Understanding mediation pathways between WASH, women empowerment, and barriers to seek healthcare: insights from a large population study
1
Community Medicine, Navodaya Medical College Hospital & Research Center, Raichur, India
2
Community Medicine, Kempegowda Institute of Medical Sciences, Bengaluru, India
3
Community Medicine, Kasturba Medical College, Manipal, India
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
Women’s access to healthcare is influenced by household Water, Sanitation and Hygiene (WASH) conditions as well as social constraints. Inadequate water and sanitation increase safety risks and restrict women’s autonomy, reducing their ability to seek care.1 The Survey-based Women’s emPowERment (SWPER) Index provides validated, survey-derived measures of empowerment for low- and middle-income countries.2 Evidence consistently links higher empowerment with improved maternal and child health outcomes.3 Using data from the National Family Health Survey-5 (NFHS-5), this study quantifies the extent to which women’s empowerment mediates the relationship between WASH conditions and perceived barriers to seeking healthcare.
METHODS:
Using data from 74735 women of reproductive age group, we constructed a WASH Index from five binary indicators: drinking water source, toilet type, cooking fuel, water availability at the hand-washing facility, and drainage type. A tetrachoric principal component analysis (PCA) generated the composite WASH score. SWPER domains, attitude to violence, decision-making, and social independence were computed following standard methodology. Barriers to seeking healthcare (permission, money, distance, transport, going alone, lack of female provider, lack of provider, drug availability) were summarized into a Barrier Index using PCA. A survey-weighted generalized structural equation model estimated direct, indirect, and total effects of WASH on the Barrier Index through SWPER domains.
RESULTS:
Women in the highest WASH category had significantly fewer perceived barriers to care than those in the lowest category (direct effect: −0.2911; p < 0.001). Indirect effects through empowerment domains were: attitude to violence −0.0225 (p < 0.001), decision-making −0.0052 (p = 0.096), and social independence −0.0537 (p < 0.001). Overall, 22% of the WASH–barriers association was mediated through empowerment, driven largely by social independence.
CONCLUSIONS:
Empowerment especially social independence partially explains this relationship, suggesting that integrating WASH improvements with gender-empowerment strategies may more effectively enhance healthcare access.
Women’s access to healthcare is influenced by household Water, Sanitation and Hygiene (WASH) conditions as well as social constraints. Inadequate water and sanitation increase safety risks and restrict women’s autonomy, reducing their ability to seek care.1 The Survey-based Women’s emPowERment (SWPER) Index provides validated, survey-derived measures of empowerment for low- and middle-income countries.2 Evidence consistently links higher empowerment with improved maternal and child health outcomes.3 Using data from the National Family Health Survey-5 (NFHS-5), this study quantifies the extent to which women’s empowerment mediates the relationship between WASH conditions and perceived barriers to seeking healthcare.
METHODS:
Using data from 74735 women of reproductive age group, we constructed a WASH Index from five binary indicators: drinking water source, toilet type, cooking fuel, water availability at the hand-washing facility, and drainage type. A tetrachoric principal component analysis (PCA) generated the composite WASH score. SWPER domains, attitude to violence, decision-making, and social independence were computed following standard methodology. Barriers to seeking healthcare (permission, money, distance, transport, going alone, lack of female provider, lack of provider, drug availability) were summarized into a Barrier Index using PCA. A survey-weighted generalized structural equation model estimated direct, indirect, and total effects of WASH on the Barrier Index through SWPER domains.
RESULTS:
Women in the highest WASH category had significantly fewer perceived barriers to care than those in the lowest category (direct effect: −0.2911; p < 0.001). Indirect effects through empowerment domains were: attitude to violence −0.0225 (p < 0.001), decision-making −0.0052 (p = 0.096), and social independence −0.0537 (p < 0.001). Overall, 22% of the WASH–barriers association was mediated through empowerment, driven largely by social independence.
CONCLUSIONS:
Empowerment especially social independence partially explains this relationship, suggesting that integrating WASH improvements with gender-empowerment strategies may more effectively enhance healthcare access.
| eISSN: | 2654-1459 |
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