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

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.

Addressing the Impact of Climate Change on Sexual and Reproductive Health Among Adolescent Girls and Young Women in Low- and Middle-Income Countries

There is an urgent need to better understand the role of climate change on sexual and reproductive health outcomes, particularly among adolescent girls and young women in low- and middle-income countries. Stakeholders at all levels should apply a rights-based, gendered approach to climate action and adaptation.

Men's household water fetching in India: Gender inequity is associated with greater responsibility and related risks

INTRODUCTION

Household water fetching elevates physical and emotional harms, and these are generally assumed to accrue to women due to gendered labor assignments. But even in cases like India where fetching remains a highly feminized task, there are households where the primary responsibility is assumed by men.

METHODS

We test the proposition that men's responsibility for water fetching is predicted by greater gender equity, reflected in measures of wives' empowerment. We used an extremely large, nationally representative Demographic and Health Survey dataset from India (2019-2020), narrowed to only households in which spouses co-reside with off-plot water sources (N = 10 616), and applying a multinomial regression approach.

RESULTS

In >20% of households, men are the primary fetchers. They are more likely to have primary responsibility when water is more distant, privately purchased, or transported by vehicle. Contrary to predictions, men assume greater responsibility for household water fetching as their wives' empowerment measures decrease and when they want to control their movement.

CONCLUSION

Married men in India sometimes assume responsibility for water fetching, but this is not explained by greater household gender equity. The findings also suggest that when men are responsible for fetching they have heightened risk of some forms of physical trauma but less relative psychological harm. Detailing why men fetch water matters for identifying and mitigating the physical and emotion harms of bearing responsibility for water labor, with implications for how gender should be conceptualized in water interventions intending to improve health and well-being.

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

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

Effects of environmental conditions on healthcare worker wellbeing and quality of care: A qualitative study in Niger

Environmental conditions (water, sanitation, hygiene, waste management, cleaning, energy, building design) are important for a safe and functional healthcare environment. Yet their full range of impacts are not well understood. In this study, we assessed the impact of environmental conditions on healthcare workers' wellbeing and quality of care, using qualitative interviews with 81 healthcare workers at 26 small healthcare facilities in rural Niger. We asked participants to report successes and challenges with environmental conditions and their impacts on wellbeing (physical, social, mental, and economic) and quality of care. We found that all environmental conditions contributed to healthcare workers' wellbeing and quality of care. The norm in facilities of our sample was poor environmental conditions, and thus participants primarily reported detrimental effects. We identified previously documented effects on physical health and safety from pathogen exposure, but also several novel effects on healthcare workers' mental and economic wellbeing and on efficiency, timeliness, and patient centeredness of care. Key wellbeing impacts included pathogen exposure for healthcare workers, stress from unsafe and chaotic working environments, staff dissatisfaction and retention challenges, out-of-pocket spending to avoid stockouts, and uncompensated labor. Key quality of care impacts included pathogen exposure for patients, healthcare worker time dedicated to non-medical tasks like water fetching (i.e., reduced efficiency), breakdowns and spoilage of equipment and supplies, and patient satisfaction with cleanliness and privacy. Inefficiency due to time lost and damaged supplies and equipment likely have substantial economic value and warrant greater consideration in research and policy making. Impacts on staff retention and care efficiency also have implications for health systems. We recommend that future research and decision making for policy and practice incorporate more holistic impact measures beyond just healthcare acquired infections and reconsider the substantial contribution that environmental conditions make to the safety of healthcare facilities and strength of health systems.

Mapping the global, regional, and national burden of diarrheal diseases attributable to unsafe water

Background

Diarrheal diseases are major contributors to deaths. Data on global and country-specific levels and trends of diarrheal diseases resulting from unsafe water are essential for policymakers to allocate resources.

Aims

This study aimed to describe the global, regional, and national spatiotemporal burden of diarrheal diseases resulting from unsafe water exposure.

Methods

According to the Global Burden of Disease (GBD) 2019 dataset, deaths, disability-adjusted life years (DALYs) of diarrheal diseases, and their age-standardized rates (ASRs) were analyzed by age and sex in 204 countries and territories. Moreover, the average annual percentage change (AAPC) was estimated by a log-linear regression model to reflect the time trend. The association between ASR of diarrheal diseases due to unsafe water and socio-demographic index (SDI) levels was also analyzed.

Results

From 1990 to 2019, the number of deaths and DALYs of diarrheal diseases resulting from unsafe water decreased by 50 and 59%, respectively. Moreover, the ASR of deaths and DALYs also decreased during the study period, with AAPCs of -3.69 (95% CI [95% confidence interval]: -3.91 to -3.47) and - 3.66 (95% CI: -3.8 to -3.52), respectively. High diarrheal diseases resulting from unsafe water occurred mainly in low SDI regions and Africa. Males exhibited greater diarrheal deaths attributable to unsafe water than females, which was contrary to the condition in terms of DALYs. The age-specific burden of diarrheal deaths attributable to unsafe water is concentrated in children younger than 5 years. The AAPCs of the ASR of both deaths and DALYs showed a strong negative correlation with the SDI levels.

Conclusion

The current study indicated that the global burden of unsafe water exposure-related diarrheal diseases decreased from 1990 to 2019 and varied significantly according to age, sex, and geographical location. Effective health promotion and health communication strategies and policies should be adopted to prevent and control diarrheal diseases resulting from unsafe water exposure.

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.

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.

Climate change and human health in the Eastern Mediterranean and Middle East: Literature review, research priorities and policy suggestions

Human health is linked to climatic factors in complex ways, and climate change can have profound direct and indirect impacts on the health status of any given region. Susceptibility to climate change is modulated by biological, ecological and socio-political factors such as age, gender, geographic location, socio-economic status, occupation, health status and housing conditions, among other. In the Eastern Mediterranean and Middle East (EMME), climatic factors known to affect human health include extreme heat, water shortages and air pollution. Furthermore, the epidemiology of vector-borne diseases (VBDs) and the health consequences of population displacement are also influenced by climate change in this region. To inform future policies for adaptation and mitigation measures, and based on an extensive review of the available knowledge, we recommend several research priorities for the region. These include the generation of more empirical evidence on exposure-response functions involving climate change and specific health outcomes, the development of appropriate methodologies to evaluate the physical and psychological effects of climate change on vulnerable populations, determining how climate change alters the ecological determinants of human health, improving our understanding of the effects of long-term exposure to heat stress and air pollution, and evaluating the interactions between adaptation and mitigation strategies. Because national boundaries do not limit most climate-related factors expected to impact human health, we propose that adaptation/mitigation policies must have a regional scope, and therefore require collaborative efforts among EMME nations. Policy suggestions include a decisive region-wide decarbonisation, the integration of environmentally driven morbidity and mortality data throughout the region, advancing the development and widespread use of affordable technologies for the production and management of drinking water by non-traditional means, the development of comprehensive strategies to improve the health status of displaced populations, and fostering regional networks for monitoring and controlling the spread of infectious diseases and disease vectors.

Growth and growth trajectory among infants in early life: contributions of food insecurity and water insecurity in rural Zimbabwe

Introduction

Stunting or linear growth faltering, measured by length-for-age Z-score (LAZ), remains a significant public health challenge, particularly in rural low-income and middle-income countries. It is a marker of inadequate environments in which infants are born and raised. However, the contributions of household resource insecurities, such as food and water, to growth and growth trajectory are understudied.

Methods

We used the cluster-randomised Sanitation Hygiene and Infant Nutrition Efficacy trial to determine the association of household-level food insecurity (FI) and water insecurity (WI) on LAZ and LAZ trajectory among infants during early life. Dimensions of FI (poor access, household shocks, low availability and quality) and WI (poor access, poor quality, low reliability) were assessed with the multidimensional household food insecurity and the multidimensional household water insecurity measures. Infant length was converted to LAZ based on the 2006 WHO Child Growth Standards. We report the FI and WI fixed effects from multivariable growth curve models with repeated measures of LAZ at 1, 3, 6, 12 and 18 months (M1-M18).

Results

A total of 714 and 710 infants were included in our analyses of LAZ from M1 to M18 and M6 to M18, respectively. Mean LAZ values at each time indicated worsening linear growth. From M1 to M18, low food availability and quality was associated with lower LAZ (β=-0.09; 95% -0.19 to -0.13). From M6 to M18, poor food access was associated with lower LAZ (β=-0.11; 95% -0.20 to -0.03). None of the WI dimensions were associated with LAZ, nor with LAZ trajectory over time.

Conclusion

FI, but not WI, was associated with poor linear growth among rural Zimbabwean infants. Specifically, low food availability and quality and poor food access was associated with lower LAZ. There is no evidence of an effect of FI or WI on LAZ trajectory.

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

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

Inequality of household water security follows a Development Kuznets Curve

Water security requires not only sufficient availability of and access to safe and acceptable quality for domestic uses, but also fair distribution within and across populations. However, a key research gap remains in understanding water security inequality and its dynamics, which in turn creates an impediment to tracking progress towards sustainable development. Therefore, we analyse the inequality of water security using data from 7603 households across 28 sites in 22 low- and middle-income countries, measured using the Household Water Insecurity Experiences Scale. Here we show an inverted-U shaped relationship between site water security and inequality of household water security. This Kuznets-like curve suggests a process that as water security grows, the inequality of water security first increases then decreases. This research extends the Kuznets curve applications and introduces the Development Kuznets Curve concept. Its practical implications support building water security and achieving more fair, inclusive, and sustainable development.

Water Insecurity is Associated with Lack of Viral Suppression and Greater Odds of AIDS-Defining Illnesses Among Adults with HIV in Western Kenya

Reliable access to safe and acceptable water in sufficient quantities (i.e., water security) is important for medication adherence and limiting pathogen exposure, yet prior studies have only considered the role of food security as a social determinant of HIV-related health. Therefore, the objective of this analysis was to assess the relationships between household water insecurity and HIV-related outcomes among adults living with HIV in western Kenya (N = 716). We conducted a cross-sectional analysis of baseline data from Shamba Maisha (NCT02815579), a cluster randomized controlled trial of a multisectoral agricultural and asset loan intervention. Baseline data were collected from June 2016 to December 2017. We assessed associations between water insecurity and HIV-related outcomes, adjusting for clinical and behavioral confounders, including food insecurity. Each five-unit higher household water insecurity score (range: 0-51) was associated with 1.21 higher odds of having a viral load ≥ 1000 copies/mL (95% CI 1.07, 1.36) and 1.26 higher odds of AIDS-defining illness (95% CI 1.11, 1.42). Household water insecurity was not associated with CD4 cell count (B: 0.27; 95% CI -3.59, 13.05). HIV treatment and support programs should consider assessing and addressing water insecurity in addition to food insecurity to optimize HIV outcomes.

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

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

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.

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.

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

Objective

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

Methods

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

Findings

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

Conclusions

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

Individual choices and universal rights for drinking water in rural Africa

Globally, four out of five people without safe drinking water live in rural areas. The human right to water identifies inalienable attributes of drinking water services in terms of affordability, proximity, quality, and reliability. It is unknown how specific attributes correspond to people’s priorities to address the multibillion-dollar costs of maintaining services in rural Africa to 2030. Evidence from Kenya indicates that improving reliability by repairing waterpoint faults within 2 d is the dominant attribute in securing user payments. Attributes of water quality and proximity register less support and seem more suited to public funding. Charting common ground between universal rights and individual choices can inform public policy in the design of sustainable funding for rural water service delivery.

More than 500 million rural Africans lack safe drinking water. The human right to water and United Nations Sustainable Development Goal SDG6.1 promote a policy shift from building water infrastructure to sustaining water services. However, the financial calculus is bleak with the costs of “safely managed”’ or “basic” water services in rural Africa beyond current government budgets and donor funds. The funding shortfall is compounded by the disappointing results of earlier policy initiatives in Africa. This is partly because of a failure to understand which attributes of water services rural people value. We model more than 11,000 choice observations in rural Kenya by attributes of drinking water quality, price, reliability, and proximity. Aggregate analysis disguises alternative user priorities in three choice classes. The two larger choice classes tolerate lower service levels with higher payments. A higher water service level reflects the smallest choice class favored by women and the lower wealth group. For the lower wealth group, slower repair times are accepted in preference to a lower payment. Some people discount potable water and proximity, and most people choose faster repair times and lower payments. We argue policy progress needs to chart common ground between individual choices and universal rights. Guaranteeing repair times may provide a policy lever to unlock individual payments to complement public investment in water quality and waterpoint proximity to support progressive realization of a universal right.

Reduced water collection time improves learning achievement among primary school children in India

In low-and-middle-income countries, the provisioning of safe drinking water is a challenge that will likely worsen with climate change. Securing water will require more work and time, burdening women and children the most. Currently, the consequences of this time burden to children's development remain understudied. To address this gap, we examine the tradeoff between children's household water collection responsibilities and learning achievement. Using nationally representative data from India, we measure the effect of daily fetching time on primary school children's learning achievement in a two-stage regression model, with rainfall as the instrument. Our analyses indicate that higher fetching times predict lower mathematics (-1.23 standard deviations, 95CI[-2.32, -0.14]), reading (-1.13 standard deviations, 95CI[-2.07, -0.19]), and writing (-1.21 standard deviations, 95CI[-1.89, -0.51]) test scores. These effects are heterogeneous across sex and infrastructure type. For example, we find girls' mathematical and reading skills profit more from reductions in fetching time than boys' (score less affected for boys by β amount: mathematics: β=0.26 points, 95CI[0.095, 0.42]; reading: β=0.27 points, 95CI[0.054, 0.49]). Children using hand pumps, open wells, or tube wells are hurt more academically in mathematics and writing by increases in fetching time than children with mostly off-premises piped access (e.g., writing scores more affected by β amount: hand pump: β=-0.18, 95CI[-0.29, -0.081]; open well: β=-0.18, 95CI[-0.33, -0.040]; tube well: β=-0.14, 95CI[-0.29, -0.00072]). Given these results, we recommend off-premises piped infrastructure in the absence of piped-to-premises water in water-insecure contexts and offer guidance for targeting infrastructure investments in India.

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

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

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

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

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.

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.