Graduation Year

2019

Document Type

Dissertation

Degree

Ph.D.

Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Public Health

Major Professor

Ricardo Izurieta, M.D., Dr.PH., MPH., DTM&H

Co-Major Professor

Linda Whiteford, Ph.D.

Committee Member

Jaime Corvin, Ph.D.

Committee Member

Sarina Ergas, Ph.D.

Committee Member

Rebecca Zarger, Ph.D.

Keywords

environmental health, global health, urbanization, equity

Abstract

The aims of this research were to examine sanitation insecurity in urban informal housing through the lens of the built environment, social disparities, and health implications. While the Millennium Development Goals for halving the global proportion of people without access to safe drinking water were met ahead of schedule, progress fell short for sanitation, creating new objectives for the Sustainable Development Goals to be met in 2030. Much research in the Global South is dedicated to community-level sanitation promotion, but often presumes a rural rather than urban setting. Urban informal housing settings constitute a unique challenge due to the range of population sizes, tenure uncertainty, and location on potentially hazardous landscapes. In addition, while social scientific work theorizes the relationship between urban planning priorities and infrastructure inequalities, less work focuses on the social and environmental dynamics that shape sanitation within poor communities.

Using quantitative, qualitative, and spatial data analyses, I examine: 1) whether demand for a household toilet is associated with the built environment; 2) socio-spatial processes that are enmeshed in daily sanitation decision-making among women householders; and 3) whether women’s defecation and urination avoidance strategies (“holding it”) correspond to the availability of a household toilet as opposed to shared facilities. The research occurred through a partnership with an NGO that has been engaged in sanitation and housing in urban slums in Maharashtra, India for more than two decades.

In synthesizing results, I argue that sanitation demand must be understood through daily sanitation journeys, which are enmeshed within social inequalities, ambiguity over shared infrastructure, and housing insecurity. These themes are shaped by the social and built environment. First, household size, home ownership, individual household water sources, and open defecation avoidance are significantly associated with sanitation demand. Second, intra-community tensions play a major role in the lack of clarity over management of shared water and sanitation infrastructure. This, alongside gender imbalances and fear of violence, shape how women seek out daily sanitation, particularly around where and when to go to the bathroom. Toilets also present the potential for formalization and upward mobility for residents, but housing insecurity and the threat of eviction complicate the decision to build a toilet. Finally, the provision of a household toilet corresponds to a major reduction in avoidance behaviors among female primary respondents. Respondents who report community toilets as unsafe are much more likely to engage in bathroom avoidance behavior, especially if their household is water-insecure.

These findings have bearings for research and policy regarding sanitation and poor urban populations. First, I shed new light on sanitation and gender inequity, especially the issue of women routinely avoiding defecation, a practice whose health implications have not been studied. Secondly, my findings suggest that sanitation promotion activities that approach the community as a single unit that will work together to solve open defecation and to manage shared facilities whose management is unclear may not be successful. Thirdly, housing insecurity constitutes a major site of tension for residents of informal settlements, and planning priorities must engage with housing insecurity alongside the provision of sanitation infrastructure overall.

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