Barriers to Accessing Water,Sanitation,and Hygiene Services for Persons With Disabilities in the Southwestern Region of Bangladesh

Abstract

Access to water, sanitation, and hygiene (WASH) services for persons with disabilities (PWDs) persists as a global challenge, including Bangladesh. This study aims to investigate the barriers PWDs encountered in accessing WASH services in the southwestern coastal region of Bangladesh. Following the social model of disability as a guiding framework, the study employed a deductive approach to get an in-depth understanding of the issue through qualitative exploration. Data were collected from the PWDs and their caregivers through in-depth interviews (IDIs) and key informant interviews (KIIs) following the snowball sampling technique. Data were analyzed following the pre-determined codes and themes. Findings revealed that PWDs experienced multidimensional barriers clustered into three domains: physical or structural, social, and institutional barriers. Physical or structural barriers included long distances to toilets, slippery and uneven roads, narrow toilet spaces, insufficient lighting, and limited access to mobility aids. Social barriers encompassed discriminatory societal norms including stigma, isolation, ignorance, and prejudice that restricted equitable WASH access. Institutional barriers were characterized by limited governmental and non-governmental initiatives aimed at providing inclusive WASH infrastructure and services for PWDs. The study concludes that inclusive and disabled-friendly WASH services need to be promoted at local levels, especially in geographically disadvantaged areas.

Introduction

Access to improved water, sanitation and hygiene (WASH) services is a fundamental component of public health (Freeman et al., 2013; Johnston et al., 2015; Prüss-Ustün et al., 2014). This is underlined by the focus of Sustainable Development Goals (SDGs) 6: ensure access to improved water and sanitation for all by 2030 (Lee et al., 2016; United Nations, 2015). In order to do this, services must be provided to the most marginalized, the poorest, and those whose requirements for WASH are now unmet by mainstream programming (White et al., 2016) particularly for persons with disabilities (PWDs). PWDs are described in the United Nations Convention on the Rights of Persons with Disabilities as those who experience long-term physical, mental, sensory or intellectual impairments which, in interaction with various barriers, may hinder their full and effective participation in society on an equal basis with others (United Nations, 2007). An estimated 1.3 billion people experience significant disabilities. This represents 16% of the global population or one in six of us experience some form of disability (World Health Organization, 2023) and the disability prevalence is higher for developing countries (World Health Organization, 2022). PWDs often face difficulties and discrimination while accessing health and health-related services, including WASH (Scherer et al., 2021). PWDs are less likely compared to persons without disabilities to live in households that have access to basic water and sanitation services (United Natons Department for Economic and Social Affairs, 2019).

It is estimated that 80% of disabled people live in the developing world (Jones & Reed, 2005) and in the poorest quintiles of low-income-country populations, as many as one in five individuals are disabled (Jones & Reed, 2005). The number of PWDs in Bangladesh is 46.2 lakh, which is 2.8% of the total population according to the National Survey of Persons with Disabilities (NSPD; Bangladesh Bureau of Statistics, 2023). Furthermore, among the people with special needs, the highest (1.35%) suffer from physical disabilities and Khulna division has the highest rate of disability (3.62%; Bangladesh Bureau of Statistics, 2023). It has been estimated that in 2015, 91% of the global population now use an improved water source and 68% used an improved sanitation facility, with 1.5% of the current global disease burden attributed to unimproved water and sanitation (Lim et al., 2012; Prüss-Ustün et al., 2014). Disabled people are more likely to experience poor access to WASH facilities (Krahn, 2011). Both disability and WASH access are related to poverty. In addition, households in the lowest wealth quintile in a country are 3.3 times more likely to lack sufficient sanitation and 5.5 times more likely to lack access to improved water supply (Rheingans et al., 2014).

Accessing water and sanitation facilities are compulsory needs worldwide irrespective of age, sex, gender, ethnicity, class and other socioeconomic, political differentiations to living healthy life (Duflo et al., 2015). Although governmental organizations (GOs) and non-governmental organizations (NGOs) including UN Convention on the Rights of Persons with Disabilities already have taken some steps to reduce the exclusion of accessing the basic needs of the disabled (Bhanushali, 2019). Despite the fact, it continues to assert a challenge to the foremost marginalized and disadvantaged groups in society including PWDs (Bhanushali, 2019). Around 360 million PWDs lack access to better sanitation and nearly 150 million PWDs practice open defecation, which puts their health and the health of the general population at risk (World Health Organization & World Bank, 2011). The barriers that PWDs encountered when using WASH services have been classified into communication challenges, social barriers connected to abuse or stigma, and technical access barriers (facility structure and distance to facilities; Groce et al., 2011; White et al., 2016), environmental (steps and narrow doors), institutional (lack of information from authorities and exclusion from consultative procedures), and attitudinal (prejudicial attitudes from the community and service providers; Krahn, 2011).

Sanitation and hygiene needs of PWDs have long been given poor priority, which has harmed both handicapped persons and the larger society, particularly families and caregivers (Mamaye et al., 2018). All people, including those with disabilities, have a fundamental right to access to clean, safe water and sanitation facilities. However, the denial of these basic rights can have serious implications on disabled people’s well-being (Mamaye et al., 2018). Wilbur et al. (2021) emphasized on ensuring meaningful participation of PWDs and supporting caregivers in WASH related meetings and access to information related to WASH. Meaningful participation depicts expressing one’s views, which influence the process of decision-making and the outcome (De Albuquerque et al., 2014).

PWDs could use the same WASH facilities as other family members, according to recent multi-country research, but they regularly needed help and frequently encountered challenges (Mactaggart et al., 2018). In a study conducted in Bangladesh found that 79% of the PWDs were unable to collect water, while 47% of PWDs faced difficulties in accessing sanitation facilities. Additionally, accessing WASH for persons with impairments results in stigma and prejudice (Enfield, 2018). PWDs were not permitted to use community water source in Uganda because they were deemed unclean and their handicap was believed to be infectious (Wilbur et al., 2013). Such discrimination and stigma can result in PWDs being excluded from participating in WASH-related decision-making processes and implementation of services and programs (Scherer et al., 2021). When using public WASH facilities, PWDs frequently report experiencing incidents of physical, verbal, and sexual abuse (Groce et al., 2011). Women and girls are also at danger of abuse and violence when utilizing WASH services (Hughes et al., 2012). Evidence from Kenya revealed that accessing WASH facilities or collecting water, particularly at night, put women and girls at danger of physical and sexual assault (Amnesty International, 2010).

Inequalities in access to better water and sanitation may be related to a variety of factors, such as the socioeconomic status of the population and their geographic locations (Azage et al., 2020). However, due to the geographical location, coastal belt of Bangladesh is identified as saline area which make difficulties to water supply compared to other parts of the country (Lam et al., 2018). Nevertheless, its geography makes it more vulnerable to various kinds of natural disasters every year which disrupts the water and sanitation facilities such as tube-wells and latrines are either broken or partially damaged; ponds and other water bodies all are polluted by the intrusion of saline water or flooding. These damages of sanitation facilities are leading to serious crisis of water and sanitation. Moreover, these geo-spatial exclusion contribute to further social risk for the PWDs (Haque et al., 2010). Thus, the present study intends to explore the scenario of WASH services for PWDs and the perceived barriers in accessing WASH services in southwestern coastal region of Bangladesh following a qualitative research design. Findings of this study might help the policymakers to give emphasis and strategically allocate scarce resources and formulate policies to mitigate the barriers encountered by PWDs in southwestern region of Bangladesh. Overall, tracking progress toward the SDGs will be made easier by exploring the geographical variations and barriers in access to WASH services for PWDs in southwestern region of Bangladesh.

Theoretical Framework

The discourse of disability and WASH has been enlightened by the social model of disability which spectacles disabled people as an oppressed group and their disability was imposed by the society throughout exclusion and limitations on an individual’s opportunity to participate (White et al., 2016). The social model of disability has been applied in previous studies to correlate the barriers person with disabilities faced in accessing WASH services (Daniel et al., 2023; Groce et al., 2011; White et al., 2016). A person with impairment experiences a disability as a result of the structural, societal, and cultural obstacles they encounter. According to the social model of disability, there are three different types of access barriers of WASH services for PWDs including physical or structural, institutional, and social barriers (Groce et al., 2011; White et al., 2016). Physical or structural barriers comprised of environmental factors like slippery or uneven paths or muddy ground, and barriers related to the built infrastructure, such as steps or raised toilets, small latrines, squatting latrines, lack of support bars, inaccessible sinks, or inappropriate pump handles often preventing PWDs from using sanitation facilities comfortably (Daniel et al., 2023; Groce et al., 2011). Institutional barriers include WASH sector policies and institutions that ignore the needs of individuals with disabilities or forbid their involvement in the development and execution of WASH initiatives (White et al., 2016). Lastly, social barriers develop from cultural ideas or practices and emerge as a result of interactions with other individuals. Social barriers might include notions that disabilities are the result of a curse and as a result, handicapped persons should keep away from WASH facilities. The unfavorable attitudes of caregivers that prohibit a handicapped person from fully engaging in communal life may also be among them. Social barriers revolve around negative stigma toward PWDs, including inadequate autonomy, privacy, and dignity when using sanitation facilities (Banks et al., 2019; Groce et al., 2011). According to this taxonomy of barrier categories, the difficulties in accessing WASH for PWDS are mostly caused by components in the external environment (White et al., 2016).

Likewise, the existing literature, the present study followed the social model of disability as a pre-existing theory as a guide of our research methodology as well as to organize the barriers PWDs faced in accessing WASH services: physical or structural, social, and institutional barriers (Figure 1). The physical or structural barriers include lack of improved water sources, unimproved and not disabled friendly toilet, long distances of toilets, slippery or uneven roads, narrow space inside the toilets, lack of lights, and lack of mobility aides. Discriminatory societal norms including stigma, ignorance, prejudices, negative attitudes of the family and community members were the major social barriers encountered by PWDs in accessing WASH services in the present study. Institutional barriers include lack of financial assistance for constructing disable-friendly toilet, negligence in accessing improved WASH services and information, lack of implementation of awareness programs related to WASH services for PWDs.

Figure 1.

Conceptual framework based on social model of disability.

Materials and Methods

Research Design

This was an exploratory and cross-sectional study that was conducted to explore the barriers encountered by PWDs in accessing WASH services. We followed a deductive approach as our research methodology. In qualitative research, a deductive approach begins with a pre-existing theory or hypothesis, serving as a framework for data collection and analysis (Bingham & Witkowsky, 2021). In our research, we employed the social model of disability (White et al., 2016) as the foundational theory to direct our data collection and analysis, ultimately enriching our overall research methodology. For this study, we utilized two qualitative methods: in-depth interviews (IDIs) and key informant interviews (KIIs) and these methods are well-established in qualitative research (Akter & Saha, 2024; Morris, 2015) and provide valuable insights for our inquiry. We followed qualitative approach to carry out the study because it helps to comprehend the meaningful and logical explanations of human actions, thinking, and behavior based on subjective opinions, experiences, and judgments (Abuhammad, 2020; Marvasti, 2004). It further enables the documentation of authentic lived experiences shaped by intersecting socioeconomic, political and cultural contexts (Lune & Berg, 2017). This approach allowed us to examine, in depth, how PWDs experience their everyday life in accessing WASH services and to identify the barriers they encountered in accessing those WASH services.

Study Area

This investigation was conducted at Dacope upazila (sub-district), the southwestern coastline area in Bangladesh. Two villages, namely Ramnagar village of Kailashgonj union and City Buniya village of Dacope union from Dacope upazila were purposively selected considering different criteria. Firstly, this area is characterized by limited access to improved water and sanitation services alongside inadequate healthcare and rehabilitative services. Secondly, the incidence of disability or impairment in Khulna division is highest (3.62%; Bangladesh Bureau of Statistics, 2023) which was attributed due to unsafe environments and prevalent infectious diseases. Besides, social and environmental barriers intensify the disabling effects of existing impairments, compounding vulnerability and restricting full participation in daily life.

Study Population and Sampling

Using snowball sampling, we selected 20 participants from the study area. Of the participants, 15 were PWDs for conducting IDIs particularly, having one or multiple physical disabilities like paralysis, limb impairment, joint pain, arthritis, and spinal curvature (see Table 1). Snowball sampling was followed due to the difficulties to find out disabled people on the remote areas. On the other hand, five participants for conducting KIIs were caregivers, neighbors, school-teacher, and NGO officer. The inclusion criteria for the IDIs participants in this study were (i) participants having one or multiple forms of physical disabilities or impairments, (ii) living in the selected study area for at least three consecutive years and the criteria for KIIs participants were (i) caregivers or neighbors of the PWDs in the study area, (ii) NGO workers having working experience with PWDs for at least 5 years, and (iii) academician. Data were collected from the respondents and caregivers at their households and for KIIs, data were collected from their place of residence and workplace considering the participants’ convenience. We determined the number of participants by taking informed oral consent through face-to-face interviews with the participants. After conducting 15 IDIs, no new themes emerged and the same for KIIs as no new ideas were generated after the fifth KIIs and when the data saturation point was achieved, we discontinued the data collection process. It is important to understand that in qualitative research, sample size is not as important as the depth of the data for generalization (Bryman, 2016).

Table1.

Profile of the Participants.

Total sample (n = 20)
Disabled participants	15
Caregivers	2
Neighbor	1
Local NGO leader	1
Local school teacher	1
Age
Range	10–80 years
Under 18 years	1
18–59 years	9
60 and above	10
Gender
Male	12
Female	8
Education
Non-literate	12
Primary	4
Secondary	2
Tertiary	2
Occupation
Employed	4
Unemployed	16
Nature of physical disability
Paralysis	2
Limb impairment	7
Joint pain and arthritis	4
Joint pain, arthritis and spinal curvature	1
Limb impairment, joint pain and arthritis	1

Data Collection and Analysis

Data collection was carried out by NAN and SA with the convenience of the participants from June to July 2023. A total of 15 IDIs were carried out with the PWDs and their caregivers and five KIIs were conducted with two caregivers, one neighbor, one school-teacher, and one NGO officer. For taking interviews, we followed semi-structured interview schedules which were developed based on the study objective and aligned with the social model of disability as well as by reviewing previous literatures (Alam & Bryant, 2016; Basiru et al., 2018; Mamaye et al., 2018; Noga & Wolbring, 2012; Nyatsanza & Chaminuka, 2014). During data collection, all the interviews were conducted in Bengali language as a local language for better understandings of the participants’ views. On the other hand, for the participants with speaking and hearing disability, data were collected from the caregivers by seeking oral consent such as family members participated in the discussion to share their feelings. Moreover, the researchers also observed the non-verbal behaviors of the participants during data collection. With the consent of the participants, the interviews were audio recorded. Besides audio recordings, field notes were also taken for better understanding of the topic. The duration of each interview session on average was 25 to 30 minutes.

After the completion of data collection, all the audio recordings were transcribed into English language by the authors. After that, the transcriptions were thoroughly checked by the authors to maintain consistency before undergoing thematic analysis with a narrative approach. Following the deductive thematic analysis, we examined the barriers that PWDs face in accessing WASH services guided by predefined themes related to physical or structural, social, and institutional barriers, in alignment with the social model of disability. The coding process was carried out independently by NAN, SA, and SRR based on these identified themes, fostering a thorough examination of the data. All authors collaboratively reviewed and approved the final coding to ensure a comprehensive understanding of the findings. A manual data analysis approach was employed to enhance the reliability of the results. To maintain anonymity, the participants were identified with a code such as IDI1, IDI2 and KII1, KII2, etc.

Results

Characteristics of the Participants

Majority of the participants (Table 1) were female (55%) and rest of them were male. The participants ranged in the age group of 10 to 80 years. Of the 20 participants, 15 were disabled persons, 2 were caregivers, 1 neighbor, 1 local NGO leader, and 1 local school-teacher. Participants were predominantly non-literate (60%) and unemployed (80%). Moreover, the participants suffered from different types of physical disability or impairments and multiple disabilities such as paralysis, limb impairment, joint pain and arthritis, and spinal curvature.

The findings regarding the barriers that PWDs face in accessing WASH services are framed in accordance with the social model of disability and categorized into three themes: physical or structural barriers, social barriers, and institutional barriers.

Physical or Structural Barriers

Access to WASH services for PWDs was challenging particularly in disaster-prone southwestern coastal region of Bangladesh where WASH services are not available, accessible, and affordable. In coastal areas, due to salinity intrusion, improved water crises are more rampant, and the mass people have to suffer a lot to manage drinking water for their family members and most of the time they had to spend on an average 4 to 5 hours collecting drinking water by walking long distance. Even the tube-well water was not drinkable due to the presence of salinity in the water. Therefore, people in these areas generally consume rainwater or filtering pond water which was brought away by their family members. The crisis of improved water not only for consumption but also for using toilet purpose was prevalent in the study area and reported by the participants.

One of the female participants of IDIs commented that

Main source of water to drink was rainwater and pond water which was preserved into tank. My daughter-in-law preserves the water in the rainy season and when the rainwater is finished, then, we consume filtering pond water. Moreover, the main source of water for toilet use was pond water. My husband draws the water for toileting from the pond and preserves the water into a container nearside the toilet. Then, I fetch the water into a container with great difficulty. It is very difficult to take water container into one hand and assistive stick into another hand to enter into the toilet. (Woman [IDI 1], age 80, paralysis)

Besides, access to sanitation was likely to be more challenging for rural dwellers, especially for PWDs. The quality of latrines in rural areas was poorer, providing little support for individuals with mobility impairments. Toilets in remote areas were more commonly shared with large family members and no specific provision for the disabled persons, making them less clean and less well suited to the needs of a disabled person. Long distance to toilets or bathrooms makes it harder for the individuals to locate, navigating slippery or uneven roads, narrow space inside the toilets, lack of lights, and lack of mobility aides impacted on accessing of toilets. Besides, toilet designs made it inflexible for some participants to use particularly at night. During the rainy season, they confronted acute inconvenience to access sanitation facilities because the surface became muddy and slippery. Even, some of the participants mentioned that their toilet had no roof and door which hamper in maintaining the privacy particularly for women. One of the respondents in IDIs claimed (with crying) that

It is hard at night to access latrine due to the long distance from home and lack of light inside the latrine. When I came to the toilet at night, I asked for torch light to my son politely. My son replied angrily, ‘Cannot you die? I would not give you any more rice at night’. My husband provided me with a stick for moving. Holding that stick, I attempted to reach the toilet at night. It is much better to die. Moreover, once in the rainy season, I asked my son for his t-shirt. I reached the toilet with the t-shirt on my head. (Woman (IDI1), age 70, paralysis)

Due to long distance of latrine and physical incapacitation, several participants exacerbated into a pot at night. In the morning, they throw it by themselves. But a few participants exacerbated at pot at night or nearside the house which was not possible to clean by own. Their family members bound to clean that. One of the respondents in IDIs mentioned that

It is not possible for me to go to the toilet at night, hence, I leave my excrement nearside the house at night and in the morning, my daughter-in-law throws it with a spade. I cannot throw the dirt with a spade due to my physical incapacitation. Therefore, my daughter-in-law is bound to do it. Moreover, in the rainy season roads often become muddy and slippery so it takes more energy to move. Additionally, sometimes I spill which is dangerous for me. Hence, during crossing the steps and muddy road, I use two assistive local sticks. (Man (IDI3), age 75, limb impairment, joint pain & arthritis)

However, all the toilets were katcha and made up of tin and golpata, and they construct toilet far away from the home. The cost of constructing improved disabled friendly toilet was not affordable for the participants because most of the participants were unemployed and belonged to poor families. One of the participants of KIIs mentioned that

Traditional setting of toilet in rural areas is that it is constructed far away from the home as it is thought that toilets are impure. Moreover, all the toilets in that area have not improved. Most of the toilets are katcha. To maintain bad smell, they construct latrines far away from home. (Man (KII-4), age 40, Team Leader of Winrock International)

Findings revealed that among the participants, only four participants used commode chair, two of them used wheel chair and one used crutches. Moreover, during the disaster period, their latrine often destroyed and then they used the toilet of the neighbor. Additionally, disabled friendly assistive technology was too expensive, hence several people with disabilities were unable to afford. One of the participants of IDIs stated that

It is very difficult for me to access the toilet with just two sticks without any digital device. If I could afford an assistive device (sketch), it would be very helpful for me to move. (Man [IDI-3], age-75, unemployed).

Accessing toilets can be challenging for individuals with mobility restrictions, particularly when they need to fetch water before toileting. This was particularly challenging for wheelchair users who had to carry assistive technology in one hand and water in the other. Of 15 participants, only five had access to stored water nearside their toilet, and the rest had to use a mug for carrying water and bucket for storing it. Due to mobility restrictions, many of them need more time to prepare themselves for toileting and collecting water. One of the participants of IDIs claimed that-

Most of the time, I bound to fetch water from the pond for toileting, because I do not get stored water and no one support me always to collect it. A mug is tied with a rope by the side of the pond. With great difficulty, I try to fetch water but my daughter-in-law sometimes assist me to collect water. (Man [IDI-3], age 75, limb impairment, joint pain & arthritis)

Additionally, the path to the toilet and water sources was uneven and muddy. Participants with physical impairments stated that carrying water without the support of another person was difficult, especially for wheelchair users as they carried assistive technology in one hand and water in another hand as well as physical incapacitation hence, it was quite difficult to collect water from the pond. One of the participants of IDIs who is a whellchair user commented that-

I use a commode chair for toileting under the open sky nearside my house. And at night, I excrete on the porch by using commode chair. It takes more energy and time to carry water container and use it. As my hands are occupied with the wheelchair. Nevertheless, using wheelchair steps were extensive challenges. (Man [IDI-2], age 30, limb impairment)

Furthermore, poor hygiene practices were demonstrated among PWDs. Due to physical difficulties and lack of support, disabled people do not enjoy hygienic toilet facilities which is a big challenge. They did not make themselves hygienic all the time. Of the 15 participants, only 5 participants had access to stored water inside the toilet. Therefore, sometimes, despite being willing, they failed to wash their hands properly after toileting due to water and financial crises. Among the participants, only four of them washed their hands with soap after toilet use and one of them used detergent for washing hands after toile use. Surprisingly, 10 of the participants did not report proper hand-washing practices and they washed their hands with water or soil. One of the respondents of IDIs responded that

I have to use the commode chair under open places. Occasionally, I wash my hands with soap, but it is not always possible to wash my hands with soap because soap is not available and affordable all the time. Moreover, adequate water is not accessible near me. Hence, I wash my hands with soil most of the time. (Man [IDI 1], age-30, limb impairment)

In addition, most of the participants were not conscious of the maintenance of hygiene practices during and after using the toilet. Besides, due to the financial crisis, they cannot buy soap. One of the participants of IDIs stated that

I cannot use soap all the time due to the unavailability of soap. My son is the only income earner in my family hence, due to the financial crisis, it was difficult to buy soaps all the time. (Woman [IDI-10], age 80, paralysis)

Social Barriers

Social barriers varied based on different cultural settings. However, persons with physical disabilities face stigma and discrimination both at the family and community levels while accessing and practicing WASH services. The majority of the participants in the study reported that their family members mainly took care of them and supported them in accessing WASH services. On the contrary, some of the participants mentioned that they were neglected by other family members, particularly by their daughters-in-law and sons. Sometimes PWDs were neglected and did not get any support from the family members as everyone is busy with their jobs. As a result, PWDs remained dirty and unclean for a longer time due to physical incapacitation and lack of support from family members.

Therefore, they were infected with various diseases. Owing to the long distances to the latrine and the lengthy water fetching process, a few of them are bound to defecate openly. Hence, they were harassed or neglected sometimes by their neighbors who made them depressed and upset and created anxiety among them. One of the participants in IDIs stated that-

I have a commode chair which is far away from my house and located in the forest. My excrement is deposited in a bucket under the chair and then I throw the dirt around the forest. Therefore, bad smell spreads all around and no one cannot walk by my side. (Man [IDI-3], age-75, limb impairment, joint pain & arthritis)

PWDs are often stigmatized by their neighbors as ‘messy and dirty’. One of the participants (neighbor) of KIIs by showing a disabled participant (wheelchair user) commented that-

This lame old man throws dirt everywhere. If he puts the dirt in a hole, then there would be no smell. No one can walk beside the forest where he exacerbates. (Woman [KII-3], age-42, neighbor)

Moreover, PWDs are isolated and discriminated. They feel shameful for their condition as well as family members think of them as a burden. People with certain types of disabilities may also need a longer time to use the toilet which was embarrassing for them and other users particularly, when it is a shared toilet which increased the stress and pressure. One of the participants of IDIs stated that-

I am wheelchair user. Four or five years ago, I fall due to cutting down trees by electric shock and I did not get any strength from my waist to my leg. Without using a wheelchair, I cannot move. It is too much embrrassing. My wife gets annoyed sometimes. I also get annoyed with myself sometimes. It is a shame to have a toilet in this open place. It is a condition that gives me a lot of stress. I have no privacy. (Mam [IDI-2], age 30, limb impairment)

The study revealed that all the respondents who can enter into the latrine attempt to use it with difficulty. But those who are unable to enter the toilet, such as wheelchair users use commode chairs for toileting. Some of the respondents exacerbate before reaching the toilet due to the long distance of the latrine as well as their physical incapacitation taking more time. Some of them were bound to spot toilets due to movement barriers. So, while constructing toilets, it is important to consider the accessibility of the PWDs. One of the respondents of IDIs commented that

Our toilet is far away from our house. Most of the time, I cannot go alone without the help of my daughter-in-law. I cannot walk properly. When my daughter-in-law does not help me, I can walk with the help of two sticks. My daughter-in-law let me fetch water from the pond which is a lengthy process. Sometimes, before reaching the toilet, I exacerbate under the open sky. I cannot clean myself properly due to mobility restriction which is embarrassing and create pressure. (Woman [IDI-1], age 45, joint pain & arthritis)

Social stigmatization and negative attitudes toward PWDs results in low self-esteem and lack of dignity experienced by those who were dependent on their family members in assisting them to use inaccessible water particularly sanitation facilities. Female participants were more stigmatized and neglected than male participants. One of the participants of KIIs claimed that-

Disabled women face serious discomfort and shame in the time of using the toilet. They need more time and water than males for toileting. Nevertheless, they face serious assault at the time of open defection. (Woman [KII-1], age-26, caregiver)

Institutional Barriers

Though different governments and non-governmental organizations provide free sanitation facilities particularly pit latrines at the local level which was not sufficient. Moreover, GOs-NGOs overlooks the sanitation needs of disbled people. Only two participants mentioned that they received a water tank for water preservation from NGOs and one participant mentioned that she got a pit latrine from NGOs. Several people did not get any financial assistance for toilet construction. One of the IDIs participants with a physical disability stated that

I asked for money to construct a latrine to our union chairman. But he did not provide me any finance to construct the toilet. Even, I do not get any support from NGOs to access hygienic sanitation. We want to get financial support from GOs and NGOs. (Woman [IDIs-13], age 73, joint pain & arthritis)

Though the majority of the participants reported that they received disabled allowances or old-age allowances from the government but did not receive any financial support from the government level to ensure improved sanitation services for PWDs. However, one of the participants in this study mentioned that he got an assistive wheelchair from an NGO. Besides, different awareness programs were implemented by the GOs and NGOs related to improved sanitation and hygiene practices. However, common people particularly, PWDs in southwestern region were neglected in accessing improved WASH services and information related to it. Several factors are responsible for their exclusion such as illiteracy, poverty, lack of exposure to mass media, economic crisis, natural disasters, lack of efficient local government, and so on.

The majority of the PWDs have not attended meetings or trainings on WASH, and their family members often inadequately share hygiene and sanitation messages with them. It is important to address these issues and highlight the importance of including PWDs in WASH meetings and trainings. Suggestions for addressing the barriers that PWDs face in attending meetings and speaking out can also be helpful in promoting greater participation and support for PWDs. Ultimately, empowering PWDs to increase their participation in the community and have their voices heard is essential for creating a more inclusive and supportive environment. One of the participants in IDIs reported that

We are not invited to attend the meeting because we are poor and disabled people. We are not confident speaking out and attending the village-level meetings. When we speak, people do not listen to us. (Man [IDI 8], age 70, joint pain and arthritis)

Discussion

Access to improved WASH services remains challenging across low-income countries for PWDs who are underprivileged both physically and socially (White et al., 2016). Recognizing the profound impacts of inadequate WASH access on both PWDs and their caregivers, this study explores the barriers to WASH services faced by PWDs in the southwestern coastal region of Bangladesh. Guided by the social model of disability (White et al., 2016), the analysis organizes the barriers into three interrelated domains: physical or structural, social and institutional barriers to provide a comprehensive understanding of the systematic challenges undermining equitable WASH access.

Findings of the current study showed that participants reported a lack of improved water sources for consumption and sanitation within physical or structural barriers. This might be explained by the fact that coastal regions of Bangladesh are frequently exposed to high water salinity (Munirul et al., 2010) and as a result, there is a lack of safe drinking water in this belt has always been a concern for the local population (Razu et al., 2018). Participants in the study area mostly consume shallow-tubewell water and pond water which contain sodium and iron agents. The present study also found that during rainy season, participants consumed rain water however, preserving rain water was not affordable for most of the participants in the study area which is supported by another study that lack of knowledge regarding rainwater harvesting hinder this process (Razu et al., 2018).

PWDs encountered more barriers in accessing sanitation services compared to water access such as longer distances to toilets, slippery or uneven roads, narrow toilet spaces, insufficient lighting, and limited access to mobility aids which is consistent with a prior study (Chowdhury et al., 2022). Moreover, the current study corroborated by findings from Ethiopia (Mamaye et al., 2018) and Uganda (Wilbur & Danquah, 2015) revealed that persons with physical disabilities face significant barriers in accessing water and sanitation including long distances to water points, difficulty of carrying filled water containers, slippery or uneven surfaces, and lack of accessible water containers near toilets. These obstacles are exacerbated during the rainy season and at night. This could be attributed by the traditional cultural norms prevalent in coastal regions motivated them to construct toilet far away from the house which negatively affect PWDs to access toilets due to long distances and their physical incapacitation.

Findings from the current study revealed that most of the participants used toilets which were not improved and disabled-friendly. Besides, most of the toilets were katcha and made of tin and golpata, where there was no good waste disposal system and it is consistent with previous studies conducted in Zimbabwe (Nyatsanza & Chaminuka, 2014), Uganda (Wilbur & Danquah, 2015), Combodia (MacLeod et al., 2014), Ethiopia (Mamaye et al., 2018), Bangladesh, Cameroon, India, and Malawi (Mactaggart et al., 2018). The cost of constructing improved disabled-friendly toilet was not affordable for the participants due to low income, unemployment, limited educational attainment, and lack of awareness. These financial and knowledge constraints hindered the adoption of disabled-friendly and improved sanitation facilities, consistent with prior literature highlighting economic and educational barriers to WASH infrastructure for marginalized populations (Banks, 2017; Ganle et al., 2016; Mahama et al., 2014; Mamaye et al., 2018; Wasonga et al., 2016; White et al., 2016).

Consistent with the findings of previous studies, the current study found that lack of access to electricity inside the toilet (Nyatsanza & Chaminuka, 2014), and narrow space inside the toilet (Alemu et al., 2017) were other barriers encountered by PWDs which created more difficulties to enter into toilet at night. Moreover, most of PWDs in the present study used local sticks for moving which is consistent with a study conducted in Kenya (Tan et al., 2013) and this might be illustrated by the fact that most of the PWDs were solely dependent on their family members who could not afford assistive devices.

Findings of our study showed that a small number of participants washed hands with soap and the rest used soil and water irrespective of their willingness due to the lack of affordability which aligns with earlier studies (MacLeod et al., 2014; White et al., 2016). PWDs were bound to keep themselves dirty and unclean for long time due to physical incapacitation and dependency on family members hence, they were infected with various kinds of diseases and suffered from anxiety and it is consistentwith another study from Zimbabwe (Nyatsanza & Chaminuka, 2014).

Discriminatory societal norms including stigma, ignorance, and prejudice were the major social barriers encountered by PWDs in accessing WASH services in the present study, which is supported by other studies (Banks et al., 2017; Groce et al., 2011). Likewise, in Madagascar, disability is seen as God’s punishment for past sins and PWDs might be viewed as useless and are often denied the ability to express their needs (Jones et al., 2012). In Uganda, PWDs were viewed as dirty and were restricted from using common sanitation services by their community members (Wilbur & Danquah, 2015) which is also supported by the findings of the current study.

This study furhter highlights that PWDs experienced stigma and discrimination at both household and community levels while accessing WASH services. Though PWDs often rely heavily on family members in accessing WASH services which was also observed in Cambodia (MacLeod et al., 2014) however, they were neglected and sometimes receive inconsistent support from the family members, as caregivers are often occupied with livelihood responsibilities. Consequently, many PWDs remained dirty and unclean for a longer time due to physical incapacitation and lack of support from the family members, which increases their risk of hygiene-related diseases and infections.

Social stigma and negative attitudes toward PWDs undermine their self-esteem and dignity, particularly when reliant on family support for accessing inaccessible water and sanitation facilities. PWDs are often perceived as dirty, cursed, or a social and financial burden, reflecting broader discriminatory norms which is also documented in Ghana, Uganda, and Bangladesh (Ganle et al., 2016; Hussain, 2020; Wilbur & Danquah, 2015).

Institutional barriers include public policies, GOs and NGOs’ funding systems and priorities, social support, and programs. These also include disability advocacy organizations, providing assistive technology devices, as well as training programs for caregivers (Desai et al., 2016). Though different GOs and NGOs provide free sanitation facilities particularly, pit latrine at local levels which was not sufficient. Consistent with the findings of current study, Wilbur and Danquah (2015) also reported that GOs-NGOs overlooks the water and sanitation needs of the disabled persons. Most of the participants in the current study did not get any financial assistance for constructing disable-friendly toilets.

Moreover, different awareness programs were implemented by the GOs and NGOs related to improved sanitation and hygiene practices which were not adequate that is also evident in a previous study (Chowdhury et al., 2022). However, PWDs in southwestern region of Bangladesh remain largely excluded from improved WASH services and related information. Majority of PWDs in the study had never attended WASH meetings or trainings, relying instead on limited secondhand messages from family members. This might be explained by the fact that several factors responsible for their exclusion such as poverty, illiteracy, limited media exposure, economic crisis, recurrent natural disasters, and weak local governance. Consistent with evidence from Ethiopia (Mamaye et al., 2018), the current study found that PWDs with higher educational status had better access to improved sanitation services compared to those who were illiterate. This might be interpreted that higher education triggers PWDs’ knowledge, communication, and capacity to access and utilize improved water and sanitation services.

Strengths and Limitations

This study contributes valuable insights into the challenges faced by physically disabled individuals in accessing improved WASH services in Bangladesh. Guided by the social model of disability, this study was conducted in a vulnerable coastal region, offering policymakers an opportunity to develop tailored policies that can ensure improved access to WASH services and reduce geographical disparities and inequalities in line with the SDGs of achieving universal access to sanitation by 2030. However, deductive research methodology in qualitative investigations can limit adaptability in exploring new issues and increase the risk of confirmation bias as researchers may focus on data that supports existing theories while ignoring unexpected findings. Nonetheless, to reduce confirmation bias and enhance trustworthiness, it is beneficial to incorporate multiple data sources or methodologies as well as promote reflexivity where researchers actively assess their influence on the study can further reduce bias. Besides, it is worth noting that the study only focused on persons with physical disabilities, which may limit the generalizability of the findings to all PWDs. Further research is recommended to address this gap through incorporating both qualitative and quantitative approaches, including persons with other types of disabilities, to provide a comprehensive assessment of the inclusiveness of WASH facilities for PWDs at the national level.

Conclusion

In the southwestern coastal region of Bangladesh, physically disabled individuals face significant challenges when it comes to accessing WASH services. These challenges include a lack of disabled-friendly and improved WASH services, as well as stigma and discrimination both at the family and community levels. To address these issues, it is crucial to construct WASH services that are designed with assistive technologies and maintained in a hygienic manner. In addition, training programs should be implemented to raise awareness about the rights of PWDs and to reduce social stigma and prejudice. Ultimately, promoting inclusive and disabled-friendly WASH services at the local levels, especially in the geographically disadvantaged areas will be critical to ensuring that PWDs have the access they need to these essential services.