Domestic water carrying and its implications for health: a review and mixed methods pilot study in Limpopo Province, South Africa

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

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

Self-reported musculoskeletal disorder symptoms and associated factors among water carrying women in Legambo district, Northeastern Ethiopia: a community-based cross-sectional study design

Introduction

Musculoskeletal disorders are the leading cause of illness, disability, and poor quality of life. Lack of access to potable water in the backyard forces women to take water from off-plot sources every day, which may expose them to various health risks. However, there has been little investigation on the musculoskeletal disorders' health effects on water-carrying women.

Objective

This study aimed to assess musculoskeletal disorders symptoms and associated factors among water-carrying women in the Legambo district, Northeastern Ethiopia.

Materials and methods

A community-based cross-sectional study was done with 618 water-carrying women chosen using simple random and systematic random sampling techniques. The data were collected using face-to-face interviews with the standard Nordic Musculoskeletal Questionnaire. Data entry were carried out using Epi-data version 4.6 and exported to SPSS version 25.0 for analysis. A binary logistic regression was used to determine the factors associated with self-reported musculoskeletal disorder symptoms at a 95% confidence interval (CI). In the multivariate model, variables with a p-value ≤0.05 and a 95% CI were declared as factors of self-reported musculoskeletal disorder symptoms. The model's fitness was assessed using Hosmer and Lemeshow, and it was found to be fit.

Results

The prevalence of self-reported MSD symptoms was 72.5% during the previous 12 months. MSD symptoms were significantly elevated among women who carried water from a distance of 501-1,000 m [adjusted odds ratio (AOR) = 5.39, 95% CI = 3.64-9.69] and >1,000 m (5.93, 2.84-12.40), carried a water load of >15 kg during pregnancy (8.29, 2.97-23.09), and carried a water load of >15 kg when not pregnant (1.59, 1.44-2.68).

Conclusion

Three-fourths of the participants had self-reported musculoskeletal disorder symptoms in the past 12 months. Distance of water sources from their house, carrying the same amount of water during pregnancy, and weight of the water load carrying were factors associated with the self-reported musculoskeletal disorder symptoms. Hence, health professionals should raise awareness of the association between carrying high water loads and the development of MSDs, especially during pregnancy. Improvement in water supply infrastructure and enhancing behavioral intervention should be done. Furthermore, Future researchers should assess MSDs using objective measurements and cohort studies should be implemented.

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.

"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.

High salinity in drinking water creating pathways towards chronic poverty: A case study of coastal communities in Tanzania

Seawater intrusion is a growing pressure in coastal communities worldwide, putting millions of people at risk of excess salinity in drinking water. This study examines the impact of saline water on people's health and labor allocation as potential pathways towards chronic poverty. Using a transdisciplinary approach based on a coupled human-water system framework, we test these linkages combining field data on well water salinity levels and rich household survey data in coastal Tanzania. The results suggest that increased salinity levels lead to more time spent collecting drinking water and an increase in illnesses. Moreover, households in poorer villages with weaker public infrastructure have limited access to alternative sources of drinking water, making them more vulnerable to scarce potable water resources stemming from high salinity. To prevent chronic poverty, communities vulnerable to saline drinking water need better adaptation strategies as well as groundwater monitoring and management.

Sustainability of drinking water and sanitation delivery systems in rural communities of the Lepelle Nkumpi Local Municipality, South Africa

Water and sanitation are core for the growth and development of communities. Yet, South African local municipalities are often unable to sustainably deliver safe water and basic sanitation for all. Drawing on perspectives of ecological economics, this study analysed the sustainability of water and sanitation systems in rural communities of the Lepelle Nkumpi Local Municipality. Mixed research approach was used to collect the data from 657 household and institutional respondents. The study found that households used water for multi-purposes including consumptive, productive and domestic, but existing facilities are in deplorable condition. Pollution arising from agrochemicals, waste systems, mining, sewerage, and industrial effluence significantly affected water systems in the communities. Bridging demand-supply gaps require initiatives like bulk water supply and implementation of the free basic water policy in underprivileged areas. Tariffs should either be waived or adjusted for extremely poor households. Waste management initiatives, like capacity building, public education, investments, and facility upgrade, could help avert spread of waterborne infections and improve the resident's health.

The consequence of head-loading on the neuro-musculoskeletal health of the ILembe District youth of KwaZulu-Natal

Background

Head-loading, as a mode of transporting food, water and firewood, is a longstanding tradition assigned to female South African youth and has been associated with adverse health consequences.

Objectives

This study determined the impact of head-loading on the neuromusculoskeletal health and proprioception of female South African youth.

Method

This study comprised a counterbalanced, within-subject, single-factor experimental design which compared the changes that occurred when the same independent variable (head-loading) within two homogenous groups was measured in terms of the dependent variables (outcomes: neuromusculoskeletal pain and proprioception) at two time periods, before and after the introduction of the independent variable. A cohort of South African female youth (n = 100), aged 9-17 years, voluntarily partook in the study. The participants were randomly distributed into an experimental (n = 50) and a control (n = 50) group. The experimental group stood in a head-loaded state with their respective habitual head-load mass. Their proprioception measurements were compared during their unloaded versus loaded states, with the proprioceptive measurements including the total proprioception index, the anterior-posterior (front-back) index and the medial-lateral (side-to-side) index. Participants furthermore completed a head-loading health-related questionnaire.

Results

Participants had a mean age of 12.3 ± 2.5 years, body mass of 44.4 ± 13.7 kg, stature of 145 ± 10 cm and a head-load mass of 8.0 ± 2.5 kg. Participants had poorer medial-lateral proprioception during head-loading as compared to their unloaded state (1.4 ± 0.8 as compared to 1.6 ± 0.9) (p < 0.05). Most youth (96%) experienced neuromusculoskeletal pain in their cervical vertebrae (40.9%), shoulders (27.3%), lumbar vertebrae (10.7%), arms (8.3%), legs (8.3%), knees (1.9%), fingers (1.5%), toes (0.5%) and thoracic vertebrae (0.5%) (χ²: p < 0.05).

Conclusion

Head-loading adversely affects the medial-lateral proprioception and neuromusculoskeletal health of participants.

Contribution

The findings of this study confirms that head-loading produces musculoskeletal pain.

Health gender gap in Uganda: do weather effects and water play a role?

BACKGROUND

Vulnerabilities of men and women to adverse health effects due to weather variability and climate change are not equal. Uganda was among the countries in the world most affected by extreme weather events during the last decade. However, there is still limited gendered empirical evidence on the links between weather variability and health and the possible pathways through which these health effects occur. Therefore, this study analyses the effect of weather variability on illness, and the extent to which water collection 'time burden' mediates the relationship between weather anomalies and illness among men and women of working age in Uganda. The study also quantifies the health inequalities to be eliminated if resources are equalized.

METHODS

Socioeconomic, health and time use data were obtained from the World Bank Living Standards Measurement Studies - Integrated Surveys on Agriculture (LSMS -ISA), combined with high resolution remotely-sensed weather data. Two-parts and non-linear decomposition regression analysis were used on the national representative pooled dataset from the four household survey waves collected between 2009 to 2014, comprising a total of 22,469 men and women aged between 15 and 64 years.

RESULTS

Empirical results show that low rainfall below the long-term mean increased the likelihood of illness by at least 8 and 6 percentage points for women and men, respectively. The indirect effect of low rainfall on illness through water access pathway was estimated at 0.16 percentage points in women. Decomposition results reveal that health inequalities among women and men would have been narrowed by 27-61%, if endowments were equalized.

CONCLUSIONS

Strategies that promote women empowerment (such as education, labor force participation, access to financial services and clean water), health adaptation and time poverty reduction strategies (such as rain water harvesting and improved access to quality health care) would reduce gender-based health inequalities in Uganda despite changing climatic conditions.

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.

Barriers and bridges on water management in rural Mexico: from water-quality monitoring to water management at the community level

Access to sufficient water of suitable quality represents a challenge for achieving several dimensions of sustainable development. Currently, water access is restricted to three of 10 persons globally. In rural areas of Mexico and other low-income countries, coverage could be even less due to the absence of formal supply; thus, rural communities usually perform water management. Surrounding community-based water management, various socio-ecological interactions emerge that determine access to water. Access to water will depend on the obstacles or capacities that arise within the socio-ecological system in which the community is immersed. This work identifies barriers and bridges to water access in a rural environment through mixed methods. The article draws on three case studies in southeastern Mexico by analyzing 90 questionnaires conducted at the household level and three focus groups in parallel with water quality analysis and its relationship with management practices. The barriers and bridges were classified into six water access challenges: (i) access to water in a sufficient quantity, (ii) access to water of adequate quality, (iii) access to water for household crop irrigation, (iv) hygiene and sanitation facilities, (v) collective organization, and (vi) climate variability. The main findings indicate that households' water quantity and quality show deficiencies due to the lack of formal infrastructure and represent a health risk. Water fetching has the highest impact on women and children in poor rural areas, and it is a significant barrier to sustainable development. In contrast, the collective organization proved to be an essential bridge for water access in these communities.

Water carrying in hills of Nepal–associations with women’s musculoskeletal disorders, uterine prolapse, and spontaneous abortions

More than a third of women in Nepal have to carry water from source to home to satisfy their families’ daily needs. A cross-sectional study was carried out in a hilly area in Nepal to assess water-carrying practices and their association with women’s health. Quantitative interviews were conducted with 1001 women of reproductive age and were complemented with health surveys carried out by health professionals and structured observations of water carrying. Multivariate mixed logistic regression models were used to assess the associations between water-carrying-related risk factors and health issues for women. Around 46% of women faced considerably increased to excessive physical stress due to water carrying during the dry season. Women suffered from a disproportionately high prevalence of back pain (61%), with about 18% of this pain being horrible to excruciating; pain in the knees (34%); uterine prolapse (11.3%); and at least one spontaneous abortion (9%). The risk category of water carrying was significantly associated with uterine prolapse (OR = 1.44, 95%CI = 1.12–1.85, p = 0.031) and pain in the hips (OR = 1.69, 95%CI = 1.27–2.26, p<0.001). Receiving help with water carrying during pregnancy and during the first three months after delivery was associated with reduced odds ratios for uterine prolapse (OR = 0.10, 95% CI = 0.01–0.87, p = 0.037), and strong back pain (OR = 0.32, 95% CI = 0.12–0.87, p = 0.026). Improvements to water supply infrastructure and the promotion of social support for carrying water during pregnancy and after delivery are recommended to reduce water-carrying-related health risks.

Water, Sanitation and Hygiene in Schools in Low- and Middle-Income Countries: A Systematic Review and Implications for the COVID-19 Pandemic

The global COVID-19 pandemic has revealed the extent to which schools are struggling with the provision of safe drinking water, sanitation and hygiene (WASH). To describe the WASH conditions in schools and discuss the implications for the safe reopening of schools during the ongoing COVID-19 pandemic, a systematic review of peer-reviewed literature on WASH in schools in low- and middle-income countries was performed. In April 2021, five databases, including MEDLINE (via PubMed), Web of Science, Scopus, AJOL, and LILACS, were used to identify studies. Sixty-five papers met the inclusion criteria. We extracted and analyzed data considering the Joint Monitoring Programme (JMP) definitions and the normative contents of Human Rights to safe drinking water and sanitation. Publications included in this systematic review considered 18,465 schools, across 30 different countries. Results indicate a lack of adequate WASH conditions and menstrual hygiene management requirements in all countries. The largely insufficient and inadequate school infrastructure hampers students to practice healthy hygiene habits and handwashing in particular. In the context of the COVID-19 pandemic, being hindered to implement such a key strategy to contain the spread of SARS-CoV-2 in the school environment is of major concern.

Influence of Axial Load and a 45-Degree Flexion Head Position on Cervical Spinal Stiffness in Healthy Young Adults

Background: Neck pain is a major cause of disability worldwide. Poor neck posture such as using a smartphone or work-related additional cervical axial load, such headgear of aviators, can cause neck pain. This study aimed at investigating the role of head posture or additional axial load on spinal stiffness, a proxy measure to assess cervical motor control. Methods: The posterior-to-anterior cervical spinal stiffness of 49 young healthy male military employees [mean (SD) age 20 ± 1 years] was measured in two head positions: neutral and 45-degree flexed head position and two loading conditions: with and without additional 3 kg axial load. Each test condition comprised three trials. Measurements were taken at three cervical locations, i.e., spinous processes C2 and C7 and mid-cervical (MC). Results: Cervical spinal stiffness measurements showed good reliability in all test conditions. There was a significant three-way interaction between location × head position × load [F(2, 576) = 9.305, p < 0.001]. Significant two-way interactions were found between measurement locations × loading [F(2, 576) = 15.688, p < 0.001] and measurement locations × head position [F(2, 576) = 9.263, p < 0.001]. There was no significant interaction between loading × head position [F(1, 576) = 0.692, p = 0.406]. Post hoc analysis showed reduction of stiffness in all three measurement locations in flexion position. There was a decrease in stiffness in C2 with loading, increase in stiffness in C7 and no change in MC. Discussion: A flexed head posture leading to decreased stiffness of the cervical spine might contribute to neck pain, especially if the posture is prolonged and static, such as is the case with smartphone users. Regarding the additional load, stiffness decreased high cervical and increased low cervical. There was no change mid cervical. The lower spinal stiffness at the high cervical spine might be caused by capsular ligament laxity due to the buckling effect. At the lower cervical spine, the buckling effect seems to be less dominant, because the proximity to the ribs and sternum provide additional stiffness.

Drinking Water Insecurity in Southwest Coastal Bangladesh: How Far to SDG 6.1?

Substantial progress has been seen in the drinking water supply as per the Millennium Development Goals (MDG), but achieving the Sustainable Development Goals (SDG), particularly SGD 6.1 regarding safely managed drinking water with much more stringent targets, is considered as a development challenge. The problem is more acute in low-income water-scarce hard-to-reach areas such as the southwest coastal region of Bangladesh, where complex hydrogeological conditions and adverse water quality contribute to a highly vulnerable and insecure water environment. Following the background, this study investigated the challenges and potential solutions to drinking water insecurity in a water-scarce area of southwest coastal Bangladesh using a mixed-methods approach. The findings revealed that water insecurity arises from unimproved, deteriorated, unaffordable, and unreliable sources that have significant time and distance burdens. High rates of technical dysfunction of the existing water infrastructure contribute to water insecurity as well. Consequently, safely managed water services are accessible to only 12% of the population, whereas 64% of the population does not have basic water. To reach the SDG 6.1 target, this underserved community needs well-functioning readily accessible water infrastructure with formal institutional arrangement rather than self-governance, which seems unsuccessful in this low-income context. This study will help the government and its development partners in implementing SDG action plans around investments to a reliable supply of safe water to the people living in water-scarce hard-to-reach coastal areas.

Understanding safe water-carrying practices during pregnancy and postpartum: A mixed-methods study in Nepal

Daily carrying of heavy loads of domestic water, especially during pregnancy and postpartum, bears a threat to maternal health in low‐income countries. Using an extended health action process approach (HAPA), we examined women's reasons for and psychosocial determinants of safe water‐carrying during pregnancy and postpartum. In a mixed‐methods study, trained local interviewers conducted 1001 quantitative interviews with women of reproductive age (n = 921 analyzed) and 21 qualitative interviews with women of reproductive age, in‐laws, and spouses in rural Nepal. We analyzed the quantitative data with generalized estimating equations to model the HAPA‐based psychosocial determinants of avoiding water‐carrying during pregnancy and postpartum. Subjective perspectives were investigated with thematic analysis. Outcome expectancies (B = 0.24), self‐efficacy (B = 0.20), and injunctive norms (B = 0.23) were significantly associated with the intention to avoid water‐carrying. Self‐efficacy (B = 0.36) and instrumental support (B = 0.05) are related to behavior (all p < 0.05). Women explained water‐carrying during pregnancy by a lack of family support, a shift of health decision‐making power to in‐laws, and low behavioral control. Overall, the necessity of water, family decision‐making structures, and low support make it difficult for women to discontinue water‐carrying. Additionally to infrastructural improvements, behavioral interventions may increase women's self‐efficacy for safe water‐carrying (e.g. reducing weight) and social support.

Donkey Ownership Provides a Range of Income Benefits to the Livelihoods of Rural Households in Northern Ghana

Simple Summary

Until recently, the important contributions donkeys make to the daily lives of millions of people around the world have been overlooked. Global donkey populations are under threat from increasing demand for their skins, a key ingredient in a traditional Chinese medicine called e’jiao. The aim of this research was to study the role of donkeys in rural households in northern Ghana. We wanted to know how donkeys support families in making a living, especially their use by women and children. We found that donkeys are highly valued by their owners. Donkeys help reduce the hard physical work of many farming and domestic activities and can also be rented out to generate income. There are actually more methods available to earn money from the family donkey than previously known. Females from donkey-owning households advised us that their donkey can provide between 30–60% of their total income. Children can also play a key role accompanying their donkey when it is hired out for cash. Donkeys are certainly important to their owners, who describe them as priceless. This research adds to our understanding of the impact of the e’jiao industry, by detailing the considerable value of live donkeys to poor farming households.

Abstract

Donkeys provide important resources and benefits for millions of people worldwide. However, global donkey populations are under increasing pressure from the growing demand for a traditional Chinese medicine, e’jiao, made from donkey-skin. The objective of this reflexive, qualitative thematic analysis was to examine the role of donkeys with 262 participants in northern Ghana and how donkeys contribute to livelihood outcomes, especially their use by women and children. Data were collected from four surveys, 12 in-depth interviews and 84 daily time budgets with the same participants, plus 16 focus groups, during one wet and one dry season across 2018-19. Uniquely, boys and girls between the ages of 10–16-years old were interviewed. Donkeys are highly valued by their owners as they play a valuable role in providing a pathway out of ultra-poverty. Donkeys’ contributions to livelihoods are significant and more complex than previously understood and documented in the literature. Donkey ownership confers up to six different income benefits in comparison to non-donkey owners. Female owners of donkeys reported that donkeys can contribute between 30–60% of their income. Children of both sexes can play an important role in the efficient deployment of one of these income generating activities.

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

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

Effects of increasing axial load on cervical motor control

To investigate the effects of increasing axial load on cervical motor control. Surrogates of cervical motor control were active cervical range of motion (C-ROM) and joint position error (JPE) assessed in flexion, extension, lateroflexion and rotation directions in 49 healthy young men (mean age: 20.2 years). All measurements were executed with 0-, 1-, 2-, and 3-kg axial loads. Linear mixed models were used to assess the effects of axial loading and cervical movement-direction on C-ROM and JPE. Post-hoc analysis was performed to compare load levels. Axial loading (p = 0.045) and movement direction (p < 0.001) showed significant main effects on C-ROM as well as an interaction (p < 0.001). C-ROM significantly changed with 3-kg axial load by decreaseing extension (− 13.6%) and increasing lateroflexion (+ 9.9%). No significant main effect was observed of axial loading on JPE (p = 0.139). Cervical motor control is influenced by axial loading, which results in decreased C-ROM in extension and increased C-ROM lateroflexion direction.

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.

Transitioning to a life with disability in rural South Africa: A qualitative study

Background

Adjustment to the onset of disability has complex reverberations relating to both socially engendered disadvantage and the realities of functional limitation. Pre-existing ways of understanding disability can meaningfully shape this experience.

Objective

This study aimed to provide an exploratory understanding of the experience of becoming disabled in a low-income, under-served, rural South African community. In particular, it was interested in how people with disabilities constructed their struggle within the conceptual split between disadvantage caused by ‘malfunctioning’ bodies (a ‘medical model’ view) and that caused by social organisation (a ‘social model’ view).

Methods

Seven people between the ages of 39 and 47 who had acquired a physical disability within the last 4 years were recruited in a rural area of Limpopo province, South Africa. Semi-structured face-to-face interviews were conducted, and the resulting data were thematically analysed. The authors were positioned as both ‘insiders’ and ‘outsiders’ to the participants and sought to use this orientation to best understand and stay faithful to participants’ views while simultaneously applying participant’s experiences to conceptual knowledge in disability studies.

Results

Four themes emerged: (1) emotional impact of onset of disability, (2) being introduced to disablist prejudice, (3) being required to take on a ‘disabled’ identity and (4) socio-economic implications of becoming disabled. The findings reflected a complex set of adverse experiences in the lives of the participants, spanning disadvantages based on embodied, cultural, relational and environmental factors, which were superimposed on existing, generalised poverty in their local communities. Participants made sense of their predicament in multiple, evolving ways.

Conclusion

This study contributes to the understanding of the complex predicaments, and sense-making, of persons who have acquired a disability in a rural, impoverished Global South environment.

Assessing the effect of irrigation on household water quality and health: A case study in rural Ethiopia

In areas with inadequate improved water supply, irrigation water serves as an alternative water source for domestic uses in addition to its prime purpose of agricultural production. This increased water availability for the household can generate positive hygiene and health impacts, but poor irrigation water quality can be a source of domestic water contamination and can be harmful to human health. Using primary household survey data from two rural districts of Ethiopia, this study seeks to disentangle these opposite effects: the results show that irrigation is associated with poor household water quality (adjusted odds ratio 1.68, 95%, CI 1.07-2.66) and a lower risk of diarrheal disease (adjusted odds ratio 2.07, 95%, CI 1.24-3.44). Domestic use of irrigation water, however, does not further degrade the microbial quality of household water. On the other hand, the domestic use of irrigation water reduces the burden of water collection (p < 0.01). Providing education and training programs to foster behavioral change towards sustainable improvements in water resource management, such as the safe use of irrigation water for domestic purposes through appropriate point-of-use water treatment, would be crucial to maximize the benefits of the domestic use of irrigation water and to minimize adverse environmental and health risks.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Household practices in accessing drinking water and post collection contamination: A seasonal cohort study in Malawi

Lack of access to safe drinking water on premises remains widespread in low- and middle-income countries. Interventions to improve access to safe water at the point of collection are essential, but water safety at the point of consumption is also an important consideration. This research aimed to 1) improve understanding of household practices in collecting water with respect to seasonality, and 2) to further assess risk associated with post-collection contamination from the point of collection to the point of consumption. A seasonal cohort study, including 115 households, was conducted in Malawi. Along with household surveys and observations, samples of water were tested for microbial water quality at four different stages of water collection: water source, collection container, storage container, cup of drinking water. Using E. coli as an indicator of contamination (cfu/100 ml), the risk of post-collection contamination was assessed. The results indicate that most water sources were free from contamination; contamination was proportionally lower in the dry season when more sources were found to be classified as having a very low risk of contamination. However, the level of risk of contamination was more likely to increase following collection in water sources that were initially free from contamination. Results show that the degradation in water quality from the point of collection to the point of consumption was more important in the rainy season, which is likely to be driven by the effect of seasonality on the household environment. Filling the collection container at the point of collection and storage at the point of consumption were found to be critical stages for an increased risk of E. coli contamination. Understanding household practices in accessing and handling water during both rainy and dry season is necessary to target appropriate interventions to reduce post-collection contamination.

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.

When Land Is Under Pressure Health Is Under Stress

The land provides vital resources to support life on Earth. Land ecosystems services have social, cultural, and spiritual benefits and promote human health and well-being. However, human activities, particularly ongoing unsustainable land practices, are negatively impacting ecosystems through desertification, land degradation and drought (DLDD). This article highlights the pressures and impacts of DLDD on human health through exposure pathways, including water security and safety; sanitation and hygiene; food security and safety; air quality; and soil quality. We describe the impacts on 19 health outcomes in three groups: non-communicable diseases; injuries; and infections, parasitic and nutritional diseases. The magnitude of these health impacts is mediated by social, economic, and health system-related factors. We propose actions for the health sector to respond to the DLDD challenges.

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.

Levels and Correlates of Physical Activity in Rural Ingwavuma Community, uMkhanyakude District, KwaZulu-Natal, South Africa

Physical activity, among others, confers cardiovascular, mental, and skeletal health benefits to people of all age-groups and health states. It reduces the risks associated with cardiovascular disease and therefore, could be useful in rural South Africa where cardiovascular disease (CVD) burden is increasing. The objective of this study was to examine levels and correlates of physical activity among adults in the Ingwavuma community in KwaZulu-Natal (KZN). Self-reported data on physical activity from 392 consenting adults (female, n = 265; male, n = 127) was used. We used the one-sample t-test to assess the level of physical activity and a two-level multiple linear regression to investigate the relationship between total physical activity (TPA) and independent predictors. The weekly number of minutes spent on all physical activities by members of the Ingwavuma community was 912.2; standard deviation (SD) (870.5), with males having 37% higher physical activity (1210.6 min, SD = 994.2) than females (769.2, SD = 766.3). Livelihood activities constituted 65% of TPA, and sport and recreation contributed 10%. Participants without formal education (20%), those underweight (27%), and the obese (16%) had low physical activity. Notwithstanding this, in general, the Ingwavuma community significantly exceeded the recommended weekly time on physical activity with a mean difference of 762.1 (675.8–848.6) minutes, t (391) = 17.335, p < 0.001. Gender and age were significant predictors of TPA in level 1 of the multiple regression. Males were significantly more active than females by 455.4 min (β = −0.25, p < 0.001) and participants of at least 60 years were significantly less active than 18–29-year-olds by 276.2 min (β = −0.12, p < 0.05). Gender, marital status, and health awareness were significant predictors in the full model that included education level, employment status, body mass index (BMI), and physical activity related to health awareness as predictors. The high prevalence of insufficient physical activity in some vulnerable groups, notably the elderly and obese, and the general poor participation in sport and recreation activities are worrisome. Hence we recommend health education interventions to increase awareness of and reshape sociocultural constructs that hinder participation in leisure activities. It is important to promote physical activity as a preventive health intervention and complement the pharmacological treatment of CVDs in rural South Africa. Physical activity interventions for all sociodemographic groups have potential economic gains through a reduction in costs related to the treatment of chronic CVD.

Burden of spine pain among rural and tribal populations in Raigad District of Maharashtra State of India

BACKGROUND

Among non-communicable disorders, low back and neck pain are the most common causes of severe, long-term pain and disability affecting more than a billion people globally. Yet, the burden and impact of these conditions are not well understood, especially among rural and tribal people living in low- and middle-income countries.

OBJECTIVE

The aims of this study were to measure point prevalence of low back and neck pain among rural and tribal people in Raigad District of Maharashtra, India, and explore attitudes and beliefs of rural people towards spine pain and disability.

DESIGN

In a cross-sectional survey of six villages in the Raigad District of Maharashtra State of India from August to October 2016, low back and neck pain were measured using the Spine Pain Questionnaire.

RESULTS

We surveyed 2323 participants, which did not include children and adolescents. Among rural people (n = 2073), the point prevalence of low back and neck pain was 4.9% (95% CI 3.94-5.79) and 2.9% (95% CI 2.21-8.87), respectively. Among tribal people (n = 250), prevalence was 10.0% (95% CI 6.28-13.71) for low back pain and 3.6% (95% CI 1.29-5.90) for neck pain. Lifting heavy weights and bending trunk were the most limiting activities. During informal discussions, most villagers attributed spine pain to traditional lifestyle and age. Participants continued occupational work in the presence of pain. Lack of transport facilities and cost of treatment emerged as the two most common reasons for delay in seeking treatment at nearby healthcare centres. This information will inform the development of customized spine care programmes through community-engaged partnerships and self-empowerment of the local community.

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:

Understanding female migrant child labor within a cumulative risk framework: The case for combined interventions in Ghana

North-to-south migration has been a persistent trend in Ghana. Yet the migrating population has recently shifted to become predominantly female and younger, with a significant increase in rural adolescent girls seeking employment in urban and peri-urban areas. For adolescents without strong networks of social and financial support, this practice can jeopardize their physical and mental health, putting them at risk of sexual victimization and economic exploitation. Building upon the work of cumulative risk and ecological systems theorists, this article examines the case of female adolescent load bearers (Kayayei) in Ghana, highlighting the need to develop and evaluate multi-component prevention efforts.

The Impact of Heavy Load Carrying on Musculoskeletal Pain and Disability Among Women in Shinyanga Region, Tanzania

Background

Heavy load carrying has been associated with musculoskeletal discomfort (MSD) and disability. However, there is a lack of research investigating this association in resource-constrained settings where heavy load carrying by women is common.

Objectives

We assessed the impact of heavy load carrying on musculoskeletal pain and disability among women in Shinyanga Region, Tanzania, in an exploratory cross-sectional study.

Methods

Eligible participants were a convenience sample of women, at least 18 years of age, who passed a study recruitment site carrying a load. We collected information on load-carrying practices, including frequency and time spent carrying water, wood, agricultural products, coal, sand, or rocks, and measured the weight of the load carried at the time. Outcomes included self-reported MSDs, defined as experiencing pain lasting >3 days in the neck, head, back, knees, feet and/or ankles within the last 1 year, and related disability. Using multivariable logistic regression we assessed for associations between load carrying exposures and MSDs and disability.

Findings

Results showed a high prevalence of MSDs across the body regions assessed and evidence to suggest a relationship of back pain and related disability with several measures of load-carrying, including duration, frequency, and weight. Multivariable analyses revealed associations of increased load carrying exposures with low back pain (LBP) and related disability, including statistically significant increases in odds of LBP with increasing weight, total duration of load carrying/week and cumulative loads/week.

Conclusions

Findings indicate a substantial burden of MSDs and disability in this population of women who carry heavy loads daily. The extent of discomfort and disability increased with increasing exposure to various load-carrying measures, especially for LBP. Larger epidemiologic studies that definitively assess relationships of load carrying with MSDs and disability are warranted.

Alternative Water Transport and Storage Containers: Assessing Sustained Use of the PackH2O in Rural Haiti

The PackH₂O water backpack carrier was developed to provide safe storage and relieve stress of head-loading during water transport with traditional containers such as buckets and jerry cans. We conducted an evaluation to assess both self-reported and observed use over a 6-month period between November 2014 and May 2015. A total of 866 packs were distributed to 618 households in six communities in rural Haiti, and 431 and 441 households were surveyed at midline and end line, respectively. We performed linear regression to assess change of self-reported use over time. Although 79.3% of respondents reported continued use of the 20-L pack after 6 months, other measures of self-reported use were low, with only 16.8% reporting to have used the pack the last time they collected water and 10.3% preferring the pack over other water collection containers. In addition, only 10.2% of all people collecting water at community sources were observed using packs and 12.0% of all households surveyed had water in the pack at the time of visit. Pack use varied by community and demographics. Although women were targeted during distribution, men preferred the pack and were more commonly observed using it at the community water sources. In conclusion, the use of the PackH₂O was not widely adopted in rural Haiti; however, further research is needed to assess the pack acceptance in areas where back-loading is more common and in emergency settings.

Water insecurity: An agenda for research and call to action for human biology

Water insecurity-the lack of adequate and safe water for a healthy and productive life-is one of the greatest threats facing humans in the coming century. By 2030, half of the world is expected to be living in water-stressed conditions, given current climate change scenarios. A key goal of the UN Water Action Decade and Sustainable Development Goal 6 is to improve water security for the three billion people globally affected, but the future looks grim. For many communities, from Cape Town, South Africa to Flint, United States, the imagined dystopian future of severe water shortages has already arrived-shaped not so much by lack of water, but by aging infrastructure, underfunded utilities, social exclusion, politicized commodification, and environmental racism. Stepping off from my biocultural research in Cochabamba, Bolivia, I discuss how recent research is dramatically advancing our understanding of water insecurity, such as new findings around the biocultural causes and consequences of dehydration, contamination, and water stress. But, much more needs be done to support local communities in creating fair and just water systems. I discuss how human biologists can make crucial contributions toward the advancement of a much-needed science of water insecurity, while highlighting some practical and ethical challenges to advancing a core mission of providing safe, sufficient water to all.

Environmental Correlates of Health-Related Quality of Life among Women Living in Informal Settlements in Kenya

Informal settlements (slums)—defined as residential areas lacking durable housing; sufficient living and public spaces; access to basic infrastructure, water, sanitation, and other services; and secure tenancy—are presumed to be poor health environments. Research in Kenya suggests that residents of these settlements have the worst health outcomes of any population, yet there is a paucity of research focused on the health and well-being of these residents. Even less attention is given to the role played by environment in health in these settings. The present study addresses these gaps by examining potential environmental correlates, specifically access to water and sanitation, of health-related quality of life (HRQOL) among 552 women in Mathare slum in Nairobi, Kenya. A Kiswahili version of the 36-Item Short Form Health Survey (SF-36) measured HRQOL. Results suggested that access to a toilet at all times was associated with every subscale of the mental health and general well-being domains of the SF-36. Primary water source was also associated with women’s HRQOL. Despite increasing efforts to expand sanitation and water access in informal settlements, more attention should be given to whether the interventions being introduced, which likely affect women’s psychosocial health, are appropriate for all residents, including women.

Drinking water accessibility and quantity in low and middle-income countries: A systematic review

BACKGROUND

Increasing the quantity of water available for consumption and hygiene is recognized to be among the most efficient interventions to reduce the risk of water-related infectious diseases in low and middle-income countries. Such impacts are often associated with water supply accessibility (e.g. distance or collection time) and used to justify investment in improving access.

OBJECTIVE

To assess the relationship between the water source location and the quantity of water available in households from low and middle-income countries by identifying the effects of interventions aiming to improve access, and to compare the indicators and measures used to collect information.

METHODS

We systematically searched seven databases (i.e. Cairn, Cochrane Library, Embase, MEDLINE, PubMed, Web of Science, Women's Studies International) along with grey literature for articles reporting indicators and measures of accessibility and quantity. We found 6492 records, of which 20 studies were retained that met the review's inclusion criteria.

RESULTS

Most studies were conducted in rural settings and provided suggestive findings to describe an inverse relationship between accessibility and quantity. Overall, a wide range of indicators and measures were used to assess water accessibility and quantity in the selected studies along with their association. The lack of consistency raised concerns regarding comparability and reliability of these methods.

CONCLUSIONS

The review findings support the hypothesis that the quantity of water available in households is a function of the source location, but the inconsistency in study outcomes highlights the need to further investigate the strength and effects of the relationship.

'Water is life': developing community participation for clean water in rural South Africa

Background

South Africa is a semiarid country where 5 million people, mainly in rural areas, lack access to water. Despite legislative and policy commitments to the right to water, cooperative governance and public participation, many authorities lack the means to engage with and respond to community needs. The objectives were to develop local knowledge on health priorities in a rural province as part of a programme developing community evidence for policy and planning.

Methods

We engaged 24 participants across three villages in the Agincourt Health and Socio-Demographic Surveillance System and codesigned the study. This paper reports on lack of clean, safe water, which was nominated in one village (n=8 participants) and in which women of reproductive age were nominated as a group whose voices are excluded from attention to the issue. On this basis, additional participants were recruited (n=8). We then held a series of consensus-building workshops to develop accounts of the problem and actions to address it using Photovoice to document lived realities. Thematic analysis of narrative and visual data was performed.

Results

Repeated and prolonged periods when piped water is unavailable were reported, as was unreliable infrastructure, inadequate service delivery, empty reservoirs and poor supply exacerbated by droughts. Interconnected social, behavioural and health impacts were documented combined with lack of understanding, cooperation and trust between communities and authorities. There was unanimity among participants for taps in houses as an overarching goal and strategies to build an evidence base for planning and advocacy were developed.

Conclusion

In this setting, there is willingness among community stakeholders to improve water security and there are existing community assemblies to support this. Health and Socio-Demographic Surveillance Systems provide important opportunities to routinely connect communities to resource management and service delivery. Developing learning platforms with government and non-government organisations may offer a means to enable more effective public participation in decentralised water governance.

Development and validation protocol for an instrument to measure household water insecurity across cultures and ecologies: the Household Water InSecurity Experiences (HWISE) Scale

INTRODUCTION

A wide range of water-related problems contribute to the global burden of disease. Despite the many plausible consequences for health and well-being, there is no validated tool to measure individual- or household-level water insecurity equivalently across varying cultural and ecological settings. Accordingly, we are developing the Household Water Insecurity Experiences (HWISE) Scale to measure household-level water insecurity in multiple contexts.

METHODS AND ANALYSIS

After domain specification and item development, items were assessed for both content and face validity. Retained items are being asked in surveys in 28 sites globally in which water-related problems have been reported (eg, shortages, excess water and issues with quality), with a target of at least 250 participants from each site. Scale development will draw on analytic methods from both classical test and item response theories and include item reduction and factor structure identification. Scale evaluation will entail assessments of reliability, and predictive, convergent, and discriminant validity, as well as the assessment of differentiation between known groups.

ETHICS AND DISSEMINATION

Study activities received necessary ethical approvals from institutional review bodies relevant to each site. We anticipate that the final HWISE Scale will be completed by late 2018 and made available through open-access publication. Associated findings will be disseminated to public health professionals, scientists, practitioners and policymakers through peer-reviewed journals, scientific presentations and meetings with various stakeholders. Measures to quantify household food insecurity have transformed policy, research and humanitarian aid efforts globally, and we expect that an analogous measure for household water insecurity will be similarly impactful.

Gender and Community Mainstreaming in Fog Water Collection Systems

Fog water collection is an emerging opportunity to combat local water shortages in water-scarce areas where sustainable access to water is unreliable, but fog events are frequent. Since fog water systems are implemented within or near communities, they eliminate or decrease the need to travel far distances for the collection of water during times of scarcity. As a result, these systems decrease the physical and social burden of water collection on women and girls, who are the primary water gatherers in most traditional communities. This is an important outcome because women and girls are disproportionately affected by water scarcity and are not seen as equals in water management, access, or control. This paper illustrates how several fog water collection projects have shown, empirically, that the positive outcomes for women and girls may include the freeing of time for domestic and educational pursuits, improved health outcomes, and improved perceptions of self and others’ perceptions of women. These findings are important at a time when the world at large is addressing the Sustainable Development Agenda, where Sustainable Development Goal (SDG) 6 necessitates safe water and sanitation for all and SDG 5 ensures gender equality to empower all women and girls.

Impact of social capital, harassment of women and girls, and water and sanitation access on premature birth and low infant birth weight in India

BACKGROUND

Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes.

METHODS AND FINDINGS

This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification.

CONCLUSIONS

The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India.

'I know how stressful it is to lack water!' Exploring the lived experiences of household water insecurity among pregnant and postpartum women in western Kenya

There is rapidly evolving literature on water insecurity in the general adult population, but the role of water insecurity during the vulnerable periods of pregnancy and postpartum, or in the context of HIV, has been largely overlooked. Therefore, we conducted an exploratory study, using Go Along interviews, photo-elicitation interviews, and pile sorts with 40 pregnant and postpartum Kenyan women living in an area of high HIV prevalence. We sought to (1) describe their lived experiences of water acquisition, prioritisation, and use and (2) explore the consequences of water insecurity. The results suggest that water insecurity is particularly acute in this period, and impacts women in far-reaching and unexpected ways. We propose a broader conceptualisation of water insecurity to include consideration of the consequences of water insecurity for maternal and infant psychosocial and physical health, nutrition, and economic well-being.

Is water carriage associated with the water carrier's health? A systematic review of quantitative and qualitative evidence

Introduction

The work of carrying water falls mainly on women and children, particularly in sub-Saharan Africa and rural areas. While concerns have been raised, how water carriage is associated with health of the water carrier is not clear. The aim of this review is to summarise evidence on whether, and how, water carriage is associated with the water carrier’s health.

Methods

A systematic review of literature was conducted, searching Embase; Medline; Web of Science Social Sciences Citation Index; Web of Science Arts and Humanities Citation Index; International Initiative for Impact Evaluation website; WHO Virtual Health Sciences Library and WHO African index medicus, from inception to 8 November 2017.

Results

Forty-two studies were included. Their ability to demonstrate cause and effect relationships was limited by study design and fair or poor methodological quality. Overall, the studies suggest that water carriage is associated with negative aspects of the water carriers’ health. There is moderate quantitative and strong qualitative evidence that water carriage is associated with pain, fatigue, perinatal health problems and violence against vulnerable people, and inconclusive evidence of an association with stress or self-reported mental health and general health status.

Conclusion

In many circumstances, water carriage is a potential barrier to Sustainable Development Goal (SDG) 6 target ‘universal and equitable access to safe and affordable drinking water for all’ and SDG 3 ‘ensure healthy lives and promote well-being for all at all ages’. Efforts should focus on providing water on premises, and where this is not possible, providing water close to home and reducing risk of gender-based violence.

Carrying water may be a major contributor to disability from musculoskeletal disorders in low income countries: a cross-sectional survey in South Africa, Ghana and Vietnam

Background

The Sustainable Development Goals include commitments to end poverty, and promote education for all, gender equality, the availability of water and decent work for all. An important constraint is the fact that each day, many millions of women and children, and much less frequently men, carry their household’s water home from off-plot sources. The burden of fetching water exacerbates gender inequality by keeping women out of education and paid employment. Despite speculation about the potential health impacts of fetching water, there is very little empirical evidence. We report the first large study of the health impacts of carrying water on women and children.

Methods

A cross-sectional survey was conducted in South Africa, Ghana and Vietnam during 2012. It investigated water carrying methods and health status. Because areas of self-reported pain were correlated we undertook factor analysis of sites of reported pain, to interpret patterns of pain reporting. Regression analysis using Generalised Estimating Equations (GEE) investigated water carrying as a risk factor for general health and self-reported pain.

Results

People who previously carried water had increased relative risk of reporting pain in the hands (risk ratio RR 3.62, 95% confidence interval CI 1.34 to 9.75) and upper back (RR 2.27, 95% CI 1.17 to 4.40), as did people who currently carry water (RR hand pain 3.11, 95% CI 1.34 to 7.23; RR upper back pain 2.16, 95% CI 1.25 to 3.73). The factor analysis results indicate that factor 1, ‘axial compression’, which is correlated with pain in the head and upper back, chest/ribs, hands, feet and abdomen/stomach, is associated with currently (0.30, 95% CI 0.17 to 0.43) or previously (0.21, 95% CI 0.01 to 0.42) carrying water. Factor 2, ‘soft tissue strain’, which is correlated with pain in the neck, shoulders/arms, lower back and hips/pelvis or legs, is marginally negatively associated with currently (-0.18, 95% CI -0.32 to -0.04) carrying water. The factor ‘axial compression’ was more strongly associated with carrying water containers on the head.

Conclusions

Participants who reported a history of current or past water carrying more frequently reported pain in locations most likely to be associated with sustained spinal axial compression in the cervical region. Given the fact that cervical spinal conditions are globally one of the more common causes of disability, our findings suggest that water carrying, especially by head loading is a major contributing factor in musculoskeletal disease burden in low income countries. Our findings support the proposed indicator for monitoring SDG6.1: “Percentage of population using safely managed drinking water services at home.”

Advancing methods for research on household water insecurity: Studying entitlements and capabilities, socio-cultural dynamics, and political processes, institutions and governance

Household water insecurity has serious implications for the health, livelihoods and wellbeing of people around the world. Existing methods to assess the state of household water insecurity focus largely on water quality, quantity or adequacy, source or reliability, and affordability. These methods have significant advantages in terms of their simplicity and comparability, but are widely recognized to oversimplify and underestimate the global burden of household water insecurity. In contrast, a broader definition of household water insecurity should include entitlements and human capabilities, sociocultural dynamics, and political institutions and processes. This paper proposes a mix of qualitative and quantitative methods that can be widely adopted across cultural, geographic, and demographic contexts to assess hard-to-measure dimensions of household water insecurity. In doing so, it critically evaluates existing methods for assessing household water insecurity and suggests ways in which methodological innovations advance a broader definition of household water insecurity.

Development and implementation of Models of Care for musculoskeletal conditions in middle-income and low-income Asian countries

This chapter discusses the challenges faced in the development and implementation of musculoskeletal (MSK) Models of Care (MoCs) in middle-income and low-income countries in Asia and outlines the components of an effective MoC for MSK conditions. Case studies of four such countries (The Philippines, Malaysia, Bangladesh and Myanmar) are presented, and their unique implementation issues are discussed. The success experienced in one high-income country (Singapore) is also described as a comparison. The Community Oriented Program for Control of Rheumatic Diseases (COPCORD) project and the role of Asia Pacific League of Associations for Rheumatology (APLAR), a professional body supporting MoC initiatives in this region, are also discussed. The experience and lessons learned from these case studies can provide useful information to guide the implementation of future MSK MoC initiatives in other middle-income and low-income countries.

Using Spatial Video to Analyze and Map the Water-Fetching Path in Challenging Environments: A Case Study of Dar es Salaam, Tanzania

Access to clean drinking water remains a significant health problem in the developing world. Traditional definitions of water access oversimplify the geographic context of water availability, the burden of water collection, and challenges faced along the path, mainly due to a lack of fine scale spatial data. This paper demonstrates how spatial video collected in three informal areas of Dar es Salaam, Tanzania, can be used to quantify aspects of the walk to water. These include impediments encountered along the path such as changes in elevation and proximity to traffic. All are mapped along with classic health-related environmental and social information, such as standing water, drains, and trash. The issue of GPS error was encountered due to the built environment that is typical of informal settlements. The spatial video allowed for the correction of the path to gain a more accurate estimate of time and distance for each walk. The resulting mapped health risks at this fine scale of detail reveal micro-geographies of concern. Spatial video is a useful tool for visualizing and analyzing the challenges of water collection. It also allows for data generated along the walk to become part of both a household and local area risk assessment.