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PWAT-D-21-00041

Water, Sanitation, and Women’s Empowerment: A Systematic Review and Qualitative Metasynthesis

PLOS Water

Dear Dr. Caruso,

Thank you for submitting your manuscript to PLOS Water. After careful consideration, we feel that it has merit but does not fully meet PLOS Water's publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please respond to the editor's and reviewers' comments below. Please note that Reviewer 1 attached a PDF file with more detailed comments.

Please submit your revised manuscript by Feb 18 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at water@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pwat/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'
• Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Dr. Inga T. Winkler

Academic Editor

PLOS Water

Journal Requirements:

1.  We have noticed that you have uploaded supporting information but you have not included a list of legends.  Please add a full list of legends for all supporting information files (including figures, table and data files) after the references list. 

Editor Comments:

The manuscript presents a wealth of information and summarizes much of the work in the field on WASH & gender. It represents a significant amount of work that will prove of great service to the sector. The framing around the concept of empowerment is original and welcome (but as I’ll explain below it also points to some of the weaknesses of the manuscript).

The reviewers raise several key points, and I’m going to summarize some of the main points.

1) The manuscript requires a background section that demonstrates solid engagement with the concept of empowerment (different frameworks and conceptualizations, critiques of the concept etc.). As there is extensive academic work on the subject including some frameworks that are highly cited and influential (such as Naila Kabeer’s empowerment framework), the decision to go with a framework only published as grey literature that has not undergone peer review would have to be thoroughly justified. The authors might want to reconsider relying on a working paper by van Eerdewijk et al. from 2017 that does not seem to have been published in the scholarly literature in the past four years. Please also see the more detailed concerns the reviewers raise about the framework itself.

2) The lack of engagement with empowerment frameworks results in the need for additional conceptual clarity that carries through the presentation of the findings and the discussion. The authors should make sure to keep the focus on empowerment and distinguish it from gender equality more broadly. As one reviewer commented, at times empowerment seems to be used interchangeably with well-being, which is much too broad.

3) The selection of databases for the search seems quite narrow, given how much of the scholarly discussion on empowerment takes places in the social sciences such as sociology, geography, feminist economics, etc. Moreover, grey literature is excluded, while the conceptual framework itself is from the grey literature. Ideally, this searched would be broadened. The fact that the senior authors on the paper manually added articles points to gaps in the search strategy.

4) The presentation of the findings is very detailed, and I agree with the reviewers that this lengthy presentation makes it very difficult to discern key messages. The individual sections would benefit from a clearer structure that carries through all the sections (e.g., always starting with either the positive or negative findings, relating these more clearly to the concept of empowerment (or the lack thereof), and providing more guidance to the reader). I would urge the authors to consider alternative modes of presenting the material (such as an annex). In any case, the manuscript reads somewhat unfinished in this regard. The manuscript does an admirable job of summarizing a significant amount of literature, but the synthesis itself could be improved. What does all the presented material tell us about women’s empowerment in the context of WASH? I would like to see more distilling of key messages and takeaways for the reader. This could be done in the introduction to each section of the findings, and it certainly needs to be done in the discussion. This discussion should be driven by the chosen model and the concept of empowerment and go beyond a summary of the findings.

5) If the paper proceeds to publication, the figures would have to be provided as high-resolution graphics. As it stands, figure 2 is illegible and the other figures are blurry.

I’m looking forward to seeing a revised manuscript which would certainly be of service to the scholarly community working on WASH.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Water’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Water does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for your excellent work on identifying and clarifying such a wealth of information in the empowerment and WASH space. I know for certain that this will be a valuable contribution to the important and growing body of scholarly work on WASH-gender connections.

I have a few specific questions regarding the protocol and framework which I have included as comments into the document. I will summarise the broad points below:

First, the abstract mentions that this is a menstruation-focused paper, but that does not seem to be the case. Perhaps there is mistake in the abstract. The abstract is also much too long for the journal requirements (300 words).

Second, as this is a published academic work, the use of a framework from grey-literature requires more justification and further engagement with the scholarly literature on gender equality, empowerment and transformations. The paper is also not clear on the connections with gender equality and empowerment and seems to assume these connections. The authors need to be careful to not claim beyond the empowerment scope of the work. I believe a background section is required in this paper to situate the work more credibly.

Third, the protocol has some weaknesses. Despite much of the WASH and gender literature appearing within the disciplines of sociology and geography, the searches only engaged with public health literature. Additionally, the search terms seem quite narrow, given the goal of breadth in the space. For example, using the phrase “institutional structures” - which is quite uncommon in the sector - and including some, but not all of the words from the framework. Phrases such as “gender dynamics”, ‘control’, ‘drawers of water’, ‘participation, and ‘voice’, along with the dimensions of the framework are missing. Additionally the review only explores published academic literature, despite a large volume of grey-literature on the topics. While all of these are justifiable, they require some discussion in the limitations.

Lastly, it would be good if the paper could speak to and connect with the protocol paper on a parallel systematic review recently published with this space.

- Macura, B., Duca, L. D., Soto, A., Carrard, N., Gosling, L., Hannes, K., Thomas, J., Sara, L., Sommer, M., Waddington, H. S., & Dickin, S. (2021). PROTOCOL: What is the impact of complex WASH interventions on gender and social equality outcomes in low- and middle-income countries? A mixed-method systematic review protocol. Campbell Systematic Reviews, 17(2), e1164. https://doi.org/10.1002/cl2.1164

Reviewer #2: Specific comments:

Line 80: Despite recognition of WASH as on the pathway to gender equality…Can the authors unpack this statement a bit? Perhaps its in the citation, but more explantation would be helpful.

Paragraph 2: Stylistically, the first three sentences all say more or less the same thing. If looking for ways to edit back the manuscript this (and similar introductory statements) could be edited out.

Analysis is a bit thin…you focused on “empow” but wouldn’t this result in missing papers that addressed one of the specific domains of empowerment? (I get this one now and the comment can be disregarded but leaving it in as it was my first reaction - almost an artefact of the structure. It may be worth including something along the lines “analysis proceeded in multiple stages. In the first, we focused specifically on how authors used and defined empowerment and similar terms.” At the time or reading it was a bit unclear how this related to the domains etc.)

Line 169 - worth mentioning that you included privacy as part of X domain and freedom of movement as part of y domain.

Results - you already have a very long article. Not sure the mini-paragraphs under each of the domains really add anything to your manuscript?

Larger comments:

The concept of empowerment seems to be used interchangeably with well-being, particularly in the discussion. While empowerment is complex and multi-dimensional, the fact that the specific theoretical organization of empowerment used here is so broad makes these two concepts a bit difficult to disentangle (or perhaps they shouldn’t be…?). The authors mentions in the discussion that there were alternative concepts of empowerment that could have guided this review - I think engaging more critically with other concepts of empowerment and how it is defined against / in relation to other concepts such as well being would be a useful addition to this manuscript.

Further to the above, the introduction is rather short - helping to position the topic of empowerment within the broader literature and current discourse on WASH / gender would be helpful. Note: I am not suggesting the authors provide a detailed overview of every definition of empowerment etc. However, a solid paragraph early in the manuscript is needed to introduce and define the topic and how it relates to other research areas is needed. Without this, the framework used comes across as too broad and all encompassing.

However: this manuscript is very long. All credit to the authors for the monumental task of trying to synthesise such a broad and complex body of literature. However, in the present form - it’s a struggle to navigate. One suggestion, and this is a suggestion only, would be to preserve the text on each of the sub-domains but move those into a longer appendix while the main study presents a more succinct and less detailed synthesis of the key findings. This could allow for the larger synthesis and understanding to emerge but still preserve the more nuanced, in-depth discussion of studies in the current manuscript and allow and still provide readers who want more details on specific sub-domains etc with the relevant information. Each of the domains included could be the subject of its own systematic review and . To borrow a tired phrase: it’s a bit difficult to see the forest through the trees in the current form.

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For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Jess MacArthur

Reviewer #2: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PWAT-D-21-00041_reviewer.pdf

PWAT-D-21-00041R1

Water, Sanitation, and Women’s Empowerment: A Systematic Review and Qualitative Metasynthesis

PLOS Water

Dear Dr. Caruso,

Thank you for submitting your manuscript to PLOS Water. After careful consideration, we feel that it has merit but does not fully meet PLOS Water's publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 09 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at water@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pwat/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Inga T. Winkler, Ph.D.

Academic Editor

PLOS Water

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article's retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Many thanks for the authors for the comprehensive revision of the manuscript and the detailed response to reviewers. I greatly appreciate the authors' explanations and justifications. The decision to move text into a supplement can never be taken lightly, but I think it much improves the readability of the manuscript.

The review is indeed an extensive one, including a large number of articles. However, that doesn’t mean that a search in different disciplinary databases wouldn’t have generated additional pieces for inclusion. With a concept as broad as empowerment, literature from sociology, economics, development studies, gender studies or other disciplines might have provided additional findings. I’d therefore support the reviewer’s comment to acknowledge the focus on public health in the limitations.

I also appreciate the authors’ justification for the use of their empowerment framework. While the engagement with the concept of empowerment is not in-depth, the additional paragraphs seem adequate.

I appreciate the author’s addition of Text Box 1, which provides a much-needed summary that distills key messages and recommendations. I’d encourage the authors to further expand the discussion and provide more detail. For instance, the authors suggest that “Our review shows that the true burden of inadequate WASH on well-being is likely far greater” – how does this link to the lack of empowerment and which sub-domains should be studied further? With regard to agency, it might also be helpful to break this down in more detail – which subdomains remain understudied? The reviewer suggests a visual approach to summarizing the findings, which might be one way of making it easier for readers to capture key findings.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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2. Does this manuscript meet PLOS Water’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Water does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: * The updates to this manuscript are well noted and the paper reads much more easily. Wonderful job on consolidating and updating.

* A visual approach to summarising the findings may be valuable and could further strengthen the argument. Perhaps a diagram with the relative weights of themes in a similar colour scheme and layout to the Gates framework.

* The article could also be strengthened by identifying who its readers should be. Text box 1 starts to do this, but with such rich findings, I would be curious to hear from the authors who would be well placed to read and use these findings. It seems quite focused on scholars, but the use of and engagement with grey-literature leans in the opposite direction.

* There is a conflation of the concepts of ’transformative-WASH’ from a public-health perspective, and 'gender-transformative WASH’ which comes from feminist development. Empowerment of women and girls through the transformation of power relations is one piece in this puzzle, but this is yet unclear. 

* The rigour of this review is held in the highest esteem, yet decision to not compare the findings with other reviews in the sector seems out of place. Where findings are overlapping (geographies, WASH-focus, participants, definition of empowerment etc.) the paper would be strengthened by highlighting these. When different methodologies and scopes produce similar results this only stands to strengthen the weight of findings. e.g. The text box, where many of these have been noted by other authors.

* It might be valuable to highlight in the limitations section that the review has arisen from scholars of public health, and to consider how future reviews might benefit from multiple disciplinary perspectives given the transdisciplinary nature of gender-WASH.

* I recommend reviewing this systematic literature review on the gender-WASH space. From 1985, it explores over 700 documents. https://www.ircwash.org/sites/default/files/202.1-85PA-2977.pdf

Reviewer #2: In providing my first round of comments, I rushed to make suggestions and did not adequately express my appreciation for the authors and their work on an important topic. This is a valuable synthesis of the current literature and provides much needed structure to the amorphous dialogue on empowerment in the water and sanitation (if not all of public health) sector. very well done.

I feel the authors have adequately addressed all comments and recommendations. Very well done!

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Water, Sanitation, and Women’s Empowerment: A Systematic Review and Qualitative Metasynthesis

PWAT-D-21-00041R2

Dear Dr Caruso,

We are pleased to inform you that your manuscript 'Water, Sanitation, and Women’s Empowerment: A Systematic Review and Qualitative Metasynthesis' has been provisionally accepted for publication in PLOS Water.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow-up email from a member of our team. 

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact water@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Water.

Best regards,

Inga T. Winkler, Ph.D.

Academic Editor

PLOS Water

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Reviewer Comments (if any, and for reference):