Water insecurity in 3 dimensions: an anthropological perspective on water and women's psychosocial distress in Ethiopia

The nexus between household water insecurity, mother's handwashing practices, and diarrheal diseases among under-five children

This study aimed to examine the association between household water insecurity (HWIS), mother's handwashing practices, and childhood diarrhea in the peri-urban and informal settlements of Hosanna town. A community-based cross-sectional study involving 424 mothers was carried out in Hosanna town, and the data were collected using a pretested structured questionnaire, HWISE Scale, and an observational checklist. Bivariate and multivariable logistic regression models were used to analyze the data. The study revealed that the prevalence of HWIS and diarrhea among under-five children was 68.6% and 16%, respectively. Only 42.2% of the mothers had good handwashing practices. Good knowledge of handwashing, positive attitudes toward handwashing, household water security (HWS), and the presence of handwashing facilities were significantly associated with good handwashing practices. Children aged 6-11 months, HWIS, uncovered and wide-mouthed water storage containers, unsafe child's stool disposal practices, and hands not washed with soap after defecation, before preparing food, and feeding a child were significantly associated with the occurrence of diarrhea. The prevalence of diarrhea and HWIS was very high. The majority of the mothers had poor handwashing practices. Therefore, findings suggest interventions to improve HWS and mother's handwashing practices, which could reduce the risk of diarrheal diseases.

Toward a more systematic understanding of water insecurity coping strategies: insights from 11 global sites

INTRODUCTION

Water insecurity-the inability to access and benefit from affordable, reliable and safe water for basic needs-is a considerable global health threat. With the urgent need to target interventions to the most vulnerable, accurate and meaningful measurement is a priority. Households use diverse strategies to cope with water insecurity; however, these have not been systematically characterised nor measured. The Food Insecurity Coping Strategies Index has been insightful for targeting nutrition interventions to the most vulnerable. As a first step towards creating an analogous scale for water, this study characterises the largest empirical data set on water insecurity coping strategies and proposes guidance on measuring it using a novel toolkit.

METHODS

Open-ended responses on water insecurity coping (n=2301) were collected across 11 sites in 10 low- and middle-income countries in the Household Water InSecurity Experiences (HWISE) Scale validation study. Responses were characterised and compared with behaviours identified in the literature to construct an instrument to systematically assess coping.

RESULTS

We identified 19 distinct strategies that households used when experiencing water insecurity. These findings, paired with prior literature, were used to develop a Water Insecurity Coping Strategies Assessment Toolkit with guidance on its piloting to assess coping prevalence, frequency and severity.

CONCLUSIONS

The widespread occurrence of water insecurity coping strategies underscores the importance of understanding their prevalence and severity. The Water Insecurity Coping Strategies Assessment Toolkit offers a comprehensive approach to evaluate these strategies and inform the design and monitoring of interventions targeting those most vulnerable to water insecurity.

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.

Water insecurity is associated with gender-based violence: A mixed-methods study in Indonesia

Gender Based Violence (GBV) is a global pandemic and water insecurity is increasing in intensity and extent. This study explores the association between these two global health threats. Cross-sectional, quantitative data were collected via surveys (n = 365 adult women) to measure household water insecurity (HWI) and women's experiences of GBV in the last year. Qualitative data were collected from semi-structured interviews (n = 24 men and women), two focus group discussions (n = 25 men and women) and a multi-stakeholder meeting (n = 35 men and women) to explore experiences, attitudes and risk factors associated with HWI and GBV. Multivariate logistic regression analysis showed that women in water insecure households were more than twice as likely to report experiencing GBV in the last year (OR = 2.2, CI: 1.0-4.9, p = 0.051). Examining household water insecurity scores as a continuous variable revealed an increased odds of reporting GBV with each increase in the HWISE score (OR = 1.1, CI: 1.0; 1.1, p < 0.001). Qualitative data indicates that the intersection between HWI, a patriarchal social organization and a caste system produced water-related conflicts between intimate partners, between daughters-in-law and their in-laws, and between masters and enslaved women. These results are presented using an integrated theoretical framework - a Feminist Political Ecology of Health (FPEH) - to illustrate the many ways women encounter and experience multi-dimensional forms of violence across scales in connection to water insecurity. The combination of robust qualitative and quantitative data presented in this study suggests that HWI may be causally related to GBV in this context.

WaSH insecurity and anxiety among people who inject drugs in the Tijuana-San Diego border region

BACKGROUND

Water, sanitation, and hygiene (WaSH) insecurity increases the risk of water-related diseases. However, limited research has been conducted on psychosocial distress as it relates to WaSH insecurity, especially among people who inject drugs (PWID). We examined the relationship between WaSH insecurity and related anxiety among PWID living in different housing conditions along the US-Mexico border region.

METHODS

From 2020-2021, a cross-sectional study was conducted among 585 people who injected drugs within the last month in Tijuana (N = 202), San Diego (N = 182), and in both Tijuana and San Diego (N = 201). Participants underwent interviewer-administered surveys related to WaSH access, substance use, and generalized anxiety disorder (GAD-7). Quasi-Poisson regressions were used to assess associations between WaSH insecurity and anxiety in the prior 6-months.

RESULTS

Participants were 75% male, 42% were unhoused and 91% experienced WaSH insecurity in the prior 6-months. After adjusting for housing status, gender, and age, lack of access to basic drinking water (Adj RR: 1.28; 95% CI: 1.02-1.58), sanitation (Adj RR:1.28; 95% CI: 1.07-1.55), and a daily bath/shower (Adj RR: 1.38; 95% CI: 1.15-1.66) were associated with mild-severe anxiety. The number of WaSH insecurities was independently associated with a 20% increased risk of experiencing anxiety per every additional insecurity experienced (Adj RR: 1.20; CI: 1.12-1.27). We also found a significant interaction between gender and housing status (p = 0.003), indicating that among people experiencing sheltered/unsheltered homelessness, women had a higher risk of mild-severe anxiety compared to men (Adj RR: 1.55; 95% CI: 1.27-1.89). At the same time, among women, those who are unhoused have 37% increased risk of anxiety than those who live in stable housing conditions (Adj RR: 1.37; 95% CI: 1.01-1.89).

CONCLUSION

The lack of specific WaSH services, particularly lack of drinking water, toilets, and daily showers were associated with higher levels of anxiety among PWID in the Tijuana-San Diego border region. Women experiencing homelessness were especially vulnerable. WaSH interventions that provide safe, 24-h access may help to reduce anxiety and health risks associated with WaSH insecurity.

Barriers to appropriate complementary feeding and the use of ultra-processed foods: A formative qualitative study from rural Oromia, Ethiopia

Children's consumption of ultra-processed foods (UPF) is increasing in Ethiopia, but relatively little is known about the specific feeding practices that underlie this pattern. The objective of this study was to explore patterns of consumption of UPF by infants and young children within a broader context of inappropriate complementary feeding practices in extremely poor households in rural Oromia, Eastern Ethiopia. A formative qualitative study was conducted using semistructured interview questionnaires developed drawing on a socioecological model. A total of 16 focus group discussions with mothers (45 respondents), fathers (21 respondents) and grandmothers (23 respondents) of children aged 6-23 months in households that were beneficiaries of the Productive Safety Net Program were conducted, along with four key informant interviews with health workers. Qualitative transcripts were complemented with field notes before qualitative content analysis was applied. The key findings suggest that UPF were widely provided to infants and young children as part of a pattern of suboptimal complementary feeding, including both early and late initiation of complementary foods. In particular, UPF (including juice, biscuits and lipid-based nutrient supplements) were diluted with or dissolved in water and fed to infants via bottle, often before the recommended age of initiation of 6 months. Mothers and caregivers reported that they perceived the products to be affordably priced and packaged, ready to use and convenient given their time constraints. The level of consumption of UPF and its effects on infant and young child feeding feeding practices and children's nutritional status in rural Ethiopia should be further explored.

Making waves: Mental health impacts of inadequate drinking water services - From sidenote to research focus

The paramount significance of the harmful impacts of poor drinking water services on physical health have been recognized for decades. Besides, over the past twenty years, an additional body of literature on their negative mental health impacts has emerged. With this brief review, we summarise the findings of the scholarship to advance addressing overall health (physical, mental, and social) in the water sector. We furthermore review the key policy documents of this field with a focus on mental health aspects and give recommendations for practitioners and decision-makers on addressing mental health in water service delivery. We reviewed the existing published works (42) assessing psychological impacts of deficient drinking water services in low-income settings. We then identified and compared the different mechanisms causing negative mental health outcomes described in them. For these purposes, we used a water insecurity experience -model and the vulnerability-stress model of clinical psychology. Next, we probed key international and national guiding documents of the water sector to analyse how mental health issues resulting from poor services are addressed today. We found that according to the literature, poor quality and quantity of water was predictably one of the most important psychosocial stressors to users. Surprisingly, however, various kinds of water-service-related inequalities (e.g. between genders, communities or socio-economic groups) showed up as equally significant stressors. Our analysis with the vulnerability-stress model furthermore indicates that insufficient drinking water services may predispose to common mental disorders particularly through external stress. Existing field guidelines have evolved to highlight the values of non-discrimination and participation, whilst mental health aspects remain ignored. This should not be the case. Therefore, practices for addressing mental health effectively in documentation and water service development should be further researched. But already in the light of the existing literature, we urge stakeholders to focus more on the negative mental health impacts of unequal service provision for users and nearby people left without improved services.

Water Insecurity and Maternal Health Among Haudenosaunee Women in Canada

Water is central to Haudenosaunee knowledge, philosophy, and culture. The health of Haudenosaunee mothers is tied to that of water. Today, the lack of access to reliable drinking water for Six Nations is a significant health concern. Technical measurement of water advisories in Canada fails to understand the interwoven relationship that Haudenosaunee women have with water. Highlighting the voices of 55 Haudenosaunee women, we provide expanded definitions of water insecurity and maternal health to include more-than-human beings. This comprehensive understanding of water insecurity and health shapes SN mothers' experiences with water in a settler colonial state, affecting their holistic wellbeing.

Evidence on the links between water insecurity, inadequate sanitation and mental health: A systematic review and meta-analysis

BACKGROUND

Water insecurity and inadequate sanitation have adverse impacts on the mental health of individuals.

OBJECTIVE

To review and synthesize evidence on the relationship between water insecurity, inadequate sanitation, and mental health globally.

DATA SOURCES

Relevant studies were identified by searching PubMed, PsycINFO, and EMBASE databases from inception up to March 2023.

STUDY ELIGIBILITY CRITERIA

Only quantitative studies were included. The exposure was water insecurity and or inadequate sanitation. The outcome was common mental disorders (CMD: depression or anxiety), mental distress, mental health or well-being. There was no restriction on geographical location.

PARTICIPANTS

General population or people attending health facilities or other services.

EXPOSURE

Water insecurity and/ or inadequate sanitation.

RISK OF BIAS

The effective Public Health Practice Project (EPHPP) assessment tool was used to assess quality of selected studies.

SYNTHESIS OF RESULTS

A meta-analysis was conducted using a random effects statistical model.

RESULTS

Twenty-five studies were included, with 23,103 participants from 16 countries in three continents: Africa (Kenya, Ethiopia, Ghana, Uganda, South Africa, Malawi, Mozambique, and Lesotho), Asia (Nepal, Bangladesh, India, and Iran) and the Americas (Brazil, Haiti, Bolivia and Vietnam). There was a statistically significant association between water insecurity and CMD symptoms. Nine studies reported a continuous outcome (5,248 participants): overall standardized mean difference (SMD = 1.38; 95% CI = 0.88, 1.87). Five studies reported a binary outcome (5,776 participants): odds ratio 5.03; 95% CI = 2.26, 11.18. There was a statistically significant association between inadequate sanitation and CMD symptoms (7415 participants), overall SMD = 5.36; 95% CI = 2.51, 8.20.

LIMITATIONS

Most of the included studies were cross-sectional which were unable to examine temporal relationships.

CONCLUSIONS

Water insecurity and inadequate sanitation contribute to poorer mental health globally.

IMPLICATIONS OF KEY FINDINGS

Interventions to provide basic water, sanitation and psychosocial support, could substantially contribute to reducing the burden of CMD alongside other health and social benefits.

TRIAL REGISTRATION

PROSPERO registration number: CRD42022322528.

Frontiers of household water insecurity metrics: severity, adaptation and resilience

The measurement of household-level and individual-level water insecurity has accelerated over the past 5 years through innovation and dissemination of new survey-based experiential psychometric scales modelled after food insecurity scales. These measures offer needed insight into the relative frequency of various dimensions of water problems experienced by households or individuals. But they currently tell us nothing about the severity of these experiences, mitigating behaviours (ie, adaptation) or the effectiveness of water-related behaviours (ie, resilience). Given the magnitude of the global challenge to provide water security for all, we propose a low-cost, theoretically grounded modification to common water insecurity metrics in order to capture information about severity, adaptation and resilience. We also discuss ongoing challenges in cost-effective measurement related to multidimensionality, water affordability and perception of water quality for maximising the impact and sustainability of water supply interventions. The next generation of water insecurity metrics promises better monitoring and evaluation tools-particularly in the context of rapid global environmental change-once scale reliability across diverse contexts is better characterised.

Measurement in the study of human exposure to animal feces: A systematic review and audit

BACKGROUND

Human exposure to animal feces is increasingly recognized as an important transmission route of enteric pathogens. Yet, there are no consistent or standardized approaches to measurement of this exposure, limiting assessment of the human health effects and scope of the issue.

OBJECTIVE

To inform and improve approaches to the measurement of human exposure to animal feces, we audited existing measurement in low- and middle-income countries.

METHODS

We systematically searched peer-reviewed and gray literature databases for studies with quantitative measures of human exposure to animal feces and we classified measures in two ways. First, using a novel conceptual model, we categorized measures into three 'Exposure Components' identified a priori (i.e., Animal, Environmental, Human Behavioral); one additional Component (Evidence of Exposure) inductively emerged. Second, using the exposure science conceptual framework, we determined where measures fell along the source-to-outcome continuum.

RESULTS

We identified 1,428 measures across 184 included studies. Although studies overwhelmingly included more than one single-item measure, the majority only captured one Exposure Component. For example, many studies used several single-item measures to capture the same attribute for different animals, all of which were classified as the same Component. Most measures captured information about the source (e.g. animal presence) and contaminant (e.g. animal-sourced pathogens), which are most distal from exposure on the source-to-outcome continuum.

DISCUSSION

We found that measurement of human exposure to animal feces is diverse and largely distal from exposure. To facilitate better assessment of the human health effects of exposure and scope of the issue, rigorous and consistent measures are needed. We recommend a list of key factors from the Animal, Environmental, and Human Behavioral Exposure Components to measure. We also propose using the exposure science conceptual framework to identify proximal measurement approaches.

A bibliometric analysis of global research on drinking water and health in low- and lower-middle-income countries

Heightened interest in drinking water research in recent decades has been aimed at narrowing the knowledge gaps surrounding water and health in a global pursuit to provide safely managed drinking water services to populations who continue to lack access. This study used bibliometrics and network analysis to produce a global overview of publications and groups that have contributed to research on drinking water and health in low- and lower-middle-income countries (LLMICs). The United States and the United Kingdom, which have historically dominated the field based on the production and impact of scientific literature, remain at the center of international collaborative research partnerships with emerging countries. However, in recent years, the volume of publications produced by India has surpassed that of the United States while Bangladesh is ranked third for the strongest international collaborations. Iran and Pakistan are also emerging as major producers of research, yet publications out of these countries and India remain disproportionately restricted behind paywalls. Contamination, diarrheal disease, and water resources are the themes that characterize the majority of research on water and health. These findings may be used to accelerate equitable, inclusive research in the realm of water and health, thereby enabling gaps in global drinking water inequalities to be filled.

Systematic mapping of gender equality and social inclusion in WASH interventions: knowledge clusters and gaps

INTRODUCTION

Poor access to water, sanitation and hygiene (WASH) services threatens population health and contributes to gender and social inequalities, especially in low-resource settings. Despite awareness in the WASH sector of the importance of promoting gender equality and social inclusion (GESI) to address these inequalities, evaluations of interventions focus largely on health outcomes, while gender equality and other social outcomes are rarely included. This review aimed to collate and describe available research evidence of GESI outcomes evaluated in WASH intervention studies.

METHODS

We applied a systematic mapping methodology and searched for both academic and grey literature published between 2010 and 2020 in 16 bibliographic databases and 53 specialist websites. Eligibility screening (with consistency checking) was conducted according to predetermined criteria, followed by metadata coding and narrative synthesis.

RESULTS

Our evidence base comprises 463 intervention studies. Only 42% of studies measured transformative GESI outcomes of WASH interventions, referring to those that seek to transform gender relations and power imbalances to promote equality. A majority of studies disaggregated outcome data by sex, but other forms of data disaggregation were limited. Most included studies (78%) lacked a specific GESI mainstreaming component in their intervention design. Of the interventions with GESI mainstreaming, the majority targeted women and girls, with very few focused on other social groups or intersectional considerations.

CONCLUSION

The review points to various areas for future primary and secondary research. Given the potential contribution of WASH to GESI, GESI considerations should be incorporated into the evaluation of WASH interventions. Regular collection of data and monitoring of GESI outcomes is needed as well as developing new and testing existing methods for monitoring and evaluation of such data.

Drinking water and the implications for gender equity and empowerment: A systematic review of qualitative and quantitative evidence

BACKGROUND

Safe drinking water is a fundamental human right, yet more than 785 million people do not have access to it. The burden of water management disproportionately falls on women and young girls, and they suffer the health, psychosocial, political, educational, and economic effects. While water conditions and disease outcomes have been widely studied, few studies have summarized the research on drinking water and implications for gender equity and empowerment (GEE).

METHODS

A systematic review of primary literature published between 1980 and 2019 was conducted on drinking water exposures and management and the implications for GEE. Ten databases were utilized (EMBASE, PubMed, Web of Science, Cochrane, ProQuest, Campbell, the British Library for Development Studies, SSRN, 3ie International Initiative for Impact Evaluation, and clinicaltrials.gov). Drinking water studies with an all-female cohort or disaggregated findings according to gender were included.

RESULTS

A total of 1280 studies were included. GEE outcomes were summarized in five areas: health, psychosocial stress, political power and decision-making, social-educational conditions, and economic and time-use conditions. Water quality exposures and implications for women's health dominated the literature reviewed. Women experienced higher rates of bladder cancer when exposed to arsenic, trihalomethanes, and chlorine in drinking water and higher rates of breast cancer due to arsenic, trichloroethylene, and disinfection byproducts in drinking water, compared to men. Women that were exposed to arsenic experienced higher incidence rates of anemia and adverse pregnancy outcomes compared to those that were not exposed. Water-related skin diseases were associated with increased levels of psychosocial stress and social ostracization among women. Women had fewer decision-making responsibilities, economic independence, and employment opportunities around water compared to men.

CONCLUSION

This systematic review confirms the interconnected nature of gender and WaSH outcomes. With growing attention directed towards gender equity and empowerment within WaSH, this analysis provides key insights to inform future research and policy.

Water insecurity, self-reported physical health, and objective measures of biological health in the Peruvian Amazon

OBJECTIVES

This study examines the associations between water insecurity, self-reported physical health, and objective measures of biological health among 225 Awajún adults (107 women; 118 men) living in the Peruvian Amazon, a "water-abundant" region.

METHODS

A survey, which included multiple measures of self-reported physical health, and objective measures of biological health such as blood pressure and nutritional and immune biomarkers.

RESULTS

Greater water insecurity was associated with multiple measures of self-reported physical health, including higher incidence of reported diarrhea, nausea, back pain, headaches, chest pain, fatigue, dizziness, overall poor perceived health, and "being sick." These symptoms align with the physical strain associated with water acquisition and with drinking contaminated water. A significant association between higher water insecurity and lower systolic blood pressure emerged, which may be linked to dehydration. None of the other biomarkers, including those for nutrition, infection, and stress were significantly associated with water insecurity scores.

CONCLUSIONS

These analyses add to the growing body of research examining the associations between water insecurity and health. Biocultural anthropologists are well-positioned to continue probing these connections. Future research will investigate relationships between measures of water insecurity and biomarkers for gastrointestinal infection and inflammation in water-scarce and water-abundant contexts.

Using water-adjusted person years to quantify the value of being water secure for an individual's quality of life

Domestic water insecurity harms quality of life outcomes beyond health, for example in worry about water availability or anger at disrupted plans. However, these outcomes are excluded from cost-benefit analyses of water supply interventions, which typically measure and value only prevented disease and time savings. In this paper, I propose a means of quantifying the value of being water secure for an individual's quality of life, the water-adjusted person year (WAPY). One WAPY represents a year lived in complete water security. It is inspired by the quality-adjusted life year in health economics, which combines time with a health-related quality of life index. The WAPY combines time using water services with a water-related quality of life (WaterQoL) index, where 0 = completely water insecure and 1 = completely water secure. The index could be derived from an existing four-attribute Water Insecurity Experiences scale, which includes questions such as "how often did you worry that you would not have enough water for all of your needs?". Other questions concern drinking water, disrupted plans, and handwashing. Responses can be combined in a weighted index based on the relative importance of the four attributes to people. If someone has a WaterQoL index of 0.6, over a 10 year period they would have 6 WAPYs. If a water supply intervention raised WaterQoL to 0.8, they would gain 2 WAPYs over 10 years. The monetary value of WAPYs gained (e.g. in US$) could be estimated by willingness to pay and included in a cost-benefit analysis. Some interventions might result in greater WaterQoL gains than others, or longer-lasting services. Incorporating WAPYs in cost-benefit analyses, alongside prevented disease and time savings, could help identify interventions which provide better water services to more people within a given budget.

Multiple aspects of energy poverty are associated with lower mental health-related quality of life: A modelling study in three peri-urban African communities

Objective

Over 900 million people in sub-Saharan Africa (SSA) live in energy poverty, relying on cooking polluting fuels (e.g. wood, charcoal). The association between energy poverty and mental/physical health-related quality of life (HRQoL) among women in SSA, who are primarily tasked with cooking, is unknown.

Methods

Females (n ​= ​1,150) from peri-urban Cameroon, Kenya and Ghana were surveyed on their household energy use and mental/physical health status using the standardized Short-Form 36 (SF-36) questionnaire. Random effects linear regression linked household energy factors to SF-36 mental (MCS) and physical component summary (PCS) scores. A binary outcome of 'likely depression' was derived based on participants' MCS score. Random effects Poisson regression with robust error variance assessed the relationship between household energy factors and odds of likely depression.

Results

The prevalence of likely depression varied by a factor of four among communities (36%-Mbalmayo, Cameroon; 20%-Eldoret, Kenya; 9%-Obuasi, Ghana). In the Poisson model (coefficient of determination (R²) ​= ​0.28), females sustaining 2 or more cooking-related burns during the previous year had 2.7 (95%CI:[1.8,4.1]) times the odds of likely depression as those not burned. Females cooking primarily with charcoal and wood had 1.6 times (95%CI:[0.9,2.7]) and 1.5 times (95%CI:[0.8,3.0]) the odds of likely depression, respectively, as those primarily using liquefied petroleum gas. Women without electricity access had 1.4 (95%CI:[1.1,1.9]) times the odds of likely depression as those with access. In the MCS model (R² ​= ​0.23), longer time spent cooking was associated with a lower average MCS score in a monotonically increasing manner. In the PCS model (R² ​= ​0.32), women injured during cooking fuel collection had significantly lower (-4.8 95%CI:[-8.1,-1.4]) PCS scores.

Conclusion

The burden of energy poverty in peri-urban communities in SSA extends beyond physical conditions. Experiencing cooking-related burns, using polluting fuels for cooking or lighting and spending more time cooking are potential risk factors for lower mental HRQoL among women.

Water Insecurity, Water Borrowing, and Psychosocial Stress Among Daasanach Pastoralists in Northern Kenya

This article quantifies Daasanach water insecurity experiences in Northern Kenya, examines how water insecurity is associated with water borrowing and psychosocial stress, and evaluates if water borrowing mitigates the stress from water insecurity. Of 133 households interviewed in 7 communities, 94% were water insecure and 74.4% borrowed water three or more times in the prior month. Regression analyses demonstrate water borrowing frequency moderates the relationship between water insecurity and psychosocial stress. Only those who rarely or never borrowed water reported greater stress with higher water insecurity. The coping mechanism of water borrowing may help blunt water insecurity-related stress.

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.

Health impacts of water and sanitation insecurity in the Global North: a scoping literature review for U.S. colonias on the Mexico border

U.S. border colonias are peri-urban settlements along the U.S.-Mexico border. Residents often face substandard housing, inadequate septic and sewer systems, and unsafe or inadequate household water. As of 2015, an estimated 30% of over 5 million U.S. colonia residents lacked access to clean drinking water, suggesting health complications. This scoping review identifies a very limited existing set of research on water and sanitation insecurity in U.S.-Mexico border colonias, and suggests value in additional focused research in this specific context to address health challenges. Preliminary health data indicates that due to water insecurity, colonia residents are more likely to contract gastrointestinal diseases, be exposed to carcinogenic compounds from contaminated water, and experience psychosocial distress. These widespread health issues in colonias are exacerbated by historical and ongoing socioenvironmental injustices in the U.S.-Mexico border region and their relation to the poor health outcomes.

Water Sharing Is a Distressing Form of Reciprocity: Shame, Upset, Anger, and Conflict Over Water in Twenty Cross-Cultural Sites

Anthropological theories of reciprocity suggest it enhances prestige, social solidarity, and material security. Yet, some ethnographic cases suggest that water sharing-a form of reciprocity newly gaining scholarly attention-might work in the opposite way, increasing conflict and emotional distress. Using cross-cultural survey data from twenty global sites (n=4,267), we test how household water reciprocity (giving and receiving) is associated with negative emotional and social outcomes. Participation in water sharing as both givers and receivers is consistently associated with greater odds of reporting shame, upset, and conflict over water. Water sharing experiences in a large, diverse sample confirm a lack of alignment with predictions of classic reciprocity theories. Recent ethnographic research on reciprocity in contexts of deepening contemporary poverty will allow development of ethnographically informed theories to better explain negative experiences tied to water reciprocity.

Household water and food insecurity negatively impacts self-reported physical and mental health in the Vietnamese Mekong Delta

Introduction

Household food insecurity and inadequate water, sanitation, and hygiene (WASH) contribute to ill health. However, the interactions between household food insecurity, WASH and health have been rarely assessed concurrently. This study investigated compounded impacts of household food insecurity and WASH on self-reported physical and mental health of adults in the Vietnamese Mekong Delta.

Materials and methods

This cross-sectional survey interviewed 552 households in one northern and one southern province of the Vietnamese Mekong Delta. The survey incorporated previously validated tools such as the Short Form 12-item Health Survey, Household Food Insecurity Assessment Scale, and the Access and Behavioural Outcome Indicators for Water, Sanitation, and Hygiene. Physical and mental health were quantified using the physical health composite score (PCS) and mental health composite score (MCS), respectively. These measures were the dependent variables of interest for this study.

Results

Statistical analysis revealed that household food insecurity and using <50 litres of water per person per day (pppd) were independently associated with lower PCS (p<0.05), after adjusting for socio-economic confounders. Household food insecurity and lack of food availability, using <50 litres of water pppd, and the use of untreated drinking water were associated with lower MCS (p<0.05), with water usage being an effect modifier of the relationship between household food insecurity and MCS. The results indicate that being food insecure and having limited potable quality water had a compounding effect on MCS, compared to being individually either food insecure or having limited water.

Conclusion

This study is one of only a few that have established a link between potable water availability, food insecurity and poorer physical and mental health. The results also indicate a need to validate national data with fine-scale investigations in less populous regions to evaluate national initiatives with local populations that may be at higher risk. Adopting joint dual-action policies for interventions that simultaneously address water and food insecurity should result in larger improvements in health, particularly mental health, compared to targeting either food or water insecurity in isolation.

Experiences of inequalities in access to safe water and psycho-emotional distress in Ghana

Research suggests that experiences of water insecurity may negatively impact the psycho-emotional wellbeing of water-insecure households. This paper examines how perceived inequalities in water access mediate the relationship between water insecurity and psycho-emotional distress. Data were collected among 1192 men and women in Ghana who are active water collectors within their households. We employed a binary logistics regression to identify the determinants of psycho-emotional distress. Sobel test was used to test the indirect effect of water insecurity and psycho-emotional distress through perceived inequalities. The results show that wealth (OR = 6.6, CI = 2.784-14.076), number of people in a household (OR = 1.07, CI = 1.002-1.145) and perceived inequalities (OR = 4.6, CI = 2.737-7.907) are significant predictors of psycho-emotional distress. Sobel test indicated that the point estimate (PE) of the indirect effect between water insecurity and psycho-emotional distress through perceived inequality is -0.136 (p = 0.000), meaning households were less likely to experience psycho-emotional distress if they felt that safe water facilities were equally distributed. The findings suggest that the distribution of water resources in cities with water challenges, no matter how scarce those resources are, has a profound effect on psycho-emotional distress. In resources constrained cities, there is a need for holistic water-related interventions that make inclusivity and fairness their primary focus.

The syndemic effects of food insecurity, water insecurity, and HIV on depressive symptomatology among Kenyan women

Depression is a leading cause of disability worldwide and a major contributor to the overall global burden of disease, especially for women of childbearing age. Social science scholarship has demonstrated significant relationships between mental health, food insecurity (FI), water insecurity (WI), and HIV. Little is known, however, about the temporal relationships between food and water insecurity or the mechanisms through which these multiple stressors may operate or interact to impact depression. We therefore used syndemic theory to explore the complex relationships between FI, WI, and HIV on depressive symptomatology among Kenyan women of mixed HIV status (n=183, NCT02979418). We sought to 1) understand the temporal relationships between time-variant risk factors for depression, i.e. FI and WI, and 2) assess how these factors potentially interacted with HIV to impact depressive symptomatology. We first assessed the bidirectional relationship between WI and FI using a cross-lagged three-wave, two-variable panel model. Next, we modeled depressive symptomatology at 21 months as a linear function of the potentially syndemic interaction between FI, WI, and HIV status, adjusting for household wealth. WI had a predominant predictive effect on FI (Bayesian posterior predictive p-value=0.13); there was no reverse causality for the influence of FI on WI. The interaction effect of FI, WI, and HIV was significantly associated with greater depressive symptomatology (β=0.06) at 21 months postpartum. These data suggest that water insecurity may be an important determinant of food insecurity. Further, the co-occurrence of FI, WI, and HIV increases the likelihood of maternal depressive symptomatology, i.e. there is a syndemic relationship. These findings suggest that the role of household WI in other adverse health outcomes beyond mental well-being should be examined, and that interventions to improve mental health will be more effective if they also consider concurrent resource insecurities, regardless of HIV status.

The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial

Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

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.

A Qualitative Exploration in Causes of Water Insecurity Experiences, and Gender and Nutritional Consequences in South-Punjab, Pakistan

Although water insecurity has been discussed in general, its impacts on mothers’ physical and mental health, and infants’ and young children’s feeding (IYCF), has largely been ignored. This study explores household water insecurity experiences and their association with optimal health and nutrition of women and children in the Rajanpur district of Punjab Province. Using focus group discussions (FGDs) and key informants (KIIs) interviews from an area with high maternal-child malnutrition prevalence, a qualitative study was conducted to describe local experiences of water acquirement and arrangement, and of the consequences of water insecurity. The findings highlight that rural Western marginalized populations of the Rajanpur district rely on brackish, canal, or flood surface water as the water supply is absent, which intensifies mothers’ work burden and stress, and often makes them victims of violence, stigma, and sickness. Water fetching impacts women in unforeseen ways, impacting the psychosocial and physical health of mothers engaged in maternal breastfeeding. Water insecurity, originally rooted in regional disparities, compounds with gender inequities, which leads to maternal stress and child sickness. Justice in water resources is imperative and urgent in the deprived South of Punjab province for improving public health nutrition.

Diverse Health, Gender and Economic Impacts from Domestic Transport of Water and Solid Fuel: A Systematic Review

(1) Background: Water and solid fuel collection and transport are domestic duties for millions of households across the globe. People in areas with limited or no access to safely managed sources of water and household energy must fetch these resources on a frequent basis. The health, gender, and economic impacts associated with water and solid fuel collection labor have not been systematically reviewed. (2) Methods: Studies were identified through database searches and included using a list of inclusion and exclusion criteria. Studies were summarized and grouped into one of eight thematic categories. (4) Conclusions: The findings suggest that a diverse and heavy health burden is associated with water and solid fuel collection and transport. The literature also suggests that the provision of safely managed and accessible water and improved fuel options can mitigate these negative outcomes. Filling research gaps and utilizing results to guide policy and funding would likely be an effective way to ensure low- and middle-income countries are not left behind as the world strives to meet the sustainable development goals.

Towards an integrated theoretical framework for understanding water insecurity and gender-based violence in Low-and middle-income countries (LMICs)

Disparities in access to basic needs and resources such as water is largely borne out of power imbalance across scale. In examining these power dynamics in the context of health inequalities, scholars have deployed Feminist political ecology analytical framework to situate gender and other forms of vulnerability as emerging from unequal power relations, and political ecology of health to emphasise the health implications of inherent relational power in the distribution of resources. Although appealing, the two theoretical frameworks over time have proven to be limiting in the study of intersectional vulnerabilities such as gender-based violence and water insecurity which reflect multiple dimensions of unequal power structures. This study expands the theoretical space for the study of inequalities in health geography by demonstrating the utility of incorporating feminist political ecology with political ecology of health to form an integrated theoretical framework - Feminist Political Ecology of Health (FPEH). This proposed theoretical framework gives guidance for engaging with a suite of questions and methods related to multifaceted problems such as water insecurity and gender based-violence. The paper highlights these theoretical issues and then discusses how FPEH can enrich research on water security and gender-based violence in Low-and middle-income countries (LMICs).

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.

Re-examining the effects of drought on intimate-partner violence

Droughts are associated with several societal ills, especially in developing economies that rely on rainfed agriculture. Recently, researchers have begun to examine the effect of droughts on the risk of Intimate-Partner Violence (IPV), but so far this work has led to inconclusive results. For example, two large recent studies analyzed comparable data from multiple sub-Saharan African countries and drew opposite conclusions. We attempt to resolve this apparent paradox by replicating previous analyses with the largest data set yet assembled to study drought and IPV. Integrating the methods of previous studies and taking particular care to control for spatial autocorrelation, we find little association between drought and most forms of IPV, although we do find evidence of associations between drought and women's partners exhibiting controlling behaviors. Moreover, we do not find significant heterogeneous effects based on wealth, employment, household drinking water sources, or urban-rural locality.

Development of water insecurity scale for rural households in Cameroon- Central Africa

Background: Water represents the core of food-energy nexus and is vital for human survival. In developing countries, contaminated water and lack of basic water services undermine efforts to improve nutritional status and related health issues. In the rural areas of Central Africa, a majority of the population lacks access to improved water sources and has to devote considerable efforts to obtain water.

Objectives: Using the following definition of water insecurity, i.e. it exists when access to adequate amount of safe and clean water does not occur all the times for the entirety of household members to lead a healthy and active life, the study aimed to develop and test a household-level experiential water insecurity scale for rural households in Central Africa.

Methods: The research was conducted in three phases: 1) the formative data collection; 2) the scale development; and, 3) the scale testing. In the third Phase, the scale was tested with 250 women who were water managing person of their households. Statistical analysis included items reduction, reliability, as well as criterion and construct validity assessment. The testing led to a final scale of 17 statements (WATINE-17), covering three domains of water insecurity: 1) psychosocial distress; 2) quantity; 3) quality of water.

Results: The scale showed an excellent reliability (Cronbach’s alpha = 0.92) and was significantly associated with lower frequency of water intake among women (p = 0.007, concurrent validity). In assessing WATINE-17’s predictive validity, it was found that water insecurity was positively related to food insecurity (p < 0.001) and the level of water insecurity was the highest among severely food insecure households [F (3, 246) = 22.469, p < 0.001].

Conclusion: The WATINE-17 is able to capture key elements of water insecurity and can be used to monitor and evaluate SDG# 6 and water-related programs, such as WASH, in Central Africa.

Water fetching burden: a qualitative study to examine how it differs by gender among rural households in the west region of Cameroon

Women act as gatekeepers in securing water for their households. Using this qualitative methodology, 35 participants were interviewed with the objectives to determine roles and responsibilities of different family members in fetching and managing water and examine differences in perceptions related to water access/use between men and women in households from rural areas of the Menoua Division, West Cameroon. We found that the household structure was key component in each family member's degree of involvement in water fetching and management. A significant gender gap was found among adults with fewer men than women experiencing coping strategies-related to water scarcity. Hence, women participation in designing water and food security initiatives is warranted.

Food Insecurity and Water Insecurity in Rural Zimbabwe: Development of Multidimensional Household Measures

Background: With millions of people experiencing malnutrition and inadequate water access, FI and WI remain topics of vital importance to global health. Existing unidimensional FI and WI metrics do not all capture similar multidimensional aspects, thus restricting our ability to assess and address food- and water-related issues. Methods: Using the Sanitation, Hygiene and Infant Nutrition Efficacy (SHINE) trial data, our study conceptualizes household FI (N = 3551) and WI (N = 3311) separately in a way that captures their key dimensions. We developed measures of FI and WI for rural Zimbabwean households based on multiple correspondence analysis (MCA) for categorical data. Results: Three FI dimensions were retained: 'poor food access', 'household shocks' and 'low food quality and availability', as were three WI dimensions: 'poor water access', 'poor water quality', and 'low water reliability'. Internal validity of the multidimensional models was assessed using confirmatory factor analysis (CFA) with test samples at baseline and 18 months. The dimension scores were associated with a group of exogenous variables (SES, HIV-status, season, depression, perceived health, food aid, water collection), additionally indicating predictive, convergent and discriminant validities. Conclusions: FI and WI dimensions are sufficiently distinct to be characterized via separate indicators. These indicators are critical for identifying specific problematic insecurity aspects and for finding new targets to improve health and nutrition interventions.

Household Water and Food Insecurity Are Positively Associated with Poor Mental and Physical Health among Adults Living with HIV in Western Kenya

BACKGROUND

Household food insecurity (FI) and water insecurity (WI) are prevalent public health issues that can co-occur. Few studies have concurrently assessed their associations with health outcomes, particularly among people living with HIV.

OBJECTIVES

We aimed to investigate the associations between FI and WI and how they relate to physical and mental health.

METHODS

Food-insecure adult smallholder farmers living with HIV in western Kenya were recruited to participate in a cluster-randomized controlled trial of a multisectoral agricultural and asset loan intervention. We used baseline data on experiences of FI (using the Household Food Insecurity Access Scale, range: 0-27) and WI (using a modified scale developed for this region, range: 0-51) in the prior month (n = 716). Outcomes included probable depression (using the Hopkins Symptom Checklist), fatigue and diarrhea in the prior month, and overall mental and physical health (using the Medical Outcomes Study HIV Health Survey, range: 0-100). We first assessed Pearson correlations between FI, WI, and sociodemographic characteristics. We then developed 3 regressions for each health outcome (control variables and FI; control variables and WI; control variables, FI, and WI) and compared model fit indexes.

RESULTS

Correlations between household FI, WI, and wealth were low, meaning they measure distinct constructs. FI and WI were associated with numerous physical and mental health outcomes; accounting for both resource insecurities typically provided the best model fit. For instance, when controlling for FI, each 10-point higher WI score was associated with a 6.42-point lower physical health score (P < 0.001) and 2.92 times greater odds of probable depression (P < 0.001).

CONCLUSIONS

Assessing both FI and WI is important for correctly estimating their relation with health outcomes. Interventions that address food- and water-related issues among persons living with HIV concurrently will likely be more effective at improving health than those addressing a single resource insecurity. This trial was registered at clinicaltrials.gov as NCT02815579.

Global Water, Sanitation, and Hygiene Approaches: Anthropological Contributions and Future Directions for Engineering

Anthropologists contribute key insights toward a comprehensive understanding of water, sanitation, and hygiene (WASH) as a multidimensional, multiscalar, and culturally embedded phenomenon. Yet, these insights have yet to be sufficiently operationalized and implemented in WASH development and wider WASH access-related paradigms. Ensuring WASH security requires a comprehensive approach to identifying both human health risk and environmental impact of WASH-related programs and strategies. It requires an understanding of how sanitation is integrated into households and communities and how individuals within particular cultural contexts practice sanitation and hygiene. This work facilitates that goal by outlining the major contributions of anthropology and allied social sciences to WASH, as well as outlining key considerations for future work and collaboration. We identify six major themes that, if applied in future engineering approaches, will more equitably integrate stakeholders and multiple vantage points in the successful implementation of WASH projects for marginalized and diverse groups. These include a critical understanding of previous approaches, culturally aware interventions, capacity building that considers (un)intended impact, co-created technology, collaboration between fields such as anthropology and engineering, and challenge-ready initiatives that respond to historic and emergent social and environmental inequity.

Interpersonal Conflict over Water Is Associated with Household Demographics, Domains of Water Insecurity, and Regional Conflict: Evidence from Nine Sites across Eight Sub-Saharan African Countries

Water insecurity may precipitate interpersonal conflict, although no studies to date have rigorously examined these relationships. We examined relationships between household demographics, water insecurity, regional conflict, and interpersonal conflict over water. Using survey data from eight sub-Saharan African countries, we found that interpersonal conflict within and outside the home is associated with multiple domains of water insecurity, particularly accessibility. Furthermore, we found that higher levels of remote violence and protests are associated with greater within household conflict, whereas riots and violent armed conflict are associated with greater conflict between neighbors. Our findings expand upon the current literature by examining factors affecting interpersonal conflict over water, which may become increasingly important as precipitation patterns and land temperatures change in this region.

The interrelationship between water access, exclusive breastfeeding and diarrhea in children: a cross-sectional assessment across 19 African countries

Background

Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers’ practice of exclusive breastfeeding.

Methods

We analyzed data on 247 090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries.

Results

The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR) = 1.04, 95% confidence interval (CI) = 0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR = 1.06, 95% CI = 0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR = 0.67, 95% CI = 0.56, 0.78).

Conclusion

Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching water.

The interrelationship between water access, exclusive breastfeeding and diarrhea in children: a cross-sectional assessment across 19 African countries

BACKGROUND

Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers' practice of exclusive breastfeeding.

METHODS

We analyzed data on 247 090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries.

RESULTS

The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR) = 1.04, 95% confidence interval (CI) = 0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR = 1.06, 95% CI = 0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR = 0.67, 95% CI = 0.56, 0.78).

CONCLUSION

Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching water.

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.

Visible and invisible risks: Exploring washing and hygiene practices with women living on low income in Kenya

Shifting environmental conditions and poor or insufficient hygiene facilitates the transmission of bacteria and viruses between and within species of animals; between humans; and between humans and animals. Taking a One Health perspective, we used interviews to explore with 20 women living on low income in Kenya: their gendered hygiene practices and daily contact with animals; how and why they access water and sanitation facilities for themselves, their families, and any livestock; and their understandings of (zoonotic) health risks and disease transmission within their local environments. The women described how they worked every day to keep bodies and homes clean by washing bodies, surfaces and clothes. Women's hygiene practices focussed on removing visible dirt partly because of concerns for health but also to support their families' social standing in their community. While they were less aware of any 'invisible' risks to health through contact with animals or other hazards present in their daily living environments, most exercised care to source and manage water for drinking. Contaminated water was recognised as a risk to health suggesting that in this case, women accepted that there were 'invisible risks' to health, even in clear water, and took steps to mitigate them.

The role of piped water supplies in advancing health, economic development, and gender equality in rural communities

In rural areas of sub-Saharan Africa, one in eight households obtain drinking water from a piped system; the rest fetch water from improved and unimproved sources located at some distance from their homes. This task falls primarily to women and girls, creating time poverty and risks to safety and health. In this paper, we present a conceptual model that elaborates the mechanisms linking access to piped water with food security and long-term economic impacts. These hypotheses were tested in a quasi-experimental study of four villages in rural Zambia using a combination of household surveys, Global Positioning System transponders, and water meters to measure time spent fetching water, water consumption, and how water was being utilized for domestic and productive activities. Households receiving the piped water intervention spent a median of 3.8 h per week less fetching water, savings that accrued primarily to women and girls. Household water consumption increased 32%, which was used for both domestic and productive uses. Increases in the frequency of gardening and the size of garden plots in treatment households were observed. Households receiving piped water reported being happier, healthier, and having more time to participate in work inside or outside the home. We find that piped water supplies can promote the economic development and well-being of rural households, with particular benefits to women and girls, conditional upon pricing and management models that ensure sustainable service.

Exploring resource scarcity and contextual influences on wellbeing among young refugees in Bidi Bidi refugee settlement, Uganda: findings from a qualitative study

BACKGROUND

Contextual factors including poverty and inequitable gender norms harm refugee adolescent and youths' wellbeing. Our study focused on Bidi Bidi refugee settlement that hosts more than 230,000 of Uganda's 1.4 million refugees. We explored contextual factors associated with wellbeing among refugee adolescents and youth aged 16-24 in Bidi Bidi refugee settlement.

METHODS

We conducted 6 focus groups (n = 3: women, n = 3: men) and 10 individual interviews with young refugees aged 16-24 living in Bidi Bidi. We used physical distancing practices in a private outdoor space. Focus groups and individual interviews explored socio-environmental factors associated with refugee youth wellbeing. Focus groups were digitally recorded, transcribed verbatim, and coded by two investigators using thematic analysis. Analysis was informed by a social contextual theoretical approach that considers the interplay between material (resource access), symbolic (cultural norms and values), and relational (social relationships) contextual factors that can enable or constrain health promotion.

RESULTS

Participants included 58 youth (29 men; 29 women), mean age was 20.9 (range 16-24). Most participants (82.8%, n = 48) were from South Sudan and the remaining from the Democratic Republic of Congo (17.2% [n = 10]). Participant narratives revealed the complex interrelationships between material, symbolic and relational contexts that shaped wellbeing. Resource constraints of poverty, food insecurity, and unemployment (material contexts) produced stress and increased sexual and gender-based violence (SGBV) targeting adolescent girls and women. These economic insecurities exacerbated inequitable gender norms (symbolic contexts) to increase early marriage and transactional sex (relational context) among adolescent girls and young women. Gendered tasks such as collecting water and firewood also increased SGBV exposure among girls and young women, and this was exacerbated by deforestation. Participants reported negative community impacts (relational context) of COVID-19 that were associated with fear and panic, alongside increased social isolation due to business, school and church closures.

CONCLUSIONS

Resource scarcity produced pervasive stressors among refugee adolescents and youth. Findings signal the importance of gender transformative approaches to SGBV prevention that integrate attention to resource scarcity. These may be particularly relevant in the COVID-19 pandemic. Findings signal the importance of developing health enabling social contexts with and for refugee adolescents and youth.

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.

Water insecurity and psychosocial distress: case study of the Detroit water shutoffs

BACKGROUND

Water insecurity poses a significant global challenge to health and development. While the biophysical and economic impacts of inadequate water and sanitation are well documented, the complex emotional and social tolls of water insecurity are less understood- particularly in the global North. In this article, we advance understandings of the psychosocial dimensions of water insecurity in Detroit, MI, where an estimated 100 000 households have been disconnected from water and sanitation services since the city declared bankruptcy in 2013.

METHODS

A community-based participatory research study was conducted among residents of a local food pantry. A culturally relevant measure of water insecurity was developed through ethnographic engagement, then administered alongside the Kessler Psychological Distress scale.

RESULTS

Our models reveal a substantial, statistically significant effect of water insecurity on psychological distress. Additionally, financial stress in paying for water and sanitation produces significant distress, even independent of water supply status.

CONCLUSIONS

Curtailing water and sanitation access has complex, intersecting effects, including implications for community mental health. Rapidly rising utility rates across the USA, in the context of growing poverty, underscore the urgency of addressing this issue. The present study is the first we know of in the USA to examine the relationship between water insecurity and psychosocial distress.

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.

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