SNAP Emergency Allotments, Emergency Rent Assistance, Rent Burden, and Housing and Food Security, June 2022-May 2023

Introduction

During the COVID-19 pandemic, Supplemental Nutrition Assistance Program (SNAP) emergency allotments and emergency rent assistance provided support to low-income households. Rent burden, a form of housing insecurity, can severely limit household resources, which, in turn, affects health equity. We explored whether these policy interventions equitably supported households that were or were not experiencing rent burden.

Methods

We used data from the US Household Pulse Survey (June 2022-May 2023) to examine whether associations between emergency support policies and indicators of food and housing security differed according to household rent burden status. We modeled each outcome (food sufficiency or being current on rent) as a function of policy exposure (SNAP emergency allotments or emergency rent assistance), rent burden, and their interaction. We included demographic characteristics, state of residence, and survey cycle as covariates. We modeled each outcome and policy exposure combination separately.

Results

Receiving emergency allotments (72.4% vs 67.2% for SNAP participants in states with and without emergency allotments, respectively) and emergency rent assistance (64.5% vs 57.6% for households that received and were waitlisted/denied assistance, respectively) were associated with greater food sufficiency. The relationship between emergency allotments and food sufficiency was stronger in rent-burdened households; however, emergency rent assistance supported food sufficiency to a greater extent in non-rent-burdened households. Emergency rent assistance supported households in being current on rent (78.7% vs 56.4% for households that received and were waitlisted/denied assistance, respectively) and supported being current on rent to a greater extent in non-rent-burdened households than in rent-burdened households.

Conclusion

The relationship between emergency support policies and food or housing security differed according to whether households were experiencing rent burden. Associations were sometimes stronger in less economically constrained conditions. These results indicate an opportunity to better design policies to support low-income households, address food and housing security, and ultimately decrease the prevalence of chronic disease.

Beyond WASH: Testing Additional Connections Between Household Water Insecurity and Child Nutrition Outcomes in Multi-Country Contexts

This study identifies multiple pathways connecting household water insecurity with child nutrition. Using nationally representative samples for 18 countries, we examine the mediating role of child's dietary diversity as a function of household water status, while also accounting for sanitation. We construct a latent household water insecurity score (HWI) and use Structural Equation approach to model underlying pathways. HWI affected child's HAZ score and hemoglobin both directly and indirectly, with a mediation from child feeding alongside effects from sanitation. Broadening the conception of household water insecurity and accommodating the indirect effects of water could improve explanations of child under-nutrition.

Sensing, knowing, and making water quality along Marikina River in the Philippines

Water quality is a major concern around the world, but assessments of quality often privilege producers, regulators and experts over consumers. With water supplies and sources constantly in flux, how do ordinary people experience and "sense" quality? How do they define "good" or "good enough" water, and what practices do they engage in to "make" good water? In this article, we attend to these questions by presenting findings from an open-ended qualitative study carried out along the Marikina River, Manila, the Philippines - a waterway that courses from rural and mountainous villages to highly urbanized communities. First, we describe the sensorial and cognitive attributes that people associate with the different water sources in their environment, as well as their decision-making regarding what kind of water to use for which purposes. Second, we present the "making" of water quality: how, in a context of polluted environments and water scarcity, do people try to secure water they consider acceptable for themselves and their families. Our findings reveal water quality as a contested, relational domain-one that reinforces social and health disparities and calls for further scholarship.

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.

HIV Vulnerabilities Associated with Water Insecurity, Food Insecurity, and Other COVID-19 Impacts Among Urban Refugee Youth in Kampala, Uganda: Multi-method Findings

Food insecurity (FI) and water insecurity (WI) are linked with HIV vulnerabilities, yet how these resource insecurities shape HIV prevention needs is understudied. We assessed associations between FI and WI and HIV vulnerabilities among urban refugee youth aged 16-24 in Kampala, Uganda through individual in-depth interviews (IDI) (n = 24), focus groups (n = 4), and a cross-sectional survey (n = 340) with refugee youth, and IDI with key informants (n = 15). Quantitative data was analysed via multivariable logistic and linear regression to assess associations between FI and WI with: reduced pandemic sexual and reproductive health (SRH) access; past 3-month transactional sex (TS); unplanned pandemic pregnancy; condom self-efficacy; and sexual relationship power (SRP). We applied thematic analytic approaches to qualitative data. Among survey participants, FI and WI were commonplace (65% and 47%, respectively) and significantly associated with: reduced SRH access (WI: adjusted odds ratio [aOR]: 1.92, 95% confidence interval [CI]: 1.19-3.08; FI: aOR: 2.31. 95%CI: 1.36-3.93), unplanned pregnancy (WI: aOR: 2.77, 95%CI: 1.24-6.17; FI: aOR: 2.62, 95%CI: 1.03-6.66), and TS (WI: aOR: 3.09, 95%CI: 1.22-7.89; FI: aOR: 3.51, 95%CI: 1.15-10.73). WI participants reported lower condom self-efficacy (adjusted β= -3.98, 95%CI: -5.41, -2.55) and lower SRP (adjusted β= -2.58, 95%CI= -4.79, -0.37). Thematic analyses revealed: (1) contexts of TS, including survival needs and pandemic impacts; (2) intersectional HIV vulnerabilities; (3) reduced HIV prevention/care access; and (4) water insecurity as a co-occurring socio-economic stressor. Multi-method findings reveal FI and WI are linked with HIV vulnerabilities, underscoring the need for HIV prevention to address co-occurring resource insecurities with refugee youth.

Variations in household water affordability and water insecurity: An intersectional perspective from 18 low- and middle-income countries

Compounding systems of marginalization differentiate and shape water-related risks. Yet, quantitative water security scholarship rarely assesses such risks through intersectionality, a paradigm that conceptualizes and examines racial, gendered, class, and other oppressions as interdependent. Using an intersectionality approach, we analyze the relationships between household head gender and self-reported socio-economic status, and water affordability (proportion of monthly income spent on water) and water insecurity (a composite measure of 11 self-reported experiences) for over 4000 households across 18 low- and middle-income countries in Central and South America, Africa, and Asia. Interaction terms and composite categorical variables were included in regression models, adjusting for putative confounders. Among households with a high socio-economic status, the proportion of monthly income spent on water differed by household head gender. In contrast, greater household water insecurity was associated with lower socio-economic status and did not meaningfully vary by the gender of the household head. We contextualize and interpret these experiences through larger systems of power and privilege. Overall, our results provide evidence of broad intersectional patterns from diverse sites, while indicating that their nature and magnitude depend on local contexts. Through a critical reflection on the study's value and limitations, including the operationalization of social contexts across different sites, we propose methodological approaches to advance multi-sited and quantitative intersectional research on water affordability and water insecurity. These approaches include developing scale-appropriate models, analyzing complementarities and differences between site-specific and multi-sited data, collecting data on gendered power relations, and measuring the impacts of household water insecurity.

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.

When the flood passes, does health return? A short panel examining water and food insecurity, nutrition, and disease after an extreme flood in lowland Bolivia

OBJECTIVES

Flooding is the most frequent extreme-weather disaster and disproportionately burdens marginalized populations. This article examines how food and water insecurity, blood pressure (BP), nutritional status, and diarrheal and respiratory illnesses changed during the 2 months following a historic flood in lowland Bolivia.

METHODS

Drawing on longitudinal data from Tsimane' forager-horticulturalist (n = 118 household heads; n = 129 children) directly after a historic 2014 flood and ~2 months later, we use fixed effects linear regression and random effects logistic regression models to test changes in the markers of well-being and health over the recovery process.

RESULTS

Results demonstrated that water insecurity scores decreased significantly 2 month's postflood, while food insecurity scores remained high. Adults' systolic and diastolic BP significantly declined 2 months after the flood's conclusion. Adults experienced losses in measures of adiposity (BMI, sum of four skinfolds, waist circumference). Children gained weight and BMI-for-age Z-scores indicating buffering of children by adults from food stress that mainly occurred in the community closer to the main market town with greater access to food aid. Odds of diarrhea showed a nonsignificant decline, while cough increased significantly for both children and adults 2 months postflood.

CONCLUSIONS

Water insecurity and BP improved during the recovery process, while high levels of food insecurity persisted, and nutritional stress and respiratory illness worsened. Not all indicators of well-being and health recover at the same rate after historic flooding events. Planning for multiphase recovery is critical to improve health of marginalized populations after flooding.

Tap Water Avoidance Is Associated with Lower Food Security in the United States: Evidence from NHANES 2005-2018

BACKGROUND

Food insecurity has profound nutritional and public health consequences. Water insecurity may exacerbate food insecurity, yet little is known about the association between water and food insecurity in the United States or other high-income countries.

OBJECTIVE

This study aimed to estimate how tap water avoidance, a proxy of water insecurity, covaries with food insecurity; examine how the probability of food insecurity changed by tap water avoidance between 2005 and 2018; and test how the association between tap water avoidance and food insecurity differed across income and housing statuses.

DESIGN

This was a secondary analysis of the cross-sectional 2005-2018 National Health and Nutrition Examination Survey.

PARTICIPANTS/SETTING

Participants were 31,390 US adults 20 years and older.

MAIN OUTCOME MEASURES

The main outcome was food insecurity, using the US Food Security Survey Module.

STATISTICAL ANALYSES

Adjusted logistic regression models estimated how tap water avoidance was associated with the odds of food insecurity. Predicted probabilities of food insecurity over time and by income and housing status were plotted using marginal standardization.

RESULTS

Adults who avoided tap water had 21% higher odds (95% CI 1.09 to 1.34) of food insecurity compared with those who drank tap water. The probability of any food insecurity doubled between 2005-2006 and 2017-2018 and was consistently higher for tap water avoiders. Food insecurity decreased across both tap water drinkers and avoiders as income increased, but was higher among tap water avoiders at all income levels. Likewise, food insecurity was higher among renters than among homeowners but was higher among tap water avoiders in both housing groups.

CONCLUSIONS

Tap water avoidance is positively associated with food insecurity in the United States, and both insecurities have increased over time. Efforts to mitigate food insecurity should simultaneously address water insecurity issues, including tap water availability and quality, as these may be a modifiable contributors to food insecurity.

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.

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.

The co-occurrence of water insecurity and food insecurity among Daasanach pastoralists in northern Kenya

OBJECTIVE

Water plays a critical role in the production of food and preparation of nutritious meals, yet few studies have examined the relationship between water and food insecurity. The primary objective of this study, therefore, was to examine how experiences of household water insecurity (HWI) relate to experiences of household food insecurity (HFI) among a pastoralist population living in an arid, water-stressed region of northern Kenya.

DESIGN

We implemented the twelve-item Household Water Insecurity Experiences (HWISE, range 0-36) Scale and the nine-item Household Food Insecurity Access Scale (HFIAS, range 0-27) in a cross-sectional survey to measure HWI and HFI, respectively. Data on socio-demographic characteristics and intake of meat and dairy in the prior week were collected as covariates of interest.

SETTING

Northern Kenya, June-July 2019.

PARTICIPANTS

Daasanach pastoralist households (n 136) from seven communities.

RESULTS

In the prior 4 weeks, 93·4 % and 98·5 % of households had experienced moderate-to-severe HWI and HFI, respectively. Multiple linear regression analyses indicated a strong association between HWI and HFI. Each point higher HWISE score was associated with a 0·44-point (95 % CI: 0·22, 0·66, P = 0·003) higher HFIAS score adjusting for socio-economic status and other covariates.

CONCLUSIONS

These findings demonstrate high prevalence and co-occurrence of HWI and HFI among Daasanach pastoralists in northern Kenya. This study highlights the need to address HWI and HFI simultaneously when developing policies and interventions to improve the nutritional well-being of populations whose subsistence is closely tied to water availability and access.

Does resource insecurity drive HIV-related stigma? Associations between food and housing insecurity with HIV-related stigma in cohort of women living with HIV in Canada

INTRODUCTION

Women living with HIV across global contexts are disproportionately impacted by food insecurity and housing insecurity. Food and housing insecurity are resource insecurities associated with poorer health outcomes among people living with HIV. Poverty, a deeply stigmatized phenomenon, is a contributing factor towards food and housing insecurity. HIV-related stigma-the devaluation, mistreatment and constrained access to power and opportunities experienced by people living with HIV-intersects with structural inequities. Few studies, however, have examined food and housing insecurity as drivers of HIV-related stigma. This study aimed to estimate the associations between food and housing insecurity with HIV-related stigma among women living with HIV in Canada.

METHODS

This prospective cohort study of women living with HIV (≥16 years old) in three provinces in Canada involved three waves of surveys collected at 18-month intervals between 2013 and 2018. To understand associations between food and housing security and HIV-related stigma, we conducted linear mixed effects regression models. We adjusted for socio-demographic characteristics associated with HIV-related stigma.

RESULTS AND DISCUSSION

Among participants (n = 1422), more than one-third (n = 509; 36%) reported baseline food insecurity and approximately one-tenth (n = 152, 11%) housing insecurity. Mean HIV-related stigma scores were consistent across waves 1 (mean [M] = 57.2, standard deviation [SD] = 20.0, N = 1401) and 2 (M = 57.4, SD = 19.0, N = 1227) but lower at wave 3 (M = 52.8, SD = 18.7, N = 918). On average, across time, food insecure participants reported HIV-related stigma scores that were 8.6 points higher (95% confidence interval [CI]: 6.4, 10.8) compared with food secure individuals. Similarly, participants reporting insecure housing at wave 1 tended to experience greater HIV-related stigma (6.2 points, 95% CI: 2.7, 9.6) over time compared to stably housed participants. There was an interaction between time and housing insecurity, whereby baseline housing insecurity was no longer associated with higher HIV-related stigma at the third wave.

CONCLUSIONS

Among women living with HIV in Canada, experiencing food and housing insecurity was associated with consistently higher levels of HIV-related stigma. In addition to the urgent need to tackle food and housing insecurity among people living with HIV to optimize wellbeing, getting to the heart of HIV-related stigma requires identifying and dismantling resource insecurity-related stigma drivers.

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.

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.

Water Security and Nutrition: Current Knowledge and Research Opportunities

Water is an essential nutrient that has primarily been considered in terms of its physiological necessity. But reliable access to water in sufficient quantities and quality is also critical for many nutrition-related behaviors and activities, including growing and cooking diverse foods. Given growing challenges to water availability and safety, including climate change, pollution, and infrastructure degradation, a broader conceptualization of water and its diverse uses is needed to sustainably achieve global nutrition targets. Therefore, we review empirical and qualitative evidence describing the linkages between water security (the reliable availability, accessibility, and quality of water for all household uses) and nutrition. Primary linkages include water security for drinking, food production and preparation, infant and young child feeding, and limiting exposure to pathogens and environmental toxins. We then identify knowledge gaps within each linkage and propose a research agenda for studying water security and nutrition going forward, including the concurrent quantification of both food and water availability, accessibility, use, and stability. By making explicit the connections between water security and nutritional well-being, we aim to promote greater collaboration between the nutrition and water, sanitation, and hygiene sectors. Interdisciplinary policies and programs that holistically address the water-nutrition nexus, versus those that focus on water and nutrition independently, are likely to significantly advance our ability to ensure equitable access to healthy foods and safe water for all.

Sexual orientation-based disparities in food security among adults in the United States: results from the 2003-2016 NHANES

BACKGROUND

Access to sufficient, safe, culturally appropriate, and nutritious food is essential for maintaining both physical and mental health. Despite a growing body of evidence suggesting that sexual minority (SM) people experience significant disparities in socioeconomic and material resource security, there remains a paucity of empirical studies examining the prevalence of food insecurity among SM people relative to their heterosexual peers.

OBJECTIVES

To determine the prevalence of adult and household food insecurity across sexual orientation groups in the United States after adjusting for multiple covariates.

METHODS

We combined 7 cycles of US NHANES, 2003-2016 (N = 21,300) to examine sexual orientation-based disparities in adult food security among lesbian/gay (n = 373), bisexual (n = 606), same-sex experienced (SSE, n = 693), other sexual minorities (OSMs, n = 88), and heterosexual (n = 19,540) people. Food (in)security was measured using the US Food Security Survey Module and categorized as secure, marginally insecure, moderately insecure, and severely insecure.

RESULTS

Severe adult food insecurity was higher among bisexuals (17.16%; 95% CI: 14.36, 20.38), SSE (13.71%; 95% CI: 11.34, 16.48), OSMs (12.50%; 95% CI: 7.04, 21.24), and lesbians/gays (13.14%; 95% CI: 10.07, 16.97) compared with heterosexuals (8.23%; 95% CI: 7.85, 8.62). Multivariable multinomial logistic regression analysis adjusting for gender, race/ethnicity, age, citizenship, education, household size, income, cycle year, emergency food use, and Supplemental Nutrition Assistance Program participation showed that bisexuals, OSMs, SSE, and lesbians/gays were more likely to experience moderate to severe food insecurity compared with heterosexuals.

CONCLUSIONS

SM people are significantly more likely to experience increased likelihood of food insecurity relative to their heterosexual peers.

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.

The prevalence and correlates of depression before and after the COVID-19 pandemic declaration among urban refugee adolescents and youth in informal settlements in Kampala, Uganda: A longitudinal cohort study

Purpose

There is scant research examining urban refugee youth mental health outcomes, including potential impacts of the COVID-19 pandemic. We examine prevalence and ecosocial risk factors of depression in the periods before and after the COVID-19 pandemic declaration among urban refugee youth in Kampala, Uganda.

Methods

Data from a cohort of refugee youth (n = 367) aged 16–24 years were collected in periods before (February 2020) and after (December 2020) the WHO COVID-19 pandemic declaration. We developed crude and adjusted generalized estimating equation logistic regression models to examine demographic and ecosocial factors (food insecurity, social support, intimate partner violence) associated with depression, and include time-ecosocial interactions to examine if associations differed before and after the pandemic declaration.

Results

The prevalence of depression was high, but there was no significant difference before (27.5%), and after (28.9%) the pandemic declaration (P = .583). In adjusted models, food insecurity (aOR: 2.54; 95% CI: 1.21–5.33) and experiencing violence (aOR: 2.53; 95% CI: 1.07–5.96) were associated with increased depression, and social support was associated with decreased depression (aOR: 0.85; 95% CI: 0.81–0.89).

Conclusions

These findings highlight the urgent need for interventions to address chronic depression, food insecurity, and ongoing effects of violence exposure among urban refugee youth in Kampala.

Food Insecurity, Nutritional Inequality, and Maternal–Child Health: A Role for Biocultural Scholarship in Filling Knowledge Gaps

Food insecurity, a significant contributor to nutritional inequality, disproportionately affects women and children in low- and middle-income countries. The magnitude of the problem has inspired research on its impacts on health, especially on nutritional status and, more recently, mental well-being. Current research is dominated by surveillance-type studies that emphasize access, one of food security's four dimensions. Findings are inconclusive regarding the association between food insecurity and women and children's nutritional status, but some evidence indicates that it is a key contributor to mental distress in women. To understand these inconsistent findings, we emphasize the need for research on the strategies that people use to cope with inadequate access to food. We contend that biocultural approaches that recognize the importance of local contexts and the role of broader political-economic factors in shaping them are well suited for addressing current knowledge gaps.

Exploring linkages between climate change and sexual health: a scoping review protocol

INTRODUCTION

The effects of climate change and associated extreme weather events (EWEs) present substantial threats to well-being. EWEs hold the potential to harm sexual health through pathways including elevated exposure to HIV and other sexually transmitted infections (STIs), disrupted healthcare access, and increased sexual and gender-based violence (SGBV). The WHO defines four components of sexual health: comprehensive sexuality education; HIV and STI prevention and care; SGBV prevention and care; and psychosexual counselling. Yet, knowledge gaps remain regarding climate change and its associations with these sexual health domains. This scoping review will therefore explore the linkages between climate change and sexual health.

METHODS AND ANALYSIS

Five electronic databases (MEDLINE, EMBASE, PsycINFO, Web of Science, CINAHL) will be searched using text words and subject headings (eg, Medical Subject Headings (MeSH), Emtree) related to sexual health and climate change from the inception of each database to May 2021. Grey literature and unpublished reports will be searched using a comprehensive search strategy, including from the WHO, World Bank eLibrary, and the Centers for Disease Control and Prevention. The scoping review will consider studies that explore: (a) climate change and EWEs including droughts, heat waves, wildfires, dust storms, hurricanes, flooding rains, coastal flooding and storm surges; alongside (b) sexual health, including: comprehensive sexual health education, sexual health counselling, and HIV/STI acquisition, prevention and/or care, and/or SGBV, including intimate partner violence, sexual assault and rape. Searches will not be limited by language, publication year or geographical location. We will consider quantitative, qualitative, mixed-methods and review articles for inclusion. We will conduct thematic analysis of findings. Data will be presented in narrative and tabular forms.

ETHICS AND DISSEMINATION

There are no formal ethics requirements as we are not collecting primary data. Results will be published in a peer-reviewed journal and shared at international conferences.

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.

A qualitative analysis of the perceived socio-cultural contexts and health concerns of sugar-sweetened beverages among adults studying or working at a post-secondary institution in Dharwad, India

BACKGROUND

We sought to explore the perceptions of the socio-cultural contexts and health concerns of consuming sugar-sweetened beverages (SSB) among Indian adults working or studying at a post-secondary institution in Karnataka, India.

METHODS

We completed a qualitative study, including 24 semi-structured interviews between 2017 and 2018 at the University of Agricultural Sciences, Dharwad, Karnataka, India. Data were analyzed using thematic content analysis.

RESULTS

One over-arching theme emerged, westernization and changing perceptions of food, sugar, and health. Participants discussed SSB and associated health concerns in the broad context of westernization and overall economic development in India. Three sub-themes regarding the health perceptions of consuming SSB were: healthy drinks are clean and natural; hydration and energy; and moderation and body weight. Hygienically-prepared beverages were a consistent concern among participants. Juices and beverages, such as tea or coffee, sweetened with jaggery were viewed positively due to their naturalness and lack of processed sugar. Participants perceived SSB as providing hydration and energy, particularly in hot weather. Lastly, if consumed in moderation, SSB were thought to have no direct adverse health consequences. Though some participants noted excessive, 'addictive' consumption would contribute to weight gain and diabetes.

CONCLUSION

Perceived health concerns of SSB reflect dominant health issues in India, namely, food insecurity, food safety, and increasingly, diabetes. Policymakers tend to prioritize acute challenges over long-term concerns. As such, the capacity of any policy to address chronic nutritional concerns related to SSB are likely to be muted in the absence of improvements to food safety and security.

Unpacking the "black box" of global food insecurity and mental health

Food insecurity is a global concern. While it was once characterized mainly as a problem of undernutrition, it is now recognized that a person may be food insecure without experiencing hunger. Numerous studies have demonstrated that food insecurity is strongly related to poor mental health around the world, but the mechanisms that underpin that relationship remain poorly understood. One body of research from nutritional sciences posits that nutrient deficiency impacts brain function, producing symptoms of depression and anxiety. Another body of research from the social sciences posits that the social consequences of having to eat non-preferred foods or obtain food in socially unacceptable ways may compromise mental health through stress. This study was designed to clarify the mechanisms linking food insecurity and mental health using case studies in rural Brazil and urban Ethiopia. Working with samples consisting of about 200 adult household decision-makers (mostly female) recruited between 2015 and 2019 at each site, we tested for nutritional and social mediation of the food insecurity-mental health relationship using multivariable linear regression and mediation analysis. Our analyses found no evidence of mediation in either setting. Moreover, there was no association between nutritional status variables and food insecurity. These findings suggest that food insecurity likely impacts mental health directly through forms of basic needs deprivation, such as worrying about where one's next meal will come from, rather than by acting as a social signal or even by impacting nutritional status. These results underscore the power of basic-needs deprivation for impacting mental health.

Household water insecurity will complicate the ongoing COVID-19 response: Evidence from 29 sites in 23 low- and middle-income countries

In March 2020, the World Health Organization (WHO) issued a set of public guidelines for Coronavirus Disease 2019 (COVID-19) prevention measures that highlighted handwashing, physical distancing, and household cleaning. These health behaviors are severely compromised in parts of the world that lack secure water supplies, particularly in low- and middle-income countries (LMICs). We used empirical data gathered in 2017-2018 from 8,297 households in 29 sites across 23 LMICs to address the potential implications of water insecurity for COVID-19 prevention and response. These data demonstrate how household water insecurity presents many pathways for limiting personal and environmental hygiene, impeding physical distancing and exacerbating existing social and health vulnerabilities that can lead to more severe COVID-19 outcomes. In the four weeks prior to survey implementation, 45.9% of households in our sample either were unable to wash their hands or reported borrowing water from others, which may undermine hygiene and physical distancing. Further, 70.9% of households experienced one or more water-related problems that potentially undermine COVID-19 control strategies or disease treatment, including insufficient water for bathing, laundering, or taking medication; drinking unsafe water; going to sleep thirsty; or having little-to-no drinking water. These findings help identify where water provision is most relevant to managing COVID-19 spread and outcomes.

Understanding Biopsychosocial Health Outcomes of Syndemic Water and Food Insecurity: Applications for Global Health

Household food and water insecurity often co-occur, and both can lead to malnutrition, psycho-emotional stress, and increased risk of infectious and chronic diseases. This can occur through multiple pathways including poor diet and inadequate sanitation. In this perspective, we discuss the potential advantages of a syndemic approach to understanding the consequences of food and water insecurity, that is, one that makes possible the assessment of their mutually enhancing effects on health. Syndemic theory considers the concerted, deleterious interaction of two or more diseases or other health conditions, such as psycho-emotional stress, that result from structural inequities. We therefore call for an approach that links localized morbidity of individual- or household-level experiences of concurrent food and water insecurity to larger structural and contextual forces/risk environments. Such an approach permits the investigation of food and water insecurity as suites of risk, such that certain disease outcomes serve as signals for interlinked stressors. For example, the use of a syndemic perspective could help explain the persistence of conditions like diarrhea or stunting after food or water interventions; that is, existing approaches may be too narrow in scope to protect individuals from multiple and overlapping environmental and biopsychosocial stressors.

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.

Producing insecurity: Healthcare access, health insurance, and wellbeing among American Indian elders

Although health care is a treaty-guaranteed right for members of federally recognized tribes, decades of research describe persistent disparities in health and access to health services for American Indians. Despite gains in insurance enrollment after the passage of the 2010 Affordable Care Act, underfunding of the Indian Health Service and national debate over the new health law contributes to insecurity, especially among the majority of American Indians aged 55 and older who rely on public insurance. We consider the production of insecurity surrounding health care for American Indian elders, analyzing its pragmatic and affective consequences. Between June 2016 and March 2017, we conducted 96 quantitative surveys and in-depth qualitive interviews with American Indian elders aged 55 and older in two states in the U.S. Southwest. Interviews were recorded, professionally transcribed, and analyzed iteratively using open and focused coding. We found that elders consistently shared discourses of doubt, fear, and uncertainty that centered on: 1) interactions with healthcare providers and facilities, especially the IHS; 2) calculations regarding health insurance and the potential costs of healthcare services; and 3) dynamics at the national level around health policy, particularly for American Indians. We argue that persistent perceptions of healthcare insecurity present a major barrier to wellbeing that remains unaddressed by existing health policy interventions for this population, which focus predominately on individual-level knowledge and behavior.

Biocultural approaches to transgender and gender diverse experience and health: Integrating biomarkers and advancing gender/sex research

Transgender and gender diverse (TGD) people are increasingly visible in U.S. communities and in national media. With this increased visibility, access to gender affirming healthcare is also on the rise, particularly for urban youth. Political backlash and entrenchment in a gender binary, however, continue to marginalize TGD people, increasing risk for health disparities. The 2016 National Institute of Health recognition of sexual and gender minority people as a health disparities population increases available funding for much-needed research. In this article, we speak to the need for a biocultural human biology of gender/sex diversity by delineating factors that influence physiological functioning, mental health, and physical health of TGD people. We propose that many of these factors can best be investigated with minimally invasively collected biomarker samples (MICBS) and discuss how to integrate MICBS into research inclusive of TGD people. Research use of MICBS among TGD people remains limited, and wider use could enable essential biological and health data to be collected from a population often excluded from research. We provide a broad overview of terminology and current literature, point to key research questions, and address potential challenges researchers might face when aiming to integrate MCIBS in research inclusive of transgender and gender diverse people. We argue that, when used effectively, MICBS can enhance human biologists' ability to empirically measure physiology and health-related outcomes and enable more accurate identification of pathways linking human experience, embodiment, and health.

Biocultural pathways linking periodontal disease expression to food insecurity, immune dysregulation, and nutrition

OBJECTIVES

In this article, we test theoretical pathways leading to and resulting from periodontal disease to better understand how periodontal disease, which is measurable in both past and present populations, integrates biocultural context and affects whole-body physiology.

METHODS

We use data from the National Health and Nutrition Examination Survey (NHANES) 2003-2004 and logistic and linear regressions to test pathways linking psychosocial stress to periodontal disease, and periodontal disease to serum vitamin C levels. We then use causal mediation analysis to test the role of mediating variables in these pathways (n = 1853 individuals).

RESULTS

Food insecurity was positively associated with periodontal disease and negatively associated with serum counts of C-reactive protein (CRP) and neutrophils. Neither CRP nor neutrophils significantly mediated the relationship between food insecurity and periodontal disease. Periodontal disease was negatively associated with serum vitamin C levels and positively associated with neutrophil counts. Neutrophils may mediate the relationship between periodontal disease and vitamin C.

CONCLUSIONS

We identify two main findings: (a) periodontal disease contributes to and may result from immune dysregulation, particularly of neutrophils, and (b) an immune response to chronic infection such as periodontal disease is metabolically expensive for the body to maintain and likely depletes serum micronutrient levels. Both micronutrient status and serum neutrophil counts affect multiple skeletal and physiological phenotypes and thus position periodontal disease in whole-body context.

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.

In pursuit of 'safe' water: the burden of personal injury from water fetching in 21 low-income and middle-income countries

INTRODUCTION

Water fetching for household needs can cause injury, but documentation of the burden of harm globally has been limited. We described the frequency, characteristics and correlates of water-fetching injuries in 24 sites in 21 low-income and middle-income countries in Asia, Africa and Latin America and the Caribbean.

METHODS

In a survey of 6291 randomly selected households, respondents reported whether and how they had experienced water-fetching injuries. Responses were coded for injury type, mechanism, bodily location and physical context. We then identified correlates of injury using a multilevel, mixed-effects logistic regression model.

RESULTS

Thirteen per cent of respondents reported at least one water-fetching injury. Of 879 injuries, fractures and dislocations were the most commonly specified type (29.2%), and falls were the most commonly specified mechanism (76.4%). Where specified, 61.1% of injuries occurred to the lower limbs, and dangerous terrain (69.4%) was the most frequently reported context. Significant correlates included being female (aOR=1.50, 95% CI 1.15 to 1.96); rural (aOR=4.80, 95% CI 2.83 to 8.15) or periurban residence (aOR=2.75, 95% CI 1.64 to 4.60); higher household water insecurity scores (aOR=1.09, 95% CI 1.07 to 1.10) and reliance on surface water (aOR=1.97, 95% CI 1.21 to 3.22) or off-premise water sources that required queueing (aOR=1.72, 95% CI 1.19 to 2.49).

CONCLUSION

These data suggest that water-fetching injuries are an underappreciated and largely unmeasured public health challenge. We offer guidelines for comprehensive data collection on injuries to better capture the true burden of inadequate water access. Such data can guide the design of interventions to reduce injury risk and promote equitable water access solutions.

Water borrowing is consistently practiced globally and is associated with water-related system failures across diverse environments

Water problems due to scarcity, inaccessibility, or poor quality are a major barrier to household functioning, livelihood, and health globally. Household-to-household water borrowing has been posited as a strategy to alleviate unmet water needs. However, the prevalence and predictors of this practice have not been systematically examined. Therefore, we tested whether water borrowing occurs across diverse global contexts with varying water problems. Second, we tested if household water borrowing is associated with unmet water needs, perceived socio-economic status (SES), and/or water-related system failures, and if water access moderated (or changed) these relationships. Using survey data from the Household Water Insecurity Experiences (HWISE) study from 21 sites in 19 low- and middle-income countries (n = 5495 households), we found that household-to-household water borrowing was practiced in all 21 sites, with 44.7% (11.4-85.4%) of households borrowing water at least once the previous month. Multilevel mixed-effect logistic regression models demonstrate that high unmet water needs (odds ratio [OR] = 2.86], 95% confidence interval [CI] = 2.09-3.91), low perceived SES (OR = 1.09; 95% CI = 1.05-1.13), and water-related system failures (23-258%) were all significantly associated with higher odds of water borrowing. Significant interactions (all p < 0.01) between water access, unmet water needs, and water-related system failures on water borrowing indicate that water access moderates these relationships. These data are the first to demonstrate that borrowing water is commonly used by households around the world to cope with water insecurity. Due to how prevalent water borrowing is, its implications for social dynamics, resource allocation, and health and well-being are likely vast but severely under-recognized.

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:

Water access transformations: Metrics, infrastructure, and inequities

Scholarship on water insecurity has carried over an important insight from studies of food insecurity: Insecurity often occurs in the midst of plenty, and water insecurity is therefore better characterized by inaccessibility than by scarcity. Access to clean, adequate, and reliable water is, however, more challenging to systematize than access to food. Water is fluid and protean, and only when it is safely stored can people pretend to own it. In this paper, I make a case for the centrality of infrastructure - systems of water storage and transport - to water security. Equitable access to water often depends on technologies that protect, filter, and distribute water; it also depends on social arrangements that protect the least powerful from exclusion. I analyse two water infrastructure projects in Ethiopia, one a project to protect village water supplies and the other a large hydroelectric dam. The project to protect springs used by villagers for household water supply had the unintended effect of limiting access to those who could pay fees to a water committee. The dam harnessed water to produce electricity and supply irrigated plantations, but deprived downstream communities of water for farming. Water infrastructure can have far-reaching implications for water access, both for better and for worse. It is often instrumental in securing one group's access to water at the cost of another's.

Sub-optimal household water access is associated with greater risk of intimate partner violence against women: evidence from Nepal

Household water management is often women's responsibility, as related to the gendered nature of household roles. Ethnographic data suggest that household water insecurity could increase women's exposure to emotional and physical forms of intimate partner violence (IPV), as punishments for failures to complete socially expected household tasks that rely on water (like cooking and cleaning) and the generally elevated emotional state of household members dealing with resource scarcity. Here, we test the associations between sub-optimal household water access and women's exposure to IPV, using the nationally-representative data from Nepal Demographic and Health Survey, 2016. Drawing upon the intra-household bargaining model as the theoretical framework, we run instrumental variable probit regression, to test the association between household water access and prevalence of IPV against women. After controlling for other known covariates of IPV such as women's empowerment and education, the findings substantiate that worse household water access consistently elevates women's exposures to all forms of IPV. This suggests that improvements in household water access may have additional ramifications for reducing women's risk of IPV, beyond currently recognized socioeconomic benefits. While both household water access and IPV have known health consequences, linking them provides another pathway through which water could affect women's health.

Cash water expenditures are associated with household water insecurity, food insecurity, and perceived stress in study sites across 20 low- and middle-income countries

Billions of people globally, living with various degrees of water insecurity, obtain their household and drinking water from diverse sources that can absorb a disproportionate amount of a household's income. In theory, there are income and expenditure thresholds associated with effective mitigation of household water insecurity, but there is little empirical research about these mechanisms and thresholds in low- and middle-income settings. This study used data from 3655 households from 23 water-insecure sites in 20 countries to explore the relationship between cash water expenditures (measured as a Z-score, percent of income, and Z-score of percent of income) and a household water insecurity score, and whether income moderated that relationship. We also assessed whether water expenditures moderated the relationships between water insecurity and both food insecurity and perceived stress. Using tobit mixed effects regression models, we observed a positive association between multiple measures of water expenditures and a household water insecurity score, controlling for demographic characteristics and accounting for clustering within neighborhoods and study sites. The positive relationships between water expenditures and water insecurity persisted even when adjusted for income, while income was independently negatively associated with water insecurity. Water expenditures were also positively associated with food insecurity and perceived stress. These results underscore the complex relationships between water insecurity, food insecurity, and perceived stress and suggest that water infrastructure interventions that increase water costs to households without anti-poverty and income generation interventions will likely exacerbate experiences of household water insecurity, especially for the lowest-income households.

Agricultural wealth better predicts mental wellbeing than market wealth among highly vulnerable households in Haiti: Evidence for the benefits of a multidimensional approach to poverty

OBJECTIVES

Lack of wealth (poverty) impacts almost every aspect of human biology. Accordingly, many studies include its assessment. In almost all cases, approaches to assessing poverty are based on lack of success within cash economies (eg, lack of income, employment). However, this operationalization deflects attention from alternative forms of poverty that may have the most substantial influence on human wellbeing. We test how a multidimensional measure of poverty that considers agricultural assets expands the explanatory power of the construct of household poverty by associating it with one key aspect of wellbeing: symptoms of mental health.

METHODS

We used the case of three highly vulnerable but distinctive communities in Haiti-urban, town with a rural hinterland, and rural. Based on survey responses from adults in 4055 geographically sampled households, linear regression models were used to predict depression and anxiety symptom levels controlling for a wide range of covariates related to detailed measures of material poverty, including cash-economy and agricultural assets, income, financial stress, and food insecurity.

RESULTS

Household assets related to the cash economy were significantly associated with lower (ie, better) depression scores (-0.7, [95% CI: -1.2 to, -0.1]) but unrelated to anxiety scores (-0.3 [95% CI: -0.8 to 0.3]). Agricultural wealth was significantly-and more strongly-associated with both reductions in depression symptoms (-1.4 [95% CI: -2.2 to -0.7]) and anxiety symptoms (-1.8 [95% CI: -2.6 to -1.0]). These associations were consistent across the three sites, except in the fully urban site in Port-au-Prince where level of depression symptoms was not significantly associated with household agricultural wealth.

CONCLUSIONS

Standard measures of poverty based on success in the cash economy can mask important associations between poverty and wellbeing, in this case related to household-level subsistence capacity and crucial food-producing household assets.

Water Security in the Galápagos: Socioecological Determinants and Health Implications

Water security is strongly associated with important health outcomes and has many socioecological determinants. Several studies have documented the social determinants of water security and impacts of water security on health, independently. Yet few have examined both components in one setting. Using data from Ecuador's nationally representative health survey (ENSANUT-ECU), we proposed a new methodological framework for assessing water security in the Galápagos and assessed the relationship between socioecological indicators and water security among 2701 individuals in 693 households. We then tested the link between water security and childhood stunting using multilevel mixed effects logistic regressions controlling for household clustering. We found that being higher income in rural settings is significantly protective of water quality (OR 7.35) and increasing household size is associated with reduced water access (OR 0.44). We found no impact of water insecurity on childhood stunting. We observed a marked divergence in water security between islands and discussed potential underlying structural determinants. Understanding the structural predictors of water security and health is a necessary step in improving local health outcomes in the Galápagos. The social and physical factors leading to this water security environment may also be shared by similar locations, broadening the application of these findings.

'We Are Drinking Diseases': Perception of Water Insecurity and Emotional Distress in Urban Slums in Accra, Ghana

Water security is critical to the health and well-being of people around the world, especially among populations experiencing water stresses and rapid urbanization in low- to middle-income countries (LMICs). Recent research suggests water insecurity is associated with negative mental health outcomes. Despite global improvement in access to safe water across the world, the World Health Organization (WHO) reports that access to safe water in urban areas has not changed significantly or has stagnated in certain countries. In most African cities, entrepreneurial water vendors have stepped up to fill supply gaps in the formal delivery system by selling vended water. As part of a larger research program that aims to assess and analyze public perceptions around vended water, this paper explores the links connecting water insecurity and emotional distress among urban slum dwellers who mostly use vended water in Accra, Ghana. We used a parallel mixed-methods approach. Our quantitative results show that water-insecure households (OR = 2.23, p = 0.01) were more likely to report emotional distresses compared to water-secure households. However, households with improved sanitation (OR = 0.28, p = 0.01) and those willing to participate for improved water and sanitation (OR = 0.28, p = 0.01) were less likely to report emotional distress. Our qualitative results offered support for the quantitative results, as participants not only hold various perceptions regarding the safety and quality of vended water but expressed emotional distresses such as fear of contamination, discomfort, worry over arbitrary change in prices, and anxiety. The implications of the results for policy and practice, specifically to ensuring access to safe water, are discussed.

Water, food, and the dual burden of disease in Galápagos, Ecuador

OBJECTIVE

Rapid development in low- and middle-income countries (LMIC) has led to changes in diet that have outpaced water and sanitation improvements, contributing to a dual burden of overweight and noncommunicable disease risk factors (OWT/NCD) and undernutrition and infectious disease symptoms (UND/ID) within individuals and households. Yet, little work has examined the joint impact of water and food exposures on the development of the dual burden.

METHODS

We use data from Ecuador's nationally representative Encuesta Nacional de Salud y Nutrición (ENSANUT-ECU) to test whether water access and quality and diet quality and security are associated with OWT/NCD and UND/ID among 1119 children and 1582 adults in Galápagos. Adjusted multinomial and logistic models were used to test the separate and joint associations between water and food exposures and the dual burden and its components at the individual and household levels.

RESULTS

The prevalence of the dual burden of OWT/NCD and UND/ID was 16% in children, 33% in adults, and 90% in households. Diet quality was associated with a higher risk of dual burden in individuals and households. Mild food insecurity was positively associated with the risk of dual burden at the household level. No water variable separately predicted the dual burden. Joint exposure to poor water access and food insecurity was associated with greater odds of dual burden in households.

CONCLUSION

Our results suggest that unhealthy diets and poor water quality contribute to the dual burden at the individual and household levels. Addressing both food and water limitations is important in LMIC.

"When you have no water, it means you have no peace": A mixed-methods, whole-population study of water insecurity and depression in rural Uganda

BACKGROUND

Lack of access to clean water has well known implications for communicable disease risks, but the broader construct of water insecurity is little studied, and its mental health impacts are even less well understood.

METHODS AND FINDINGS

We conducted a mixed-methods, whole-population study in rural Uganda to estimate the association between water insecurity and depression symptom severity, and to identify the mechanisms underlying the observed association. The whole-population sample included 1776 adults (response rate, 91.5%). Depression symptom severity was measured using a modified 15-item Hopkins Symptom Checklist for Depression. Water insecurity was measured with a locally validated 8-item Household Water Insecurity Access Scale. We fitted multivariable linear and Poisson regression models to the data to estimate the association between water insecurity and depression symptom severity, adjusting for age, marital status, self-reported overall health, household asset wealth, and educational attainment. These models showed that water insecurity was associated with depression symptom severity (b = 0.009; 95% confidence interval [CI], 0.004-0.15) and that the estimated association was larger among men (b = 0.012; 95% CI, 0.008-0.015) than among women (b = 0.008; 95% CI, 0.004-0.012. We conducted qualitative interviews with a sub-group of 30 participants, focusing on women given their traditional role in household water procurement in the Ugandan context. Qualitative analysis, following an inductive approach, showed that water insecurity led to "choice-less-ness" and undesirable social outcomes, which in turn led to emotional distress. These pathways were amplified by gender-unequal norms.

CONCLUSIONS

Among men and women in rural Uganda, the association between water insecurity and depression symptom severity is statistically significant, substantive in magnitude, and robust to potential confounding. Data from the qualitative interviews provide key narratives that reveal the mechanisms through which women's lived experiences with water insecurity may lead to emotional distress.

Household water insecurity is strongly associated with food insecurity: Evidence from 27 sites in low- and middle-income countries

OBJECTIVES

Food and water insecurity have both been demonstrated as acute and chronic stressors and undermine human health and development. A basic untested proposition is that they chronically coexist, and that household water insecurity is a fundamental driver of household food insecurity.

METHODS

We provide a preliminary assessment of their association using cross-sectional data from 27 sites with highly diverse forms of water insecurity in 21 low- and middle-income countries across Africa, Asia, the Middle East, and the Americas (N = 6691 households). Household food insecurity and its subdomains (food quantity, food quality, and anxiety around food) were estimated using the Household Food Insecurity Access Scale; water insecurity and subdomains (quantity, quality, and opportunity costs) were estimated based on similar self-reported data.

RESULTS

In multilevel generalized linear mixed-effect modeling (GLMM), composite water insecurity scores were associated with higher scores for all subdomains of food insecurity. Rural households were better buffered against water insecurity effects on food quantity and urban ones for food quality. Similarly, higher scores for all subdomains of water insecurity were associated with greater household food insecurity.

CONCLUSIONS

Considering the diversity of sites included in the modeling, the patterning supports a basic theory: household water insecurity chronically coexists with household food insecurity. Water insecurity is a more plausible driver of food insecurity than the converse. These findings directly challenge development practices in which household food security interventions are often enacted discretely from water security ones.

Building on the biocultural syntheses: 20 years and still expanding

Building a New Biocultural Synthesis: Political Economic Perspectives in Human Biology called for an integration of political economy with ecological and adaptability perspectives in biocultural anthropology. A major goal of this volume was to explore the utility of including political-economic and sociocultural processes in analyses of human biological variation, nutrition, and health. A second goal was to enhance collaboration among subfields and work against the "chasm" that separated complementary perspectives in cultural and biological anthropology. Twenty years hence, new ways to link social inequalities and human biology have emerged in part through contributions of developmental origins of health and disease, epigenetics, microbiomes, and other new methods for tracing pathways of embodiment. Equally important, notions of "local/situated biologies" and "reactive genomes," provide frameworks for understanding biology and health at the nexus of ecologies, societies, and histories. We review and highlight these contributions toward expanding critical approaches to human biology. Developments over the past two decades have reinforced the central role of social environments and structural inequalities in shaping human biology and health. Yet, within biocultural approaches, a significant engagement with historical, political-economic, and sociocultural conditions remains relatively rare. We review potential barriers to such analyses, focusing on theoretical and methodological challenges as well as the subfield structure of anthropology. Achieving politically and socially contextualized and relevant critical biocultural approaches remains a challenge, but there is reason for optimism amid new theoretical and methodological developments and innovations brought by new generations of scholars.