Understanding empowerment in water, sanitation, and hygiene (WASH): a scoping review

In lowand middle-income countries, a common component of water, sanitation, and hygiene (WASH) interventions is the goal of empowerment of beneficiaries, particularly poor households. Empowerment is viewed as an important development goal in itself, as well as a way to obtain improved WASH outcomes. However, empowerment is a complex and multi-dimensional concept, and it is often not clear how it is defined in WASH sector programming. This scoping review explores how concepts of empowerment have been used in the WASH sector and delineates relevant empowerment dimensions. Medline, Embase, and Global Health databases were searched for in the peer-reviewed literature published in English. A total of 13 studies were identified. Five major interrelated empowerment dimensions were identified: access to information, participation, capacity building, leadership and accountability, and decision-making. This review provides researchers and practitioners with a greater understanding of dimensions of empowerment that are relevant for strengthening WASH interventions, as well as tracking progress toward gender and social equality outcomes over time. This understanding can help ensure inclusive WASH service delivery to achieve gender-sensitive Sustainable Development Goal (SDG) targets for universal water and sanitation access. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/). doi: 10.2166/washdev.2019.077 ://iwaponline.com/washdev/article-pdf/10/1/5/723654/washdev0100005.pdf Florence Dery (corresponding author) School of Kinesiology and Health Studies, Queen’s University, Kingston K7L 3N6, ON, Canada E-mail: 17fad@queensu.ca Elijah Bisung School of Kinesiology and Health Studies, Queen’s University, Kingston, ON, Canada Sarah Dickin Stockholm Environment Institute, Stockholm, Sweden Michelle Dyer Stockholm Resilience Centre, Stockholm, Sweden This article has been made Open Access thanks to the generous support of a global network of libraries as part of the Knowledge Unlatched Select initiative.


INTRODUCTION
Though water and sanitation are fundamental for promoting good hygiene behavior, health, and well-being, many individuals and communities remain without safe water and sanitation facilities. The WHO/UNICEF Joint Monitoring Program for Water Supply, Sanitation and Hygiene (JMP) reported that 2.1 billion people lack access to safely managed drinking water at home and 4.5 billion people do not have access to safely managed sanitation facilities globally (UNICEF ; UNICEF & WHO ). In addition, existing services are threatened by rapid urban population growth, rising inequalities, and climate change associated events such as droughts that exacerbate WASH challenges and undermine efforts to address service gaps (World Water Assessment Program ). Inadequate access to water has impacts on public health and the mental, physical, and spiritual well-being of individuals and households (Sultana ).
Aside from preventable deaths and physical illnesses related to waterborne disease, the lack of access to water and sanitation leads to feelings of anxiety, a sense of embarrassment, and feelings of distress (Wutich ; Harryson et al. ).
In many cases, women, poor household, and marginalized groups disproportionately experience the impacts of inadequate WASH partly because they are more likely to have limited access to services (Graham et  Measuring WASH outcomes from empowerment perspective involves assessing important technical concerns of services and infrastructure and how these interact with social and cultural factors (Leahy et al.  Kabeer () also defines empowerment as 'the processes by which those who have been denied the ability to make choices acquire such an ability' (p. 13). Kabeer explored empowerment through three interconnected dimensions: resources, agency, and achievement ( Figure 1).
In her view, resources do not only include material resources but human and social resources which enhance one's ability to choose (Kabeer ). Thus, resources are the channels for exercising agency. Agency refers to the ability of a person to define goals and acts upon them or to put them into effect (Kabeer , ). The last dimension, achievement, represents the failure or realization of individuals' potential for living the life they want (Kabeer , ). We draw on these understandings to define empowerment as a process through which individuals or groups exercise the ability to choose and live the life they desire.  (Kabeer 1999

Search strategy
Three main electronic databases were used for the search: Embase, Medline, and Global Health. Two main concepts were used to develop the search strategy: water, sanitation and hygiene; and empowerment (detailed search terms are provided in Table 1). All searches were conducted in March 2018.

Selection criteria and screening
Peer-reviewed studies on empowerment within the WASH sector published in English were selected for the review.
Articles were included without methodological restriction. We did not exclude any paper based on the date of publication or the country of publication. Removing methodological restrictions was particularly important for identifying a wide range of evidence related to empowerment indicators. Papers that were focused solely on empowerment in health promotion interventions without reference to WASH were excluded (for example, Lindacher et al. ).

Data management and extraction
All the articles were saved on a folder and charted using a Word document. The papers were screened sequentially in three stages (titles, abstracts, and full texts) by two researchers using the inclusion criteria discussed above. Disagreements were resolved by consensus. The following data were obtained from each article: authors, study location, study objective, study method, and empowerment dimensions.

Access to information
Access to WASH information was identified as a dimen-