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Table 3 Summary of Included Studies

From: Health and social impacts of open defecation on women: a systematic review

Authors, year and origin

Type and domain of study

Sample size (n)


Measurement of exposure and outcome

Findings and Recommendations

Limitations and Critical Appraisal

Jadhav et al. 2016 [38]


Social: Quantitative

(Secondary Data)

75,619 women

(15–49 years)

Whether women’s lack of household sanitary facilities is associated with a higher likelihood of experiencing non-partner sexual violence (NPSV)

Based on two dichotomous questions

Bivariate analysis for non-partner sexual violence and multivariate analysis to adjust participants’ demographic characteristics. Logistic regression used to conclude the results

Multiple results:

53% had access to toilets. 0.1% experienced sexual violence in past one year

8% had pit/latrine. 0.1% experienced non-partner sexual violence in past one year

39% use open defecation. 0.2% experienced sexual violence in past one year

t-test confirmed the difference, sexual violence is twice as common among women using open defecation than it is among women using toilets (p < 0.05)

2.14 times more risk of sexual violence is experienced by women who use open defecation

empirical research is required to investigate in-depth, improving social acceptability of toilet use and behavioural change is imperative,

Information from secondary data was not robust enough to explain the complex issue of open defecation in-depth; limited to past one year; findings potentially lack depth

Hirve et al. 2015 [39]


Social: Mixed method approach

308 women

165 (13–17 years)

143 (18–35 years)

To examine the sources and extent of psychosocial stress linked with latrine use or open defecation by women at home, workplace or schools

Survey questionnaires: Likert scale. Electronically recorded, steps taken to avoid data entry errors, STATAv11 used to analyse the data, psychosocial stressors tested using t test and chi square test

Focus Group Discussion and Key Informant Interview:

Audio recorded in local language, translated in English used codes in MaxQDA software. A social scientist verified 10% of translated information as accurate and complete. Single and multiple codes are defined in detail. Coding verified by two researchers. Content analysis

Free listing exercise: Smith’s solution

Clear evidence of association between various forms of stress and limited access to sanitation

Toilet at home: 64% open defecators and 6% toilet users reported level of stress due to perceived lack of personal safety (p < 0.001)

44% open defecators and 3% toilet users reported stress level due to lack of privacy (p < 0.001)

47% open defecators and 5% toilet users reported stress due to insufficient cleanliness (p < 0.001)

Toilet at workplace: 16% women open defecate at workplace- concerns about dirty toilets (29%) and unavailability of water (22%) but no concerns about access, personal safety or indignity reported during FGD

Toilet at schools:6% open defecate, 82% toilet within yard, 13% toilet outside yard; common problem reported insufficient cleanliness and unavailability of water

Overall education attainment difference in open defecators and toilet users

Social and mental health impacts resulting from limited access to sanitation are equally important as physical health impacts of sanitation. Addressing sociocultural, environmental and behavioural barriers faced by women along with building toilets may empowered them by offering dignity and integrity

Potential bias of social desirability was identified as the personal security concerns faced by adolescent girls were voiced by the teachers of school instead of girls in a focus group discussion

Winter and Barchi 2015 [40]




(Secondary Data)

6191 women

(15–49 years)

To study the relationship between violence against women and open defecation and role of social disorganisation in influencing this relationship

Content analysis: Stata/MP 13.1 statistical analysis

3 binary logistic regression, sensitivity analysis

Quantitative evidence of 40% greater odds of having experienced non partner sexual violence by women last 12 months (p < 0.05)

Women practicing open defecation in highly disorganised communities have 13 times the odds of experiencing sexual violence (p < 0.01), open defecation in non-highly disorganised communities has no significant association

Limited information of past year

Authors may have altered the scope of their analysis as secondary data provided limited information to facilitate their research question

Sahoo et al. 2015 [41]


Social: Qualitative

56 women

14 below 25 years

14 newly married

15 pregnant

13 (25–45 years)

To study the psychological and social impacts of sanitation routines among women of reproductive age

Grounded theory research, 56 in-depth interviews, digitally recorded and transcribed using MaxQDA software

51 respondents faced environmental barriers to reach their site of defecation(fear of snake biting or other animals n = 32, infections n = 46, ghosts or supernatural forces n = 35)

51 participants had privacy concerns (newly married and pregnant women faced different social restrictions than adolescents i.e. approved time, place and support network needed before open defecation)

19 respondents encountered some sort of sexual violence (impact was severe for young girls)

Psychosocial stress is mitigated by practicing open defecation in groups, performing sanitation related activities before dawn, limiting intake of food and liquids)

Toilet structure is imperative but is not sufficient to address psychosocial stress, broader view of sanitation and open defecation is required

Based on interviews; reported incidents may be biased

No confirmations of results, Cannot generalised

Janmohamed et al. 2016 [37]


Health: Quantitative

(Secondary Data)

n = 544

18–46 years

To investigate any relationship between household sanitation facility and Hb concentration, BMI and underweight among women in their first trimester of gestation

Multivariable linear and logistic regression models

IBM SPSS software

Nearly 60% of study population practicing open defecation (non-improved sanitation facility)

BMI and Hb concentrations found to be lower among women practicing open defecation than women using closed latrine (p = 0.01 and p = 0.001 respectively)

Prevalence of moderate anemia was higher among women practicing open defecation (34% versus 23%)

Cross-sectoral and integrated programs are required

Limited discussion of open defection as a contributing factor

Padhi et al. 2015 [35]


Health: Population-based cohort study

670 pregnant women

(18–48 years)

To quantify the risks of adverse pregnancy outcomes (APOs) i.e. event of preterm birth, low birth weight, abortions or miscarriages in relation to non-improved sanitation facility

Questionnaires and checklists

Socio-demographic information obtained via face to face interviews

Data analysed with STATA (version 13)

58.17% of had no access to latrine,

Risk of preterm birth and low birth weight (p < 0.001) significantly increased for women who had no access to toilet and who used toilet occasionally

Poverty correlated with lack of sanitation access

Additional research required

Limited discussion of assessing the findings in context of literature evidence, lack of measurement of confounding risk factors (smoking, alcohol use, history of maternal health, etc.) for adverse pregnancy outcomes

Majumdar et al. 2009 [36]


Health: Quantitative; Cross sectional study

193 pregnant women

To study the magnitude and correlates of hookworm infestation among pregnant women

Face to face interview, digital recording, laboratory specimen testing

Chi-square test to analyse distributions of categorical variables

Open defecation is cofounding factor in prevalence of hookworm infestation among pregnant women

Women defecating in open-fields were more infected with hookworm (24.3%) than women using sanitation latrine (6.8%)

Focus on behavioural change is recommended

No age specified,

Limited literature background, risk of selection bias as appropriate randomised sampling was not achieved (first 193 pregnant women were selected who visited antenatal clinic at that time)

Kotian et al. 2014


Health: Quantitative

Total sample size = 327

123 women

all age group

To investigate the prevalence of intestinal parasitic infection in general population

Microbiological laboratory sample test,, multivariate data analysis

More women (17.07%) were infected with parasitic infection than men (8.33%)

Prevalence of infection was higher in population practicing open defecation (22.69%) than people using latrines (11%)

Interventions addressing early health education, proper waste disposal and safe drinking water were recommended

Single laboratory observation,

Recruitment of participants from one hospital, cannot generalised, not transferable

Greenland et al. 2015


Health: Quantitative

1279 school children; 52% female (4–17 years)

To report the cases and intensity of soil-transmitted helminths

Sample test, survey (two-stage cluster sampling scheme); univariate and log binomial model, Stata 12 for analysis

52% participants were female,

63% of children practiced open defecation, no sex difference in the risk of infection, children over 12 years were likely to be more infected than others, children using open defecation were highly infected (48.9%) in comparison to children using toilets (13%)

sample size confined to girls between the age of 4 and 17 years