Women and girls experience gender-specific health impacts related to inadequate sanitation, including adverse maternal health outcomes, altered eating or drinking habits to limit urination and defecation, and the inability to meet basic needs, including those related to menstrual health (Benova et al., 2014; Caruso et al., 2022; Caruso et al., 2017; Fewtrell et al., 2007; Fisher et al., 2017; Goddard and Marni, 2020; Khanna and Das, 2016; Padhi et al., 2015). Recognizing these disproportionate burdens, the 2030 Agenda for Sustainable Development aims to ‘achieve access to adequate and equitable sanitation and hygiene for all and end open defecation’ with ‘special attention to the needs of women and girls’ under Target 6.2. (United Nations, 2023; WHO/UNICEF Joint Monitoring Programme, 2023). Beyond physical health, a growing body of research shows that inadequate sanitation can cause women to face a greater burden of sanitation-related psychosocial stress – resulting in distress, anxiety, and poor well-being (Bisung and Elliott, 2017; Caruso et al., 2017; Hulland et al., 2015; Sahoo et al., 2015; Sclar et al., 2018). These stressors include shame from lack of privacy; physical or sexual violence; threat of injury from wildlife or the environment; and limited autonomy related to societal norms like caste, class, and gender. Research conducted in Odisha, India quantitatively demonstrated that sanitation insecurity (negative urination and defecation concerns and experiences) was linked to anxiety, depression, and poor well-being, irrespective of access to a functional household latrine (Caruso et al., 2018). Despite these findings, sanitation programs have historically focused on infrastructure development rather than prioritizing physical and social sanitation environments that are specifically designed to meet women's needs and reduce gendered stressors.

Various factors may influence the relationship between sanitation and mental health, beyond access to a functional latrine, including women's decision-making. It is hypothesized that improving decision-making influence grants women greater access to resources, ability to cope with stressful life circumstances, and overall self-efficacy (Richardson et al., 2019). Therefore, women's decision-making may contribute positively to their overall well-being (Richardson et al., 2019; Shankar et al., 2019). However, limited research has investigated women's sanitation-related decision-making and its relationship to well-being.

Current research shows that women typically have a limited role in sanitation-related decision-making, which negatively impacts their sanitation experiences (Annan et al., 2021; Das and Tampubolon, 2022; Khanna and Das, 2016; Routray et al., 2017). Qualitative studies in India found men did not prioritize the gender-specific needs of women when deciding if and how to construct latrines, which often led to women's avoidance of these latrines due to privacy, dignity, and safety concerns (Khanna and Das, 2016; Routray et al., 2017). As such, women's ability to exert control over their sanitation locations' placement, design, and maintenance may influence well-being (Khanna and Das, 2016; Routray et al., 2017; Sahoo et al., 2015).

Bangladesh is an appropriate location for exploring the relationship between women's sanitation-related decision-making and well-being. While the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) reported open defecation to be eliminated in urban areas of Bangladesh, only 26.6 % of urban households have access to basic sanitation services, and 34.7 % have access to limited sanitation facilities (Joint Monitoring Programme, 2022). Additionally, Bangladesh has a patriarchal culture that is largely influenced by traditional and religious beliefs, and men typically have the final say in decisions (Chandramohan et al., 2023; Haque et al., 2011). While we were not able to identify research on gender and sanitation-related decision-making in Bangladesh, women's decision-making capabilities related to water were found to be limited (Clement, 2012). There is a need to investigate women's sanitation-related decision-making and well-being as findings can inform how future public health sanitation interventions in Bangladesh are planned and implemented.

This study aims to (1) understand women's perceived decision-making capabilities related to sanitation in two urban areas of Bangladesh, (2) evaluate the association between the use of unshared latrines and mental well-being and (3) examine the association between sanitation-related decision-making and mental well-being, (4) explore how associations between sanitation-related decision-making and well-being may differ based on overall decision-making and individual decision-making factor scores, and (5) assess how associations vary by city.