the relationships between each and provide guidance that incorporates all.
4.2. Shifting Unequal Power Dynamics
The concept and right of Participation is included relatively frequently in WASH policy
documentation with regard to disability and gender inclusion (11% each), reflecting the
drive for greater empowerment of women and girls and inclusion of people with disabili-
ties in WASH (and other) systems. In the disability sector, this includes the movement of
“Nothing About Us, Without Us”, which advocates the principle that people with disabili-
ties know what is best for them and their community and must be valued as contributors
to the policies, programs, and services that affect their lives [33,34].
That being said, the majority of references across policy documents and programs
are focused on WASH infrastructure (i.e., concepts of Access and Individualized services)
and other than Participation, very few references relate to rights and concepts of empower-
ment of people with disabilities, and women and girls, such as Autonomy and Contribution.
Empowerment and participation reduce stigma and discrimination, which can, in turn,
promote further empowerment and participation, helping to break the cycle of exclu-
sion [35–37].
Empowerment must also reflect the capacity of people with disabilities, and women
and girls, in the implementation and management of WASH services and facilities. Women
and people with disabilities are often excluded from positions of leadership in WASH,
whether that be in policy development, WASH management committees, or program
implementation teams. Supporting these groups to exercise their capability and capacity
is needed to achieve a systems change toward inclusive WASH [
38
]. Capability-based
services is included in policy documentation for both groups (6% disability inclusion and
8% gender inclusion), to some extent, and program reports indicate a greater degree of
support in practice for people with disabilities (16%). To further promote successful and
sustainable implementation of inclusive WASH will require training, capacity building, and
support for management committees, government leadership, service providers, and civil
society organizations [10].
Int. J. Environ. Res. Public Health 2021,18, 5087 14 of 19
4.3. WASH and Health
WASH is an important determinant of individual health and protection from disease,
a notable example being its importance in interrupting the transmission of the coronavirus
disease 2019 (COVID-19) [
39
]. Women and girls may also face additional health concerns due
to WASH burdens and duties, such as carrying water. However, Prevention of health condi-
tions associated with WASH is a right rarely included in policy or program documentation
(
≤
2%). As demonstrated in a 2019 systematic review, there is a dearth of evidence on WASH
interventions and their effect on infections in health care settings in LMICs, and this lack
of research may contribute to a limited focus and understanding of Prevention [
40
]. Further
research on WASH interventions, with specific focus on the needs of people with disabilities,
and women and girls, would support evidence-based approaches in policy and practice.
4.4. Reducing the Risk of Violence Associated with WASH
Despite being vulnerable to abuse when using WASH facilities, information on Protection
from harm is rarely included in relation to people with disabilities, in either policy documents
(3%) or programming (0%). However, it is referenced more frequently in policy documentation,
in relation to women and girls (12%), which is a positive finding, although few specific details
are given on the protection of women with disabilities. Safety from abuse is of the utmost
importance in WASH provision. The Sanitation and Hygiene Applied Research for Equity
(SHARE) consortium has developed a practitioner’s toolkit on ensuring safe and accessible
WASH services, which may aid governments and service providers in providing safe WASH
services for people with disabilities, and women and girls [41].
4.5. Recognizing the Role of Caregivers
It is important to note few references toward Family resource and Family support in
either policy or program documents, which is not reflective of the key role that family
members and caregivers provide in supporting people with disabilities in WASH practice.
Many family members take on informal caregiving duties for people with disabilities, and
this responsibility is often placed on women in particular. Family members and caregivers
without support may be unaware of effective hygienic WASH practices on topics such as
menstrual health and hygiene, limiting their ability to best support their family member
manage their menstruation hygienically and comfortably [
42
]. Moreover, results from
Nepal and Malawi document that additional WASH-based tasks placed upon caregivers
of people with disabilities result in psychological distress and feelings of isolation [
19
,
20
].
Support, training, and guidance for families and caregivers is needed to ensure inclusive
WASH provision.
4.6. Target Groups
As with the broader population, WASH is an important public health concern for child
health, impacting survival and development. Conditions such as diarrhea, worms, and
dehydration (all linked to poor WASH) are associated with long-term negative outcomes
in mortality, physical growth, and cognitive, motor and language functioning [
12
,
43
]. Evi-
dence from a number of countries, including Bangladesh, demonstrates the role of WASH
provision and intervention in promoting survival, growth, and child development [
44
–
46
].
Further evidence estimates that improvements in sanitation practices account for just under
10% of the decline in child mortality, between 1990 and 2015 [47].
Despite the importance of WASH for children, just 4% of references in included
policy documents target children with disabilities. As well as the impact on survival and
development, inadequate and inaccessible WASH facilities contribute to children with
disabilities not attending school, and they can increase a child’s vulnerability to abuse [
10
].
Children with disabilities are a marginalized and vulnerable group, facing a number of
challenges in school and community life, and the very little reference of this group in policy
contributes to their continued exclusion [
48
]. There is an argument that children with
disabilities are included in references to people with disabilities more broadly (90%), and
Int. J. Environ. Res. Public Health 2021,18, 5087 15 of 19
although correct, there is a clear need for specific policy direction for this group, given
the number of important, individualized considerations for them in WASH provision.
The proportion of references targeting children with disabilities is considerably higher in
program documentation (26%). One contributing factor to this higher proportion may be
the analysis of the ADD International-run program, ‘Improved Sanitation for Women and
Children with Disabilities living in extreme poverty in Bangladesh’, in which children with
disabilities are a targeted beneficiary and referenced frequently.
In contrast, girls are well represented across both policy documents (28%) and pro-
grams (36%). WASH is a vital consideration for girls, impacting educational outcomes and
menstrual health and hygiene as well as survival and development [
49
]. Strong propor-
tional representation of girls in policy and practice is needed to advance gender inclusion,
and the results of this study indicate that girls are represented in Bangladesh and Cambodia
to a similar extent as adult women, which is an encouraging finding.
Relatively few references are made to the rights of women with disabilities. This is
higher in programs (19%) than in policy (7%), but as with children with disabilities, this is
driven by the assessment of the ADD International program, in which WASH support for
women with disabilities is a core focus. Women with disabilities are disproportionately
affected by inequalities in WASH, and for the policies of Bangladesh and Cambodia to omit
specific considerations for this group is a major oversight. It is important that this group
not be forgotten in WASH service provision.
4.7. Policy to Practice
The observed disparities in relative inclusion of rights of people with disabilities,
and women and girls, between policy documents and program reports may suggest a
disconnect between policy development and program implementation. In Cambodia, only
two policy documents were available prior to the first program report published in 2015,
of which one contained no information on disability-inclusive rights, and the other was
focused on rural populations. This may account for the limited reference to the rights of
people with disabilities in the program reports of Cambodia.
Across programs, Capacity Building is highly valued, with regard to disability (27%),
and gender inclusion (18%), but this is less the case in policy documents (9% and 3%,
respectively). Limited knowledge and skills in appropriate practices are often a barrier to
disability-inclusive WASH, and capacity building is a core need across the sector for WASH
leadership and service implementers, as well as communities and households [
10
,
50
].
Greater inclusion of this concept in programming may reflect the limited personnel capable
of implementing disability and gender-inclusive WASH, and thus the need to incorporate
capacity strengthening schemes into program delivery, to ensure successful implementation.
This supports findings from ODI, who reported limited capacity as a primary reason for
the slow implementation of disability-inclusive programs [
23
]. The policy documents of
Bangladesh and Cambodia, and future guidance, may demand greater reference to Capacity
building, as the situation amongst implementing organizations appears to indicate a need.
Further, Coordination of services,Efficiency, and Accountability are rarely referenced in
the policy and program documentation, despite their importance to sustained disability
and gender-inclusive WASH provision. Again, these areas are reported by ODI to be factors
toward the slow implementation of disability-inclusive programming in LMICs, and they
appear to be a needed focus in guidance on disability-inclusive WASH, if countries are to
implement inclusive WASH at scale [23].
The findings of this study will inform qualitative research in both countries, in which
we can explore and identify the factors that facilitate and disrupt the implementation of
disability-inclusive WASH policies and programs in more detail. We will be interviewing
policy-makers, service providers, women and men with disabilities, and caregivers. Dis-
parities in policy and program (for example, with regard to the inclusion of information
relevant to Access and Capacity Building) will be discussed. Lessons learned from this
content analysis and the qualitative research will help inform our future guidance devel-
Int. J. Environ. Res. Public Health 2021,18, 5087 16 of 19
opment. This inclusive WASH guidance will complement the new operational guide on
leaving no one behind, developed by the United Nations Sustainable Development Group
to support Member States in reaching the furthest behind first, across all rights enshrined
in the SDGs [51].
4.8. Limitations
Our inclusion criteria for program reports was broad, to help capture as many program
reports as possible. Those published by the same implementation team or organization may
be subject to information bias, depending on the specific purpose and intended audience
of the end-line report. Our original aim was to include both planning and end-line reports,
but these documents were rarely publicly available. In only including publicly available
end-line reports, we have missed the opportunity to assess the inclusion of rights in
programs that did not produce a final evaluation or have these accessible online. We tried
to mitigate this by contacting program implementers directly and by working with teams
in Bangladesh and Cambodia to source documents not readily available through online
searches. Despite our broad inclusion criteria, just two program reports were collected
from Cambodia, limiting the interpretation of findings from this country. We conducted the
search for program reports with the help of in-country teams, but with our focus typically
on larger NGOs and organizations known to be operating on WASH projects, reports may
have been missed from grassroots organizations. A more systematic search strategy of
bibliographic databases would have been preferred, but with very few program reports
indexed on these platforms, we believed our strategy of searching organizations directly
offered the most appropriate methodology. However, there is the risk of selection bias, as
described. With each country operating a decentralized system, it would also have been
beneficial to analyze local or regional WASH policies, to expand our analysis, although
these should always be guided by the national policies included in this review.
In interpretation of the data, it is important to acknowledge that many of the concepts
may have been referenced in the documents, without a specific focus on people with
disabilities, or women and girls. Concepts may have been included more broadly, under
a general, all-encompassing language that applies to the entire population. Although
information pertinent to these concepts should be covered for people with disabilities, and
women and girls, specifically, there may be relevant information for these populations that
is not captured in this study.
5. Conclusions
Our findings have highlighted the inclusion and neglect of core concepts of human
rights of people with disabilities, and women and girls, in WASH policy documents
and programs of Bangladesh and Cambodia using EquiFrame. Information relevant to
accessibility was commonly included, but greater emphasis is needed toward concepts of
empowerment, family support, and sustainable service provision. Specific guidance on the
rights of children and women with disabilities is limited and needed in WASH policy and
programming. Programs did not reflect the same rights as endorsed in policy documents,
and the reasons for this should be explored further in qualitative research. Other countries
would benefit from conducting similar analysis to identify gaps in their WASH policies, of
which to address.
Supplementary Materials:
The following are available online at https://www.mdpi.com/article/10
.3390/ijerph18105087/s1, Table S1: Core concept coverage across the policy documents of Bangladesh
and Cambodia; Table S2: Core concept coverage across the program reports of Bangladesh
and Cambodia.
Author Contributions:
Conceptualization, J.W., N.S., C.H., P.P., M.-u.R. and A.B.; methodology, N.S.
and J.W.; formal analysis, N.S., J.W. and I.M.; investigation, N.S., J.W., C.H., P.P. and M.-u.R.; data
curation, N.S., J.W. and I.M.; writing—original draft preparation, N.S.; writing—review and editing,
J.W., I.M., C.H., P.P., M.-u.R. and A.B.; visualization, N.S., J.W. and I.M.; supervision, J.W.; project
Int. J. Environ. Res. Public Health 2021,18, 5087 17 of 19
administration, N.S., J.W. and C.H.; funding acquisition, J.W. and C.H. All authors have read and
agreed to the published version of the manuscript.
Funding:
This work was supported by funding from the Australian Government, Department
of Foreign Affairs and Trade’s Water for Women Fund, under the project “Translating disability-
inclusive WASH policies into practice: lessons learned from Cambodia and Bangladesh”. The views
expressed in this publication are those of the authors and not necessarily those of the Commonwealth
of Australia. The Commonwealth of Australia accepts no responsibility for any loss, damage or
injury resulting from reliance on any of the information or views contained in this publication.
Institutional Review Board Statement:
The study was approved by: the Ethics Committee of
the London School of Hygiene & Tropical Medicine (17679), 30 October 2019; the National Ethics
Committee for Health Research in Cambodia (042), 2 March 2020; and the Bangladesh Medical
Research Council (BMRC/NREC/2019–2022/608), 17 February 2020.
Informed Consent Statement: Not applicable.
Data Availability Statement:
Further information on the data presented in this study is available on
request from the corresponding author.
Acknowledgments:
The authors wish to thank Mac MacLachlan and Hasheem Mannan of the
EquiFrame development team for providing valuable advice into our adaptation and use of the
content analysis tool. Thank you also to Mirza Manbira Sultana for providing comment to the final
manuscript.
Conflicts of Interest: The authors declare no conflict of interest.
References
1.
United Nations. General Assembly Resolution 64/292, the Human Right to Water and Sanitation, A/RES/64/292; United Nations General
Assembly: Geneva, Switzerland, 2010.
2.
United Nations. Sustainable Development Goal 6: Ensure Availability and Sustainable Management of Water and Sanitation for
All. Available online: https://sustainabledevelopment.un.org/sdg6 (accessed on 3 September 2020).
3.
United Nations Children’s Fund; World Health Organization. Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and
SDG Baselines; United Nations Children’s Fund and World Health Organization: Geneva, Switzerland, 2017.
4.
United Nations Children’s Fund; World Health Organization. Progress on Household Drinking Water, Sanitation and Hygiene 2000–2017.
Special Focus on Inequalities; United Nations Children’s Fund and World Health Organization: New York, NY, USA, 2019.
5.
United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development; United Nations General Assembly: Geneva,
Switzerland, 2015.
6. World Health Organization; World Bank. World Report on Disability; World Health Organization: Geneva, Switzerland, 2011.
7.
Mactaggart, I.; Schmidt, W.-P.; Bostoen, K.; Chunga, J.; Danquah, L.; Halder, A.K.; Jolly, S.P.; Polack, S.; Rahman, M.; Snel, M.; et al.
Access to water and sanitation among people with disabilities: Results from cross-sectional surveys in Bangladesh, Cameroon,
India and Malawi. BMJ Open 2018,8, e020077. [CrossRef]
8.
Enfield, S. Mainstreaming Disability and Making WASH Programmes Inclusive. K4D Helpdesk Report; Institute of Development
Studies: Brighton, UK, 2018.
9.
Wilbur, J.; Jones, H.; Gosling, L.; Groce, N.; Challenger, E. Undoing Inequity: Inclusive water, sanitation and hygiene programmes
that deliver for all in Uganda and Zambia. In Proceedings of the 336th WEDC International Conference, Nakuru, Kenya, 1–5 July
2013; WEDC: Madison, WI, USA, 2013.
10.
United Nations Children’s Fund. WASH Disability Inclusion Practices; United Nations Children’s Fund: New York, NY, USA, 2016.
11.
Groce, N.; Bailey, N.; Lang, R.; Trani, J.; Kett, M. Water and sanitation issues for persons with disabilities in low- and middle-
income countries: A literature review an discussion of implications for global health and international development. J. Water
Health 2011,9, 617–627. [CrossRef]
12.
Mills, J.; Cumming, O. The Impact of Water, Sanitation and Hygiene on Key Health and Social Outcomes: Reviews of Evidence; Department
for International Development: London, UK, 2016.
13.
Pouramin, P.; Nagabhatla, N.; Miletto, M. A Systematic Review of Water and Gender Interlinkages: Assessing the Intersection
with Health. Front. Water 2020,2, 1–25. [CrossRef]
14.
Hennegan, J.; Shannon, A.; Rubli, J.; Schwab, K.; Melendez-Torres, G. Women’s and girls’ experiences of menstruation in low-
and middle-income countries: A systematic review and qualitative metasynthesis. PLoS Med. 2019,16, e1002803. [CrossRef]
15.
Hughes, K.; Bellis, M.A.; Jones, L.; Wood, S.; Bates, G.; Eckley, L.; McCoy, E.; Mikton, C.; Shakespeare, T.; Officer, A. Prevalence
and risk of violence against adults with disabilities: A systematic review and meta-analysis of observational studies. Lancet
2012
,
379, 1621–1629. [CrossRef]
16.
Amnesty International. Insecurity and Indiginity: Women’s Experiences in the Slums of Nairobi, Kenya; Amnesty International:
London, UK, 2010.
Int. J. Environ. Res. Public Health 2021,18, 5087 18 of 19
17.
Dumpert, J.; Gelbard, S.; Huggett, C.; Padilla, A. WASH Experiences of Women Living with Disabilities in Cambodia. CRSHIP:
Issue Brief. Available online: https://www.wsscc.org/media/resources/wash-experiences-women-living-disabilities-cambodia
(accessed on 5 September 2020).
18.
Wilbur, J.; Torondel, B.; Hameed, S.; Mahon, T.; Kuper, H. Systematic review of menstrual hygiene management requirements, its
barriers and strategies for disabled people. PLoS ONE 2019,14, e0210974.
19.
White, S.; Kuper, H.; Itimu-Phiri, A.; Holm, R.; Biran, A. A Qualitative Study of Barriers to Accessing Water, Sanitation and
Hygiene for Disabled People in Malawi. PLoS ONE 2016,11, e0155043. [CrossRef] [PubMed]
20.
Wilbur, J.; Kayastha, S.; Mahon, T.; Torondel, B.; Hameed, S.; Sigdel, A.; Gyawali, A.; Kuper, H. Barriers to Menstrual Hygiene
Management Faced by Adolescents and Young People with a Disability, and their Carers in the Kavrepalanchok District, Nepal
(preprint). BMC Public Health 2020. [CrossRef]
21.
United Nations Children’s Fund. WASH Technical Paper: The Case for Investment in Accessible and Inclusive WASH; United Nations
Children’s Fund: New York, NY, USA, 2018.
22.
Office of the United Nations High Commissioner for Human Rights. Convention on the Rights of Persons with Disabilities; United
Nations General Assembly: Geneva, Switzerland, 2008.
23.
Jones, N.; Presler-Marshall, E.; Stavropoulou, M. Adolescents with Disabilities: Enhancing Resilience and Delivering Inclusive
Development; Overseas Development Institute: London, UK, 2018.
24.
United Nations Water. Eliminating Discrimination and Inequalities in Access to Water and Sanitation; UN Water: Geneva, Switzerland, 2015.
25.
Wilbur, J.; Huggett, C. WaterAid Bangladesh Equity and Inclusion Review: A Review of the Rights, Equity and Inclusion Work of WaterAid
Bangladesh; WaterAid: London, UK, 2015.
26. Keo, C.; Bouhours, T.; Bouhours, B. Accessible WASH in Cambodia; WaterAid and Australian Red Cross: London, UK, 2014.
27.
Hadi, T. An Analysis of Water Policies and Strategies of Bangladesh in the Context of Climate Change. Asia-Pac. J. Rural Dev.
2019,29, 111–123.
28.
Amin, M.; MacLachlan, M.; Mannan, H.; El Tayeb, S.; El Khatim, A.; Swartz, L.; Munthali, A.; Van Rooy, G.; McVeigh, J.; Eide, A.;
et al. EquiFrame: A framework for analysis of the inclusion of human rights and vulnerable groups in health policies. Health
Hum. Rights 2011,13, 1–20.
29. Mannan, H.; Amin, M.; Maclachlan, M. The EquiFrame Manual; The Global Health Press: Dublin, Ireland, 2011.
30.
Mannan, H.; MacLachlan, M.; McVeigh, J. Core concepts of human rights and inclusion of vulnerable groups in the United
Nations Convention on the rights of persons with disabilities. Alter 2012,6, 159–177. [CrossRef]
31.
Office of the United Nations High Commissioner for Human Rights. Convention on the Elimination of All Forms of Discrimination
against Women; United Nations General Assembly: Geneva, Switzerland, 1979.
32.
Banks, L.M.; Kuper, H.; Polack, S. Poverty and disability in low- and middle income countries: A systematic review. PLoS ONE
2017,13, e0204881. [CrossRef] [PubMed]
33.
Charlton, J. Nothing about Us without Us: Disability Oppression and Empowerment; University of California Press: Berkley, CA, USA, 1998.
34.
United Nations Entity for Gender Equality and the Empowerment of Women. Gender Equality in the 2030 Agenda: Gender-Responsive
Water and Sanitation Systems; United Nations Entity for Gender Equality and the Empowerment of Women: New York, NY, USA, 2018.
35. Rohwerder, B. Disability Stigma in Developing Countries. K4D Helpdesk Report; Institute of Development Studies: Brighton, UK, 2018.
36.
Nyblade, L.; Stockton, M.A.; Giger, K.; Bond, V.; Ekstrand, M.L.; McLean, R.M.; Mitchell, E.M.H.; Nelson, L.R.E.; Sapag, J.C.;
Siraprapasiri, T.; et al. Stigma in health facilities: Why it matters and how we can change it. BMC Med.
2019
,17, 25. [CrossRef]
[PubMed]
37.
Stangl, A.L.; Earnshaw, V.A.; Logie, C.H.; van Brakel, W.; Simbayi, L.C.; Barré, I.; Dovidio, J.F. The Health Stigma and Discrimina-
tion Framework: A global, crosscutting framework to inform research, intervention development, and policy on health-related
stigmas. BMC Med. 2019,17, 31. [CrossRef] [PubMed]
38.
Water for Women Fund; SNV; Australian Government Department of Foreign Affairs and Trade (DFAT). Disability Inclusive
Systems Strengthening in WASH: How Can We Do It Better? Learning Brief ; Water for Women Fund: Melbourne, Australia, 2019.
39.
World Health Organization. Water, Sanitation, Hygiene, and Waste Management for SARS-CoV-2, the Virus that Causes COVID-19;
World Health Organization: Geneva, Switzerland, 2020.
40.
Watson, J.; Mello-Guyett, L.; Flynn, E.; Falconer, J.; Esteves-Mills, J.; Prual, A.; Hunter, P.; Allegranzi, B.; Montgomery, M.;
Cumming, O. Interventions to improve water supply and quality, sanitation and handwashing facilities in healthcare facilities,
and their effect on healthcare-associated infections in low-income and middle-income countries: A systematic review and
supplementary scoping review. BMJ Glob. Health 2019,4, e001632.
41.
Sanitation and Hygiene Applied Research for Equity (SHARE). A Practitioner’s Toolkit: Making Water, Sanitation and Hygiene
Safer through Improved Programming and Services. Available online: https://violence-wash.lboro.ac.uk/ (accessed on 20
September 2020).
42.
House, S.; Mahon, T.; Cavill, S. Menstrual Hygiene Matters: A resource for improving menstrual hygiene around the world.
Reprod. Health Matters 2013,21, 257–259.
43. World Health Organization. Diarrhoeal Disease Fact Sheet; World Health Organization: Geneva, Switzerland, 2017.
44.
Tofail, F.; Fernald, L.C.; Das, K.K.; Rahman, M.; Ahmed, T.; Jannat, K.K.; Unicomb, L.; Arnold, B.F.; Ashraf, S.; Winch, P.J.; et al.
Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH
Benefits Bangladesh): A cluster-randomised controlled trial. Lancet Child Adolesc. Health 2018,2, 255–268. [CrossRef]
Int. J. Environ. Res. Public Health 2021,18, 5087 19 of 19
45.
Gizaw, Z.; Worku, A. Effects of single and combined water, sanitation and hygiene (WASH) interventions on nutritional status of
children: A systematic review and meta-analysis. Ital. J. Pediatri. 2019,45, 77. [CrossRef]
46.
Bekele, T.; Rawstorne, P.; Rahman, B. Effect of water, sanitation and hygiene interventions alone and combined with nutrition
on child growth in low and middle income countries: A systematic review and meta-analysis. BMJ Open
2020
,10, e034812.
[CrossRef]
47.
Headey, D.; Palloni, G. Water, Sanitation, and Child Health: Evidence from Subnational Panel Data in 59 Countries. Demography
2019,56, 729–752. [CrossRef]
48.
Kuper, H.; Monteath-van Dok, A.; Wing, K.; Danquah, L.; Evans, J.; Zuurmond, M.; Gallinetti, J. The impact of disability on the
lives of children; cross-sectional data including 8900 children with disabilities and 898,834 children without disabilities across
30 countries. PLoS ONE 2014,9, e107300. [CrossRef]
49.
United Nations Children’s Fund. Strategy for Water, Sanitation and Hygiene 2016–2030; United Nations Children’s Fund: New York,
NY, USA, 2016.
50.
Wilbur, J.; Norman, R.; Huggett, C. Reducing Inequalities in Water, Sanitation and Hygiene (WASH): A Synthesis of Experiences and
Lessons Discussed in the RWSN Equality, Non-Discrimination and Inclusion (ENDI) Group; RWSN: St. Gallen, Switzerland, 2015.
51.
United Nations Sustainable Development Group. Leaving No One behind: A UNSDG Operational Guide for UN Country Teams
(Interim Draft); UNSDG: New York, NY, USA, 2019.
