A participatory SWOT analysis on water, sanitation, and hygiene management of disabled females in Dhaka slums of Bangladesh

Despite several constraints, Bangladesh in recent years has gained prominent development in Water, Sanitation, and Hygiene (WASH). Government (GO) and non-government organisations (NGOs) have been working to improve healthcare services for all (Angeles et al. 2019). The key achievement was the shift from open defecation to ‘fixed point defecation’ (Mahmud & Mbuya 2015). Open defecation has been abandoned for many years and is considered as a historical practice now. Among many WASH-related successes, the installation of separate toilet facilities for men and women in important public places is worth mentioning (Snehalatha et al. 2015). In line with the global development agenda, menstrual issues also have gained attention in Bangladesh with a focus to increase awareness and access to menstrual hygiene management (MHM) for women and girls (Warrington et al. 2021). The 7th Five-Year Plan of the GO set a target to achieve safe water access for all, and improved sanitation for 100% of people in urban and 90% of people in rural areas by 2021. According to the United Nations International Children's Emergency Fund (UNICEF) and the World Health Organization (WHO) (2021), 97% of Bangladesh's urban population has a basic level of drinking water through piped (37%) and non-piped (62%) connections. Forty-five percent of the 82% of the population with access to water sources on premises can use water free from contamination. In the case of basic sanitation services, 51% of urban dwellers have access to basic services, 32% have limited or shared toilets, 18% still use unimproved sanitation and only less than 1% defecate in the open (WHO & UNICEF 2021).

Around 30% of Dhaka's 14 million residents have been living in slums in unhygienic conditions with overcrowded and cramped spaces in homes that have no secure land tenure (Ahmed 2014). Basic services are commonly denied despite these poor conditions contributing extensively to the city's productivity and growth. According to the survey of 2013 (WFP 2015), more than 3 in 4 families share a single room with an area of 12 m² on average. On the whole, sanitation and drainage are subject to frequent flooding (Olthuis 2020), alongside a lack of clean water, reflected by the absence of water collection points, and a lack of bathing facilities. 91% of families state to share a toilet with other households having 1 in 10 families using a temporary hanging toilet. Adolescent girls also face multiple health-related problems abstaining themselves from availing the low standard services of public toilets (Hussain & Wakkas 2019). Government policies and strategies still lack the appropriate measures for improving MHM.

So far several studies (Angeles et al. 2019; Haque 2019; Sehreen et al. 2019) have been done on slums regarding water and sanitation globally as well as in Bangladesh. Most of the researchers highlighted the ignored needs of women, girls, and children. However, limited studies (Warrington et al. 2021; Wilbur et al. 2021) have been done on disabled-female of the global south, particularly on their MHM aspects. It is now highly needed to identify and manage the SWOT (an acronym standing for strengths, weaknesses, opportunities, and threats) of the urban slums with respect to disabled-females to help in providing a sustainable gender-inclusive plan in the future policy framework.

Therefore, the research aims to (i) perform SWOT analyses on ongoing WASH and MHM practices of disabled-females in slums and (ii) formulate recommendations and community choices for the improvement of the current situation. The paper is divided into six sections. The first section summarises the existing living situation of slum dwellers affecting WASH in Dhaka city and pointed out the value of understanding SWOT of disabled-female's life in slums. Sections 2 and 3 depict the study area and research analysis methods used, respectively. Section 4 discusses the issues and problems associated with WASH and MHM of disabled-female in Dhaka slums through the lens of two specific case studies. From the findings of the case studies review, the paper suggests, in Section 5, what needs to be done for disabled-female living in slums. Finally, Section 6 emphasises the key messages the paper seeks to convey.

Dhaka, being a slum-choked-sky-climbing city in the developing world with greater than 1 million disabled inhabitants (Sakakijibon & Gomes 2018) is selected as a case study in this regard. It is expected that understanding the field level reality may guide different stakeholders, i.e., GO, NGOs, healthcare service providers, and receivers in (re)taking up necessary steps to meet up SDGs 3 (good health and well-being), 5 (gender equality), 6 (clean water and sanitation), and 10 (reduced inequalities) at the local level and scaling up the same concept at the global level.

Quantitative data of the questionnaires were evaluated by the Statistical Package for the Social Sciences (SPSS) software. Apart from that, FGDs, IDIs, and KIIs were also helpful for SWOT analysis in identifying internal dimensions (i.e., strengths and weaknesses) and external dimensions (i.e., opportunities and threats), as explained by Gürel & Tat (2017) and van Wijngaarden et al. (2012). Outputs from both disabled and non-disabled females were ultimately used in situation analyses for a comparative SWOT product. Notably, all ethical issues were carefully maintained and participants' consents were taken while conducting research.

Societal disparities in slums for women living in slums are already intensified. On top of that intellectual or physical impairment is a barrier for disabled-female residents making them more fragile to be deprived of equitable water and MHM access. Thereby, the following sections state, in brief, the SWOT outputs for both WASH and MHM perspectives of non-disabled-female residents in slums (Table 2) and subsequently of disabled-female (Table 3) for comparison purposes.

From the perspective of WASH for non-disabled-females, strengths identified from WASH perspectives were access to water sources and toilets, community initiatives to maintain water and toilet facilities, as well as measures to regulate and maintain hygiene and cleanliness in the toilet where female participation is ensured, increasing literacy rate among slum girls, and willingness of the community to pay for safe water and enthusiasm in gaining relevant knowledge on WASH, etc. (Table 2).

Weaknesses were insufficiency and irregularity of water supply, long queues and facing crowds during water collection, and no separate water and toilet facilities for males and females all over the slum area, etc. Most common WASH-related issues such as inconsistent/infrequent and inequitable supply of water, insufficient/inadequate number of toilets with disputes in maintaining the hygiene of the sanitation system, expensive sanitary pads, drainage congestion, and irregular waste/garbage handling are affecting non-disabled-female.

In addition, opportunities were the willingness of people especially females to manage water sources and to maintain proper sanitation, people's support in separating out water points and toilets for males and females with the ownership of land, and GO/NGO initiatives to ensure environment-friendly toilet technology, etc.

On the other hand, increasing population density, risk of waterborne diseases (e.g., skin diseases) from unsafe poor water quality, movement constraints due to waterlogged conditions, and poor road communication were identified as threats.

In the case of SWOT for the disabled-females, identified strengths were family support in collecting water and using the toilet, helpful neighbours and sometimes neighbours, willingness to gain WASH-related knowledge through training, etc. (Table 3). Disabled-females are found to be enthusiastic about developing skills and availing income-generating services to contribute to the family income.

Reported weak points were the infrequent and inequitable supply of water, inadequate cum far-reaching disabled-friendly facilities with poor road communication, absence of disabled-friendly structures, and priority-based access to the water collection point and toilet, e.g., higher plinth level of toilets with no pipeline supply.

In addition, identified opportunities were utilising support from the community (e.g., neighbours, landlords), application of modern technology-based facilities (like a wheelchair, pipeline supply, better commutes, roads, etc.), and arrangement of Community-based Health Care programmes in the slum. Access to credits for families with disabled members can be useful to reduce the dependency ratio by increasing the workforce. A separate toilet complex for males and females with the application of modern technology-based facilities (like a wheelchair) would provide confidence to the disabled-females to be independent. More GO/NGO initiatives with the listed participatory SWOT outputs in Table 3 can be beneficial to overcome their limitations and improve the current state of affairs. Especially, an equity-based affordable housing plan or civic engagement informal land tenure (i.e., land ownership through selling and long-term leasehold) (Alam & Matsuyuki 2017) can be emphasised where the government will play a facilitator role; thus, community ownership will be built.

In general, the strengths of MHM are similar to WASH for disabled-females. Interestingly, most school-going girls and employed women in slums are in favour of availing MH commodities, and extra expenditures for toiletries for them are willingly financed by family (Table 2). Different organisations are trying to make the MH products available, accessible, and affordable to all females in the slum areas. On top of that, social acceptance in using MH products, and the non-existence of MHM related taboo or discrimination, or social exclusion are well noted (Table 3).

On the contrary, there are many promising opportunities in slum areas. For example, increasing literacy rates can give females the confidence and space to voice their need for improved menstrual hygiene. Advertisements, awareness programmes, and gender education for adolescents can change societal views. Easy access and availability of MH products can improve living standards. Involvement of the male members in support of many more gender roles, such as reproductive and community roles can reduce the burden on women. Coupled with the opportunities stated in Section 3.1, promoting MHM awareness can replace current perspectives but, infectious diseases stemming from the unhygienic management of napkins or prolonged contact with sanitary pads may pose a threat.

In general, identified threats were increasing population demand management and the risk of extreme climatic events causing uncontrollable hazards and damages may become a huge challenge. MHM services will continue to be a challenge as the unhygienic management of menstrual pad disposals will increase the risk of diseases (Table 3). In this regard, slum girls and women are found to be more exposed to the risk of spreading infection and transmitting diseases including pandemics like COVID-19. Also, the risk of poverty and the high price of MH products may emerge as threats in the future.

Based on the findings and concerns of the respondents, recommendations are suggested in Table 4 classifying them into three categories, namely, policy, intervention, and research.

Policy actions taken or proposed have to be participatory based. In this context, study recommendations emphasise self-help and in-situ advancement coupled with (enough) schools and healthcare centres, where adolescent disabled-females can get a priority. Different types of small-scale activities related to ‘Cheap WASH’ (i.e., water access, sanitation access, and hygiene practices) (Ross et al. 2020) and MHM have to be disabled inclusive and conducted in a disabled-friendly environment. In the case of MHM, the higher price of MH products can be minimised by creating empowerment opportunities. But, further disposal of non-biodegradable used MH products may appear like a huge challenge or threat. Expert informants highlighted inter-institutional programmes and initiatives to involve all stakeholders: GO, NGOs, and community people. Targeted training for income generation, access to credits, and awareness programmes for disabled-females should be initiated. Formal education cum caring facilities for disabled-females can be introduced in laws/acts 2013 for protecting disabled-female rights.

Improvement of drainage lines and pipeline water supply requires immediate attention with regular maintenance in the budgetary processes. High seats instead of high plinth platforms in toilets and support rails for easy accessibility should be encouraged in flood-prone areas. Priority for families with a disabled member to receive faster pipeline connections; extra and affordable care centres with the provision of training, medicine supply, and MH products through GO–NGO partnership; and a facilitative support worker at school are also recommended.

This study sought to identify which theories of change are needed to implement interventions to support women and girls with disabilities. Running Theory of Change Workshops can effectively break social taboos towards MHM and females with disability. Identifying the scope for self-help by skill development, entrepreneurship, etc., melding inter-sectoral conflict, and improving community coordination are particularly pressing for disabled-females with more complex support needs.

The lived reality of disabled females in slums is complicated partly due to hampered WASH and menstruation issues. Understanding female-specific SWOT of disabled slum dwellers is crucial to ensure inclusive management approaches to be applied to the community programme and assist in future policy frameworks. Despite having many interventions of GO and NGOs, some weaknesses and threats still render their vulnerable situation unsafe. They agonise most over inaccessibility and inconveniences linked to the existing inadequate number of toilets and unavailable MHM facilities. Available amenities are not designed to tackle their complex support needs and are often barriers to self-dependency. Immediate demand includes empowerment via non-governmental loans and skill development training for families with a disabled member and formal education facilities with caretaker support. Current plans and policies need to focus on adequate and inclusive toilet facilities for disabled-females in public places and should address the affordability and availability of the MH products for all. Policy, intervention, and research study recommendations based on community choices thus set guidelines for sustainable gender-inclusive steps. Vigorous policy recommendations will also help in preparing a gender comprehensive road map to meet up SDGs for other slums in the global south.

The research work including its methodology and data collection protocol was internally reviewed for ethical compliance according to the ethical norms and protocols by Share-Net Bangladesh, a country hub of Share-Net International, and was approved for the Young Researcher Fellowship Grant 2019 (Ref. No ROL/ SNBD/ Research-01/07-19).

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.