Water insecurity and urban poverty in the Global South: Implications for health and human biology

Urbanization and Infectious Disease

The United Nations currently estimates that over half of the global population has lived in cities since 2017 and that this proportion is continuing to grow, particularly in the Global South. While urbanization is not new, increased population density combined with accelerating rates of (re)emerging and noncommunicable diseases as well as growing economic disparities has created new challenges to human health and well-being. Here, I examine peri-urban communities, peripheral settlements on the edges of urban areas populated by rural people, and argue that these areas are often overlooked, despite becoming increasingly common. Thus, human biologists should move beyond categorizing these spaces as transitional. Using unplanned, peri-urban communities around Lima, Peru as a case study, I detail the complexity of political ecological factors that impact infectious disease risk and rates in peri-urban communities. Using disease mechanisms, I demonstrate the importance of a biocultural approach and a political ecology perspective when investigating infectious disease. I highlight how human biologists and anthropologists are uniquely positioned to explore the heterogeneity of infectious disease patterns and pathways in an increasingly urbanized world.

Mobility ideation due to water problems during historic 2022 drought associated with livestock wealth, water and food insecurity, and fingernail cortisol concentration in northern Kenya

Climate change is triggering environmental mobility through chronic water problems and punctuated events. Thinking about moving locations, or "mobility ideation", is the precursor to migration intentionality and actual migration. Drawing on the embodiment construct, this study examines how the worst drought in recent history in the Horn of Africa affected water-related mobility ideation and, in turn, fingernail cortisol concentration (FCC), a chronic stress biomarker, among Daasanach semi-nomadic pastoralists in northern Kenya. To address these questions, we primarily draw on survey, anthropometric, water quality, and biomarker data among 175 adults living in seven communities in 2022. We used mixed-effects ordered logistic regression to test how livestock wealth, water insecurity, food insecurity, and anxiety/depression symptom scores were associated with household mobility ideation. We then used generalized linear models to test the association between mobility ideation on FCC. Thinking about moving at least once due to water problems increased from pre-drought in 2019 (55%) to during the drought in 2022 (92%), while actual mobility declined. Livestock wealth, while associated with actual mobility in the prior year, was protective against increased mobility ideation, while water insecurity, food insecurity, and anxiety/depression symptoms were associated with greater odds of thinking of leaving in 2022. Compared to adults who did not consider moving, those who considered moving rarely, sometimes, and often had FCC levels 18.1% higher (95% CI, 1.01-1.38; p = 0.039), 19.4% higher (1.01-1.41; p = 0.040), and 32.3% higher (1.01-1.73; p = 0.039), respectively, with results consistent in sensitivity analyses. Extreme climatic events in water scarce regions may increase mobility ideation through worsened experiential indicators of well-being and resource insecurity. Mobility ideation may capture measures of adversity suffered by pastoralists and signify climate distress. This research broadens understanding of how droughts get under the skin by leading to resource insecurity and triggering thoughts of moving, which increases chronic stress.

Water fetching and musculoskeletal health across the life-course in Sub-Saharan Africa: A scoping review

The world is experiencing a global water crisis and Sub-Saharan Africa (SSA) is expected to be a hotspot for increasing global water scarcity in years to come. Water is quintessentially a gendered issue; indeed, sociocultural norms hold women responsible for household water collection, requiring them to travel far distances while carrying water. This paper reports the findings of a scoping review of peer-reviewed and grey literature that examines the relationship between water fetching and the musculoskeletal (MSK) health of women in SSA. The work is informed by a gendered life-course perspective, and the authors follow the PRISMA-ScR guidelines. Results indicate a bidirectional relationship between water fetching and poor MSK health as chronic and acute incidences of water carrying are highly related to MSK pain and dysfunction. This has negative implications for the overall health and wellbeing of women and their households. Gaps in the literature are identified, including the experiences of elderly people and people with various vulnerabilities. Recommendations from the literature are compiled to outline potential avenues of future research and innovation to better support the MSK health of water fetchers in SSA.

Creative health in the urban Global South: barriers and facilitators in the cases of Cochabamba and Salvador

AIMS

The Global South has some of the world's largest cities, where rapid, ad hoc development of urban centres and 'megacities' has fuelled major socio-economic, environmental, and public health concerns. These urban environments can generate feelings of loneliness, with multiple barriers for access and participation in socio-cultural infrastructures. An inclusive future agenda for global creative health must, therefore, consider how urbanisation impacts social public health, what creative health approaches can do to alleviate this, and what the barriers are to access. This article explores barriers and facilitators to accessing socio-cultural urban infrastructures in two case-study cities: Salvador in Brazil and Cochabamba in Bolivia.

METHODS

Data were collected as part of a survey examining access to, and engagement in, arts and cultural activities undertaken between 25 January and 1 May 2023. This article focuses on two questions: What helps you to access artistic and cultural events in your city? and What barriers do you face in accessing artistic and cultural events in your city? 239 open responses from adults, in Portuguese and Spanish, were analysed using descriptive thematic analysis.

RESULTS

Findings highlight how emergent issues around existing economic inequality, safety, and accessibility can limit residents' capacity to engage in creative health activities. While preliminary in scope, this raises wider public health implications for how creative health approaches may be leveraged within urban, Global South contexts.

CONCLUSIONS

Findings highlight how greater dialogue is needed between the urban development, public health, and creative health sectors. Given the emerging evidence of the role of creative engagement to alleviate loneliness, integrating creative health approaches within urban public health may further strengthen connections with the most vulnerable communities, and help to build healthier cities. The article ends by outlining an approach that incorporates both local and city-wide creative encounters, highlighting how future interventions could be appropriately designed that gradually scale these types of interventions from tailored local offerings to larger, city-wide activities.

Water Supply Interruptions Are Associated with More Frequent Stressful Behaviors and Emotions but Mitigated by Predictability: A Multisite Study

Water supply interruptions contribute to household water insecurity. Unpredictable interruptions may particularly exacerbate water insecurity, as uncertainty limits households' ability to optimize water collection and storage or to modify other coping behaviors. This study used regression models of survey data from 2873 households across 10 sites in 9 middle-income countries to assess whether water supply interruptions and the predictability of interruptions were related to composite indicators of stressful behaviors and emotional distress. More frequent water service interruptions were associated with more frequent emotional distress (β = 0.49, SE = 0.05, P < 0.001) and stressful behaviors (β = 0.39, SE = 0.06, P < 0.001). Among households that experienced interruptions, predictability mitigated these respective relationships by approximately 25 and 50%. Where the provision of continuous water supplies is challenged by climate change, population growth, and poor management, water service providers may be able to mitigate some psychosocial consequences of intermittency through scheduled intermittency and communication about water supply interruptions. Service providers unable to supply continuous water should optimize intermittent water delivery to reduce negative impacts on users, and global monitoring regimes should account for intermittency and predictability in post-2030 water service metrics to better reflect household water insecurity experiences.

Local Economic Conditions Affect Aedes albopictus Management

Invasive mosquitoes are an emerging public health issue, as many species are competent vectors for pathogens. We assessed how multiple environmental and socio-economic factors affected the engagement of municipalities in Italy (n = 7679) in actions against Aedes albopictus, an invasive mosquito affecting human health and well-being, between 2000 and 2020. We collected information about mosquito control from official documents and municipal websites and modeled the role played by multiple environmental and socioeconomic factors characterizing each municipality through the random forest algorithm. Municipalities are more prone to manage A. albopictus if more urbanized, in lowlands and with long infestation periods. Moreover, these variables are more predictive of management in municipalities with a high median income and thus more economic resources. Only 25.5% of Italian municipalities approved regulations for managing A. albopictus, and very few of them were in Southern Italy, the most deprived area of the country. Our findings indicate that local economic conditions moderate the effect of other drivers of mosquito control and ultimately can lead to better management of A. albopictus. If the management of invasive mosquitoes, or other forms of global change, is subjected to local economic conditions, economic inequalities will jeopardize the success of large-scale policies, also raising issues of environmental and climate justice.

"Quenching the thirst of others while suffering": Embodied experiences of water vendors in Ghana and Kenya

Informal water sellers (commonly known as water vendors) have emerged as part of urban water infrastructure systems in many low- and middle-income countries to meet the water needs of unserved urban populations. These vendors include water tanker operators, those who sell water from private standpipes and boreholes, and those who use hand carts, bicycles, tricycles to transport water around for sale. However, we know little about the embodied impacts of their work on their health and wellbeing. In this article, we consider how embodied experience can add to our understandings of water access and decent work in urban centers in Sub-Saharan Africa. The study examines health risks associated with informal water vending in three cities, Accra and Wa (Ghana) and Kisumu (Kenya), where close to 48%, 65%, and 26% of residents respectively rely on vendors for their drinking water needs. We used in-depth interviews to explore the lived experiences of 59 water vendors and perspectives of 21 local stakeholders. Water vendors were mostly exposed to injury, environmental pollution, stigma, and work-life balance. Vendors who transport water in containers using bicycles or hand-pushed carts and those who carry water around complained about harsh weather conditions, poor physical terrain, and abuse from customers. Female water vendors also complained about pregnancy complications, baldness and water related diseases. Female water vendors experience unique physical threats that may put them at greater risk for chronic health and safety impacts. Gaining a better understanding of the health risks faced by these water vendors will provide policy makers with greater insight into how water vendors can be better supported to provide more improved services to enhance greater access to safe water. Findings from this work are also important for contributing to social protection policies, promoting inclusive growth, and designing empowerment programs for women.

Understanding the behavioral determinants of adolescents' water consumption: A cross-country comparative study

Substituting the consumption of sugar-sweetened beverages (SSB) with that of water can have a positive effect on adolescents' health. However, despite the attention on this topic in the Global North, it is relatively understudied in other regions of the world, such as the Caribbean. To guide the development of future interventions, understanding the factors determining water consumption among Caribbean adolescents is important. This study examined the behavioral determinants of water consumption among adolescents in Aruba (the Caribbean) and compared them to those in the Netherlands (Western Europe). We used a theoretical model that integrates the dominant theoretical perspectives in the field of public health, including theories of planned behavior, social norms, and intrinsic motivation. This cross-country study included 1,584 adolescents from Aruba and the Netherlands (52% girls; M = 12.34 years; SD = 2.14). The data were analyzed using regression analyses. This study found that in Aruba, adolescents with higher scores of intrinsic motivation, friends' descriptive norms, attitudes, and behavioral control regarding water consumption drank more water. Moreover, the associations between water consumption and both intrinsic motivation as well as friends' descriptive norms for adolescents in Aruba were stronger than those found in the Netherlands. These associations imply that it is even more important for Aruban adolescents than Dutch adolescents to be intrinsically motivated or to perceive their friends often consuming water to drink more water. The cross-country comparison implies that future interventions in Aruba aimed at increasing adolescents' water consumption as an alternative to SSB should focus on enhancing their intrinsic motivation while considering their friends' social norms.

Experiences of poverty amongst low-income older adults living in a high-income country: A qualitative study

AIM

To understand the experience of low-income older adults living in poverty in a high-income country.

DESIGN

A qualitative study based on Gadamer's hermeneutic phenomenology.

METHODS

A convenience sample of twenty-seven low-income older adults were interviewed in-depth between September 2021 and January 2022. Fleming's method for conducting phenomenological qualitative studies was followed and ATLAS.ti software was used for data analysis.

RESULTS

Three main themes were extracted from the analysis: (i) 'living in the shadow of poverty', (ii) 'unprotected by the 'social shield' of the welfare state' (iii) 'the struggle to attain good health'.

CONCLUSION

Living in poverty affects all spheres of life. Older adults living in poverty feel excluded from social support policies and laws. This has a negative impact on the older adults' mental health and can lead to social isolation.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nursing interventions to promote health amongst older adults living in poverty should include an assessment of the patient's social determinants and a focus on increasing social participation. Older people living in poverty experience difficulties accessing formal social support so nurses should implement patient navigation interventions that aim to help them overcome the complexities of the system. Nursing interventions to improve mental health amongst older adults living in poverty are much needed.

IMPACT

Living in poverty increases older adults' vulnerability. Older adults living in poverty suffer from mental health issues as they live under constant pressure to meet their basic needs and lack formal social support. These findings are important for nurses, who play a pivotal role in the design, implementation and evaluation of policies and interventions that promote health equity.

REPORTING METHOD

The study has been conducted following the COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

There has been no public or patient involvement in the design or development of the study.

Challenges in identifying simple pattern-forming mechanisms in the development of settlements using demographic data

The rapid increase of population and settlement structures in the Global South during recent decades has motivated the development of suitable models to describe their formation and evolution. Such settlement formation has been previously suggested to be dynamically driven by simple pattern-forming mechanisms. Here, we explore the use of a data-driven white-box approach, called SINDy, to discover differential equation models directly from available spatiotemporal demographic data for three representative regions of the Global South. We show that the current resolution and observation time of the available data are insufficient to uncover relevant pattern-forming mechanisms in settlement development. Using synthetic data generated with a generic pattern-forming model, the Allen-Cahn equation, we characterize what the requirements are for spatial and temporal resolution, as well as observation time, to successfully identify possible model system equations. Overall, the study provides a theoretical framework for the analysis of large-scale geographical and/or ecological systems, and it motivates further improvements in optimization approaches and data collection.

Exploring the invisible water insecurity of water utility shutoffs in Detroit, Michigan

A lack of regular access to clean and safe water and sanitation is a persistent problem in many parts of the world. Most water insecurity studies focus on the world's less-industrialized and lower-income countries, where sanitation and water delivery infrastructure may never have existed. However, many individuals in higher-income countries experience invisible water insecurity, wherein specific households or individuals lack access to sanitation and clean water despite the relative wealth of their country. In the United States, invisible water insecurity tends to manifest as a result of homelessness, a lack of plumbing facilities, and water utility shut-offs. Using a water shut-off dataset from the Detroit Water and Sewerage Department, we investigate the relationship between a suite of demographic variables and the water shut-off rates in different neighborhoods throughout Detroit, Michigan. We find that shut-offs are more common in areas with more Black households that are more impoverished. Our findings indicate that this relationship links to structural disadvantage resulting from a legacy of racism and segregation in the city.

The mismatch of narratives and local ecologies in the everyday governance of water access and mosquito control in an urbanizing community

Mosquito-borne disease presents a significant threat to urban populations, but risk can be uneven across a city due to underlying environmental patterns. Urban residents rely on social and economic processes to control the environment and mediate disease risk, a phenomenon known as everyday governance. We studied how households employed everyday governance of urban infrastructure relevant to mosquito-borne disease in Bengaluru, India to examine if and how inequalities in everyday governance manifest in differences in mosquito control. We found that governance mechanisms differed for water access and mosquitoes. Economic and social capital served different roles for each, influenced by global narratives of water and vector control.

Do perceived inequalities in safe water access manifest in collective action? Evidence from urban Ghana

Access to safe drinking water is critical in improving health and well-being. It is estimated that >40% of urban households in Ghana do not have access to safe drinking water. Although the willingness and ability of community members to collectively take local initiatives are essential to curtailing inequities in water access in Ghana, the determinant of collective action is less explored. This paper explores determinants of collective action in water-insecure neighbourhoods and examines how perceived inequities in access to water and trust mediate the relationship between lack of access to water and collective action in urban Ghana. The results show that the urban poor OR = 12.047 (p = 0.000) were more likely to participate in water-related collective action compared to wealthy individuals. Primary decision-makers were 1.696 times more likely to participate in collective (p = 0.02). We also found that perceived inequities OR = 0.381 (p = 0.00) significantly predict participation in collective action to address water insecurity. Water service providers should be subjected to a rigid state-level framework that ensures inclusivity, fairness and justice in their distribution systems.

Food, water, and sanitation insecurities: Complex linkages and implications for achieving WASH security

Food, water and sanitation insecurities are complex, multi-dimensional phenomena that entail more than availability and access; food, water, and sanitation resources must be safe and culturally appropriate. Researchers and implementers concerned with these insecurities have demonstrated that there are notable interactions between them resulting in significant psychological and biological outcomes. Recent randomised controlled trials (RCTs) in Bangladesh, Kenya (WASH Benefits) and Zimbabwe (SHINE) demonstrated no effect from water, sanitation and hygiene (WASH) interventions on linear growth, and mixed evidence on enteropathogen burden and risk of diarrhoea in young children. These data suggest a need for a more comprehensive understanding of WASH security. The risks posed by multiple resource insecurities shift depending on the individual, their movement throughout their day, their economically and socially prescribed roles, and ecological features such as seasonality and precipitation. By more fully integrating food, water and sanitation security in interventions and subsequent impact evaluations, we can achieve WASH security-one that addresses myriad transmission pathways and co-occurring diseases-that ultimately would improve health outcomes throughout the world. In this critical review, we outline the complexity of combined resource insecurities as a step towards transformative WASH.

Estimating national, demographic, and socioeconomic disparities in water insecurity experiences in low-income and middle-income countries in 2020-21: a cross-sectional, observational study using nationally representative survey data

BACKGROUND

We are facing a global water crisis. However, because most water indicators assess physical availability or infrastructure in aggregate, knowing which sociodemographic groups experience water insecurity is difficult. We aimed to assess the prevalence of water insecurity across low-income and middle-income countries (LMICs) and examine how it varies by sociodemographic characteristics and exposure to life disruptions due to the COVID-19 pandemic across and within countries.

METHODS

In this observational study, we used Individual Water Insecurity Experiences (IWISE) scale data from a cross-sectional, nationally representative sample of individuals aged 15 years and older (defined as adults) in 31 LMICs. The IWISE scale range is 0-36, and water insecurity was defined as a score of 12 or higher. We used multivariable linear regression models to assess how individual-level experiences with water insecurity related to sociodemographic characteristics in each country, region, and the pooled sample.

FINDINGS

45 555 individuals from 31 LMICs completed the IWISE module between Sept 4, 2020, and Feb 24, 2021, and were included in the 2020 Gallup World Poll (GWP) database; 45 365 individuals had sufficient data to estimate the prevalence of water insecurity. 42 918 individuals from 30 LMICs had sufficient data to assess sociodemographic characteristics associated with water insecurity, and 39 161 individuals in 29 countries had sufficient data to assess how IWISE scale scores covaried with life disruptions due to the COVID-19 pandemic. The overall prevalence of water insecurity in 2020 was 14·2%, ranging by region from 36·1% in the sub-Saharan Africa region to 9·1% in the Asia region, and by country from 63·9% in Cameroon to 3·6% in China. In the pooled model including sociodemographic and COVID-19 factors, difficulty getting by on household income (vs no difficulty getting by: β 2·76 [95% CI 2·45-3·07]), living in the outskirts of a city (vs living in a large city: 0·85 [0·29-1·41]), and being greatly affected by the COVID-19 pandemic (vs not being affected: 2·36 [1·96-2·77]) were strongly associated with higher IWISE scores. In country and regional models, the sociodemographic factors most consistently associated with higher IWISE scores were difficulty getting by on household income and life disruptions due to the COVID-19 pandemic, but the strength of these associations varied across countries and regions.

INTERPRETATION

Through extrapolation of these nationally representative data, we estimate that hundreds of millions of people had life-altering experiences with water insecurity globally in 2020, and that their sociodemographic characteristics vary by country and region. Additional individual-level measurements globally could help pinpoint the characteristics of those who are most water insecure, thereby guiding the development of context-specific policy and interventions that will best serve those most affected.

FUNDING

Carnegie Corporation, Northwestern University, and USAID.

Water journeys: Household water insecurity, health risks, and embodiment in slums and informal settlements

Water insecurity is a critical public-health challenge in Africa's urban informal settlements, where most of the population often lacks access to household taps. In these settings, water fetching is disproportionately performed by women. While water fetching is physically laborious and exposes women to multiple risks, the water-insecurity literature has predominantly focused on household experiences, ignoring women's water-collection journeys. This paper uses the water journey as a window into the embodied dimensions of water insecurity. Combining theoretical insights from embodiment, embodied political ecology of health, and time geographies, we use video-recorded walking interviews to analyze women's everyday water journeys in Ntopwa, an urban informal settlement in Blantyre, Malawi, from initial decision making through exposure to water-fetching risks and household practices regarding use and storage. We identify three principal sources of environmental risk- terrain, built environment, and human behavior-that present challenges for water collectors. Using the walking interview as a heuristic, we show how the seemingly simple practice of water fetching is compounded by complex decision making, constant spatiotemporal trade-offs, and exposure to diverse risks, all of which have embodied health consequences. Based on our findings, we conclude that interventions seeking to improve household water insecurity must consider the embodied effects of water-fetching journeys. This study also provides methodological insights into using walking interviews and videos for water and health research.

Measurement invariance of a household water insecurity metric in Greater Accra, Ghana: Implications for test-retest reliability

The mitigation of household water insecurity is recognized as an important component of global poverty alleviation, but until recently was difficult to measure. Several new metrics of household water insecurity have been proposed and validated, but few have been field-tested for reliability in diverse contexts. We used confirmatory factor analysis to test the psychometric equivalence of one such metric-the Household Water Insecurity Experiences (HWISE) scale-across two survey waves administered 18 months apart in similar climatic conditions among households in a peri-urban community outside of Accra, Ghana. The HWISE metric was not equivalent across survey waves, which may be attributable to the metric itself, sample size, subtle instrumentation changes, or other unobserved factors. Test-retest reliability may also be difficult to achieve given the dynamic nature of household water use, and we discuss the implications of using household water insecurity metrics as longitudinal measures of well-being in global anti-poverty programs.

Rainwater Harvesting to Address Current and Forecasted Domestic Water Scarcity: Application to Arid and Semi-Arid Areas

This paper discusses the effectiveness of rooftops rainwater harvesting (RRWH) in addressing domestic water scarcity, emphasizing the West Bank (Palestine) as an example of arid to semi-arid areas with limited water resources. The paper deals with the actual and future water demand by considering climate-change impact and urban growth. The analysis is based on the evaluation of (i) the supply–demand balance index (SDBI), which designates the ratio between the total water supply (TWS) and total water demand (TWD), and (ii) the potential of RRWH. Applying this methodology to the West Bank shows that the potential RRWH can contribute by about 40 million cubic meters/year in 2020, which is approximately the same amount of water as the municipal water supply (42 million cubic meters/year). This contribution can effectively reduce the suffering governorates from 64% to 27% in 2020. Furthermore, it can support water-related decision-makers in the arid to semi-arid areas in formulating efficient and sustainable water resources strategies. The analysis also shows that the domestic water scarcity in 2050 will be worse than in 2020 for all governorates. For example, 73% of the West Bank governorates are expected to suffer from extreme to acute water scarcity in 2050 compared to 64% in 2020. Thus, RRWH appears to be highly efficient in mitigating the current and future domestic water scarcity in the West Bank.

The embodiment of water insecurity: Injuries and chronic stress in lowland Bolivia

Water is critical to health and wellbeing. Studies have theorized that problems with water can become embodied, yet few studies have quantified this. Therefore, we first sought to understand the lowland Bolivian water environment of Tsimane' forager-horticulturalists. We assessed the water environment holistically, using objective measures of water quality and water services (Joint Monitoring Programme's drinking water services ladder) and subjective measures, including perceived water safety and water insecurity experiences [Household Water Insecurity Experiences Scale (HWISE)]. We tested how water service levels, perceived water safety, and water fetching frequency were associated with HWISE scores using Tobit regression models among 270 households. We then tested if and how water becomes embodied via self-reported water-related injury and a chronic stress biomarker, hair cortisol concentration (HCC). Results demonstrated that, compared with households using surface water, households with basic water services had HWISE scores 1.59-pts lower (SE = 0.29; P < 0.001). Ingestion of water perceived to be "bad" and more daily water-fetching trips were associated with higher HWISE scores. Twenty percent of households reported prior water-related injuries, with women most commonly injured. In logistic regressions, each point higher HWISE score was associated with 28% (95%CI:1.16-1.41; P < 0.001) higher odds of injury. Basic water services compared to surface water was associated with 48% lower odds (OR = 0.52; 95%CI:0.33-0.82; P = 0.005) of injury. Finally, using linear regressions among 332 adults, HWISE scores were not associated with HCC. Past water-related injury was associated with higher HCC (Beta = 0.31; SE = 0.09; P = 0.029) among women, but not men. Relying on unimproved water services compared to surface was associated with 46.2% higher HCC for women (Beta=0.38; SE=0.14; P=0.048) and 55.3% higher HCC for men (Beta=0.44; SE=0.15; P=0.044), respectively. Overall, our findings demonstrate that water insecurity can become embodied through water-related injuries and elevated HCC. Improving water service levels through an equity lens may help ameliorate water insecurity and its accompanying negative health effects.

The Individual Water Insecurity Experiences (IWISE) Scale: reliability, equivalence and validity of an individual-level measure of water security

Objective

The lack of a validated and cross-culturally equivalent scale for measuring individual-level water insecurity has prevented identification of those most vulnerable to it. Therefore, we developed the 12-item Individual Water InSecurity Experiences (IWISE) Scale to comparably measure individual experiences with access, use, and stability (reliability) of water. Here, we examine the reliability, cross-country equivalence, and cross-country and within-country validity of the scale in a cross-sectional sample.

Methods

IWISE items were implemented by the Gallup World Poll among nationally representative samples of 43 970 adults (>15 y) in 31 low-income and middle-income countries (LMICs). Internal consistency was assessed with Cronbach’s alpha. Equivalence was tested using multigroup confirmatory factor analysis (MGCFA), the alignment method, and item response theory. Cross-country validity was assessed by regressing mean national IWISE scores on measures of economic, social, and water infrastructure development. Within-country validity was tested with logistic regression models of dissatisfaction with local water quality by IWISE score and regressing individual IWISE scores on per capita household income and difficulty getting by on current income.

Findings

Internal consistency was high; Cronbach’s alpha was ≥0.89 in all countries. Goodness-of-fit statistics from MGCFA, the proportion of equivalent item thresholds and loadings in the alignment models, and Rasch output indicated equivalence across countries. Validity across countries was also established; country mean IWISE scores were negatively associated with gross domestic product and percentage of the population with access to basic water services, but positively associated with fertility rate. Validity within countries was also demonstrated; individuals’ IWISE scores were positively associated with greater odds of dissatisfaction with water quality and negatively associated with lower financial standing.

Conclusions

The IWISE Scale provides an equivalent measure of individual experiences with water access and use across LMICs. It will be useful for establishing and tracking changes in the prevalence of water insecurity and identifying groups who have been ‘left behind’.

Perspective: The Importance of Water Security for Ensuring Food Security, Good Nutrition, and Well-being

Water security is a powerful concept that is still in its early days in the field of nutrition. Given the prevalence and severity of water issues and the many interconnections between water and nutrition, we argue that water security deserves attention commensurate with its importance to human nutrition and health. To this end, we first give a brief introduction to water insecurity and discuss its conceptualization in terms of availability, access, use, and stability. We then lay out the empirical grounding for its assessment. Parallels to the food-security literature are drawn throughout, both because the concepts are analogous and food security is familiar to the nutrition community. Specifically, we review the evolution of scales to measure water and food security and compare select characteristics. We then review the burgeoning evidence for the causes and consequences of water insecurity and conclude with 4 recommendations: 1) collect more water-insecurity data (i.e., on prevalence, causes, consequences, and intervention impacts); 2) collect better data on water insecurity (i.e., measure it concurrently with food security and other nutritional indicators, measure intrahousehold variation, and establish baseline indicators of both water and nutrition before interventions are implemented); 3) consider food and water issues jointly in policy and practice (e.g., establish linkages and possibilities for joint interventions, recognize the environmental footprint of nutritional guidelines, strengthen the nutrition sensitivity of water-management practices, and use experience-based scales for improving governance and regulation across food and water systems); and 4) make findings easily available so that they can be used by the media, community organizations, and other scientists for advocacy and in governance (e.g., tracking progress towards development goals and holding implementers accountable). As recognition of the importance of water security grows, we hope that so too will the prioritization of water in nutrition research, funding, and policy.

The Physical Burden of Water Carrying and Women's Psychosocial Well-Being: Evidence from Rural Nepal

Many women in low-income countries carry heavy loads of drinking water for their families in difficult terrain. This can adversely affect their health and well-being. The present study is the first to investigate the physical burden of water carrying and women's psychosocial well-being, and how this relationship is moderated by environmental and health conditions. Trained local interviewers conducted interviews with 1001 women across five rural communities in Nepal. In addition, objective measurement was used to assess the weight carried and distance from the water source. The physical burden of water carrying was calculated from weight, distance, and frequency of trips. Its association with psychosocial well-being was modeled using generalized estimating equations. Two additional models included the terrain and uterine prolapse as moderators. The physical burden of water carrying is directly related to higher emotional distress and reduced daily functioning. This correlation was exacerbated for women carrying in hilly versus flat terrain, and for those who had uterine prolapse. Our results underline the importance of adequate water access for women's psychosocial well-being, especially for vulnerable populations such as women with impaired health (e.g., uterine prolapse) or those living in hilly terrain. The results further highlight the interconnectedness of the Sustainable Development Goal (SDG) 6: water access, SDG 3: health and well-being, and SDG 5: gender equality.

Clinical Ecopsychology: The Mental Health Impacts and Underlying Pathways of the Climate and Environmental Crisis

Humankind is confronted with progressing climate change, pollution, environmental degradation, and/or destruction of the air, soil, water, and ecosystems. The climate and environmental crisis is probably one of the greatest challenges in the history of humankind. It not only poses a serious current and continuing threat to physical health, but is also an existing and growing hazard to the mental health of millions of people worldwide. This synergy of literature provides a current summary of the adverse mental health impacts of the climate and environmental crisis from the perspective of Clinical Psychology. Furthermore, it presents potential underlying processes, including biological, emotional, cognitive, behavioral, and social pathways. The existing data suggest that the climate and environmental crisis not only acts as a direct stressor, but can also exert a detrimental impact on the various pathways, with the potential to amplify an individual's biopsychosocial vulnerability to develop mental ill-health. This is a call for an increased investigation into this emerging research field of Clinical Ecopsychology by clinical psychologists and other researchers.

Cross-sectional study to measure household water insecurity and its health outcomes in urban Mexico

OBJECTIVE

To assess the links between structural and household determinants of household water insecurity and test three water insecurity measures against self-reported diarrhoea, dengue fever and perceived stress in the middle-income and low-income urban areas of Torreón, Mexico.

DESIGN

Cross-sectional household survey conducted in two waves (rainy and dry seasons).

PARTICIPANTS

500 households selected via multistage cluster sample in selected communities. Socioeconomic status determined the selection of participant neighbourhoods; five were identified in low socioeconomic status neighbourhoods and five in low-medium socioeconomic status neighbourhoods. We examine how the context of urban water provision is related to a new cross-culturally valid Household Water Insecurity Experiences (HWISE) Scale.

PRIMARY OUTCOME MEASURES

The HWISE Scale, self-reported diarrhoea, dengue fever and the Perceived Stress Scale.

RESULTS

Water system intermittency (adjusted OR (AOR) 3.96, 95% CI 2.40 to 6.54, p<0.001), unpredictability (AOR 2.24, 95% CI 1.34 to 3.74, p=0.002) and the dry season (AOR 3.47, 95% CI 2.18 to 5.52, p<0.001) were structural correlates of the HWISE Scale. This study also found that the HWISE Scale was associated with two health outcomes, self-reported diarrhoea (AOR 1.09, 95% CI 1.03 to 1.15, p=0.002) and perceived stress (β=0.28, SE=0.07, t=4.30, p<0.001), but not self-reported dengue fever (AOR 1.02, 95% CI 0.98 to 1.06). A 3-item hygiene subscore and a 3-item water worry subscore were also both positively associated with self-reported diarrhoea and perceived stress.

CONCLUSION

Short-form screeners of water insecurity may be useful for assessing certain health risks by lay survey workers in settings with limited healthcare resources, particularly in lieu of more expensive microbiological tests that require specialised training and facilities.

Children and adolescents’ health on focus: Gastrointestinal injuries associated with Helicobacter pylori

Objective: To describe the prevalence of Helicobacter pylori (HP) in children and adolescents, and to assess its association with lesions in the esophagus, stomach, and duodenum according to the patient’s life cycle. Methodsː A cross-sectional analytical study with children and adolescents referred to a gastroenterology service and underwent esophagogastroduodenoscopy at a hospital in Vitória, Espírito Santo, Brazil, from 2001 to 2013. Variables analyzed were the following: sex, age, macro and microscopic alterations and severity of infestation. The Chi-square and Fisher's exact tests and adjusted residue analysis were used (α = 5%). Resultsː the prevalence of infection was 24.4%. Esophagitis (29.4%) and gastritis (34.1%) were associated with HP. The life cycle was associated with esophagitis and duodenitis. Infection was associated with life cycle: infants (0.8%), preschool children (10.5%), school-aged children (16.5%), and adolescents (72.2%). The residues showed a strong association between HP and gastritis, and no association between the school-aged and esophagitis. Adolescents were the major contributors to the association between life cycle and infection, and life cycle and lesion. Conclusionsː Infection with HP was associated with esophagitis and gastritis and was higher among adolescents, who had a marked tendency to develop gastritis and a milder tendency to develop esophagitis. The tendency of developing infection and gastritis was not present in the other life cycles. Public policies focusing on promotion and protecting health, especially in vulnerable population groups, are needed.

Daily changes in household water access and quality in urban slums undermine global safe water monitoring programmes

Global drinking water monitoring programmes and studies on water quality in urban slums often overlook short-term temporal changes in water quality and health risks. The aim of this study was to quantify daily changes in household water access and quality in an urban slum in Malawi using a mixed-method approach. Household drinking water samples (n = 371) were collected and monitored for E. coli in tandem with a water access questionnaire (n = 481). E. coli concentrations in household drinking water changed daily, and no household had drinking water that was completely safe to drink every day. Seasonal changes in drinking water availability, intermittent supply, limited opening hours, and frequent breakdown of public water points contributed to poor access. Households relied on multiple water sources and regularly switched between sources to meet daily water needs. There were generally similar E. coli levels in water samples considered safe and unsafe by residents. This study provides the first empirical evidence that water quality, water access, and related health risks in urban slums change at much finer (daily) temporal scales than is conventionally monitored and reported globally. Our findings underscore that to advance progress towards Sustainable Development Goal (SDG) Target 6.1, it is necessary for global water monitoring initiatives to consider short-term changes in access and quality.

Geographies of insecure water access and the housing-water nexus in US cities

Safe, reliable, and equitable water access is critical to human health and livelihoods. In the United States, an estimated 471,000 households or 1.1 million individuals lack a piped water connection and 73% of households are located in cities, close to networked supply. In this study, we undertake a nationwide analysis of urban water access in the United States, with the aim of explaining the drivers of infrastructural inequality in the 50 largest metropolitan areas. Drawing on statistical analysis and regression modeling of census microdata at the household scale, our analysis reveals spatial and sociodemographic patterns of racialized, class-based, and housing disparities that characterize plumbing poverty. Among unplumbed households, we show that households headed by people of color are almost 35% more likely to lack piped water as compared to white, non-Hispanic households. Precarious housing conditions are an equally strong predictor: Renter-occupied households in the 50 largest US metros were 1.61 times more likely than owner-occupied households to lack piped water. We argue that insecure domestic water access in the United States should be understood as a housing issue that reflects structural inequalities of race and class, particularly in cities with widening wealth gaps. The article concludes with a call for research and action at the intersection of water provision, housing, and social inequality-a paradigm we call the housing-water nexus.

Out of the silos: embedding injury prevention into the Sustainable Development Goals

Globally, unintentional injuries contribute significantly to disability and death. Prevention efforts have traditionally focused on individual injury mechanisms and their specific risk factors, which has resulted in slow progress in reducing the burden. The Sustainable Development Goals (SDGs) represent a global agenda for promoting human prosperity while respecting planetary boundaries. While injury prevention is currently only recognised in the SDG agenda via two road safety targets, the relevance of the SDGs for injury prevention is much broader. In this State of the Art Review, we illustrate how unintentional injury prevention efforts can be advanced substantially within a broad range of SDG goals and advocate for the integration of safety considerations across all sectors and stakeholders. This review uncovers injury prevention opportunities within broader global priorities such as urbanisation, population shifts, water safeguarding and corporate social responsibility. We demonstrate the relevance of injury prevention efforts to the SDG agenda beyond the health goal (SDG 3) and the two specific road safety targets (SDG 3.6 and SDG 11.2), highlighting 13 additional SDGs of relevance. We argue that all involved in injury prevention are at a critical juncture where we can continue with the status quo and expect to see more of the same, or mobilise the global community in an 'Injury Prevention in All Policies' approach.

Water and mental health

There is a well‐established connection among water quality, sanitation, and physical health. The potentially important relationship between water and mental health is considerably less studied. Reviewing evidence from ethnography, geography, folklore, indigenous studies, rural medicine, drought research, and large‐n statistical studies, we argue there is now good theoretical rationale and growing evidence of water insecurity as a possible driver of mental ill‐health. Furthermore, some nascent evidence suggests that emotionally meaningful interactions with water might improve mental health outcomes. Leveraging these literatures, we address the many ways in which mental health outcomes are conceptualized and operationalized in water research, including as emotional distress, perceived stress, depressive symptoms, anxiety symptoms, somatic symptoms, and quality of life. We outline arguments supporting seven possible (and likely interlocking) mechanisms that could explain such a relationship: (a) material deprivation and related uncertainty, (b) shame of social failure, (c) worry about health threats, (d) loss of connections to people and places, (e) frustration around opportunity losses and restricted autonomy, (f) interpersonal conflict and intimate partner violence, and (g) institutional injustice or unfairness. However, we explain that as most existing studies are ethnographic, qualitative, or cross‐sectional, a causal relationship between water and mental ill‐health is yet to be confirmed empirically. More research on this topic is needed, particularly given that poorly understood connections may create barriers to achieving Sustainable Development Goals 3 (health) and 6 (water). We further suggest that tracking mental health indicators may provide unique and as‐yet underappreciated insights into the efficacy of water projects and other development interventions.

This article is categorized under:

Climate Change and Mental Health: Implications for Nurses

Climate change has received public health attention over the past 3 decades. It is well established that climate change is associated with myriad health issues, but less has been mentioned in public health discourse about the impacts of climate change on population mental health. The purpose of the current article is to provide an overview of the impacts of climate change on mental health, and to discuss opportunities for mental health nurses to reduce health problems related to climate change. Acute events and chronic consequences of climate change can impact mental health outcomes and contribute to depressive disorders, anxiety, and trauma-related disorders. The nursing profession must be prepared to address climate change to promote best health outcomes for individuals around the globe. It is critical that mental health nurses act as leaders in understanding and addressing climate change to improve the mental health of populations. [Journal of Psychosocial Nursing and Mental Health Services, 58(9), 25-30.].