Associations between water insecurity and mental health outcomes among lesbian, gay, bisexual, transgender and queer persons in Bangkok, Thailand and Mumbai, India: Cross-sectional survey findings

Background

Water insecurity disproportionally affects socially marginalized populations and may harm mental health. Lesbian, gay, bisexual, transgender and queer (LGBTQ) persons are at the nexus of social marginalization and mental health disparities; however, they are understudied in water insecurity research. Yet LGBTQ persons likely have distinct water needs. We explored associations between water insecurity and mental health outcomes among LGBTQ adults in Mumbai, India and Bangkok, Thailand.

Methods

This cross-sectional survey with a sample of LGBTQ adults in Mumbai and Bangkok assessed associations between water insecurity and mental health outcomes, including anxiety symptoms, depression symptoms, loneliness, alcohol misuse, COVID-19 stress and resilience. We conducted multivariable logistic and linear regression analyses to examine associations between water insecurity and mental health outcomes.

Results

Water insecurity prevalence was 28.9% in Mumbai and 18.6% in Bangkok samples. In adjusted analyses, in both sites, water insecurity was associated with higher likelihood of depression symptoms, anxiety symptoms, COVID-19 stress, alcohol misuse and loneliness. In Mumbai, water insecurity was also associated with reduced resilience.

Conclusion

Water insecurity was common among LGBTQ participants in Bangkok and Mumbai and associated with poorer well-being. Findings signal the importance of assessing water security as a stressor harmful to LGBTQ mental health.

"Gender-Based Water Violence": Cross-Cultural Evidence for Severe Harm Associated With Water Insecurity for Women and Girls

We examined how study participants in Indonesia and Peru viewed the relationship between water insecurity and women's health via thematic analysis of interviews and focus groups. Participants reported that water insecurity led to vaginal infections, miscarriage, premature births, uterine prolapse, poor nutrition, restricted economic opportunities, and intergenerational cycles of poverty. Participants in both countries stated that extreme burdens associated with water insecurity should be categorized as violence. Based on these findings, we developed the concept of "gender-based water violence," defined as the spectrum of stressors associated with water insecurity that are so severe as to threaten human health and well-being, particularly that of women and girls.

Kukaa Salama (Staying Safe): a pre-post trial of an interactive informational mobile health intervention for increasing COVID-19 prevention practices with urban refugee youth in Uganda

BACKGROUND

Tailored coronavirus disease 2019 (COVID-19) prevention strategies are needed for urban refugee youth in resource-constrained contexts. We developed an 8-wk interactive informational mobile health intervention focused on COVID-19 prevention practices informed by the Risk, Attitude, Norms, Ability, Self-regulation-or RANAS-approach.

METHODS

We conducted a pre-post trial with a community-recruited sample of refugee youth aged 16-24 y in Kampala, Uganda. Data were collected before (T1) and immediately following (T2) the intervention, and at the 16-wk follow up (T3), to examine changes in primary (COVID-19 prevention self-efficacy) and secondary outcomes (COVID-19 risk awareness, attitudes, norms and self-regulation practices; depression; sexual and reproductive health [SRH] access; food/water security; COVID-19 vaccine acceptability).

RESULTS

Participants (n=346; mean age: 21.2 [SD 2.6] y; cisgender women: 50.3%; cisgender men: 48.0%; transgender persons: 1.7%) were largely retained (T2: n=316, 91.3%; T3: n=302, 87.3%). In adjusted analyses, COVID-19 prevention self-efficacy, risk awareness, attitudes and vaccine acceptance increased significantly from T1 to T2, but were not sustained at T3. Between T1 and T3, COVID-19 norms and self-regulation significantly increased, while community violence, water insecurity and community SRH access decreased.

CONCLUSIONS

Digital approaches for behaviour change hold promise with urban refugee youth but may need booster messaging and complementary programming for sustained effects.

Water Insecurity Indicators Are Associated with Lower Diet and Beverage Quality in a National Survey of Lower-Income United States Adults

BACKGROUND

Tap water distrust and avoidance, indicators of water insecurity, are prevalent in marginalized United States populations. As future environmental challenges stress water resources, further understanding of the scope of water insecurity and its impact on diet quality is needed, particularly in vulnerable United States populations.

OBJECTIVES

To evaluate associations between 3 potential indicators of water insecurity-1) perception of tap water safety for drinking, 2) perception of tap water safety for cooking, and 3) tap water avoidance-and dietary quality and beverage intake in lower-income United States adults.

METHODS

A cross-sectional, web-based survey was fielded to 1798 lower-income (<250% federal poverty guidelines) United States adults. Participants answered questions detailing tap water safety perceptions and avoidance, beverage intake, dietary intake (30-d prime diet quality score), and sociodemographic covariates. Sociodemographic differences in drinking water insecurity measures were evaluated using chi-square and Fisher-Freeman-Halton tests. Associations between water insecurity measures and dietary outcomes were assessed using generalized linear models adjusted for sociodemographic covariates, and effect modification by sociodemographic covariates was assessed.

RESULTS

Over half of the adults surveyed experienced some aspect of water insecurity. Measures of water security differed significantly by sociodemographic covariates (Ps < 0.05), with higher percentages of women and gender-nonconforming persons, minoritized racial and ethnic groups, lower-income groups, and food-insecure adults reporting indicators of water insecurity. Presence of any water insecurity was associated with lower diet quality (β = -1.07; 95% CI: -2.11, -0.03; P = 0.04), lower tap water intake (relative difference [RD] = 0.35; 95% CI: 1.28, 2.12; P < 0.0001), higher bottled water intake (RD = 1.64; 95% CI: 1.28, 2.12; P = 0.0001), and higher sugar-sweetened beverages intake frequency (frequency ratio = 1.13; 95% CI: 1.01, 1.27; P = 0.03).

CONCLUSIONS

Water insecurity indicators are associated with poorer diet quality and beverage intake in a population of United States adults with lower-incomes. Addressing the intersection of water insecurity, food security, environmental impacts, and nutrition may help to improve the well-being and resiliency of vulnerable populations.

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.

Water Insecurity and Maternal Health Among Haudenosaunee Women in Canada

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

Food and Water Insecurity in Sexual and Gender Minority Groups Living With HIV in Lagos, Nigeria

BACKGROUND

Food and water insecurity are associated with poor health outcomes that may be exacerbated by social marginalization and barriers to health care experienced by sexual and gender minorities (SGM) in resource-limited settings. We explored factors associated with food and water insecurity in SGM with HIV.

SETTING

A longitudinal study of 357 men who have sex with men, transgender women, and other gender-identifying people in Lagos, Nigeria.

METHODS

Laboratory testing, interviews, food and water assessments, and anthropometry were performed quarterly. Robust Poisson regression with generalized estimating equations was used to evaluate factors potentially associated with food and water insecurity.

RESULTS

From 2014 to 2018, 357 SGM with HIV completed either the food or water assessments. At baseline, participants identified as cisgender men who have sex with men 265 (74.2%), transgender women 63 (17.7%), or as nonbinary/other gender 29 (8.1%). Food insecurity and water insecurity were reported by 63/344(18.3%) and 113/357(31.7%), respectively, at any visit. Food and water insecurity each decreased with ongoing study participation. Food insecurity was associated with nonpartnered relationship status, CD4 count <500 cells/mm 3 , and lack of access to piped water. Water insecurity was associated with age 25 years or older, living with a man, transactional sex, and food insecurity.

CONCLUSIONS

Food and water insecurity were common among SGM in Nigeria and decreased with continued study participation, suggesting amenability to intervention when SGM are successfully engaged in care. Targeted interventions to support food and water security may improve HIV-related outcomes, such as CD4 count.

Joint Food and Water Insecurity Had a Multiplicative Effect on Women's Depression in Urban Informal Settlements in Makassar, Indonesia during the COVID-19 Pandemic

BACKGROUND

Women living in urban informal settlements may be particularly vulnerable to the detrimental effects of the COVID-19 pandemic because of increased economic and psychosocial stressors in resource-limited environments.

OBJECTIVES

The objective of this study was to assess the associations between food and water insecurity during the pandemic and depression among women living in the urban informal settlements in Makassar, Indonesia.

METHODS

We implemented surveys at 3 time points among women enrolled in the Revitalizing Informal Settlements and their Environments trial. Depression was measured using the Center for Epidemiologic Studies Depression Scale-10 (CESD-10) between November and December 2019 and again between February and March 2021. Food insecurity was measured using questions from the Innovation for Poverty Action's Research for Effective COVID-19 Reponses survey and water insecurity was measured using the Household Water Insecurity Experiences Short Form. Both were measured between August and September 2020. We built 3 multivariate quantile linear regression models to assess the effects of water insecurity, food insecurity, and joint food and water insecurity during the COVID-19 pandemic on CESD-10 score.

RESULTS

In models with the full sample (n = 323), food insecurity (β: 1.48; 95% CI: 0.79, 2.17), water insecurity (β: 0.13; 95% CI: -0.01, 0.26), and joint food and water insecurity (β: 2.40; 95% CI: 1.43, 3.38) were positively associated with CESD-10 score. In subgroup analyses of respondents for whom we had prepandemic CESD-10 scores (n = 221), joint food and water insecurity (β: 1.96; 95% CI: 0.78, 3.15) maintained the strongest relationship with CESD-10 score. A limitation of this study is that inconsistency in respondents from households across the survey waves reduced the sample size used for this study.

CONCLUSIONS

Our results find a larger association between depression and joint resource insecurity than with water or food insecurity alone, underlining the importance of addressing food and water insecurity together, particularly as they relate to women's mental health and well-being.

Is Suicide a Water Justice Issue? Investigating Long-Term Drinking Water Advisories and Suicide in First Nations in Canada

First Nations experience disproportionate rates of suicide when compared to the general population. Various risk factors are identified to increase understanding of the prevalence of suicide among First Nations, but environmental dimensions of suicide are understudied. This study asks whether water insecurity, as reflected by long-term drinking water advisories (LT-DWA), has any bearing on the distribution of suicide in First Nations across Canada, and specifically in Ontario. To assess this, we established the proportion of First Nations with LT-DWAs in Canada and in Ontario that have had suicides occur between 2011 and 2016 through a review of media archives. This proportion was compared to census data on the proportion of First Nations with suicides in Canada and in Ontario between 2011 and 2016, and statistical significance of difference was determined through chi-square goodness of fit test. Overall, the findings were mixed. Nationally, there was no significantly difference of proportion of First Nations with LT-DWAs with combined (confirmed and probable) reported suicides occurring when compared to census proportions; however, at the provincial level, findings had significant differences. The authors conclude that water insecurity in First Nations, as indicated by the presence of a LT-DWA in First Nations across may be an important environmental dimension of suicide, contributing to enhanced risk for suicide in First Nations.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Extreme climatic events and human biology and health: A primer and opportunities for future research

Extreme climatic events are increasing in frequency, leading to hotter temperatures, flooding, droughts, severe storms, and rising oceans. This special issue brings together a collection of seven articles that describe the impacts of extreme climatic events on a diverse set of human biology and health outcomes. The first two articles cover extreme temperatures extending from extreme heat to cold and changes in winter weather and the respective implications for adverse health events, human environmental limits, well-being, and human adaptability. Next, two articles cover the effects of exposures to extreme storms through an examination of hurricanes and cyclones on stress and birth outcomes. The following two articles describe the effects of extreme flooding events on livelihoods, nutrition, water and food insecurity, diarrheal and respiratory health, and stress. The last article examines the effects of drought on diet and food insecurity. Following a brief review of each extreme climatic event and articles covered in this special issue, I discuss future research opportunities-highlighting domains of climate change and specific research questions that are ripe for biological anthropologists to investigate. I close with a description of interdisciplinary methods to assess climate exposures and human biology outcomes to aid the investigation of the defining question of our time - how climate change will affect human biology and health. Ultimately, climate change is a water, food, and health problem. Human biologists offer a unique perspective for a combination of theoretical, methodological, and applied reasons and thus are in a prime position to contribute to this critical research agenda.

Associations between water insecurity and depression among refugee adolescents and youth in a humanitarian context in Uganda: cross-sectional survey findings

BACKGROUND

Water insecurity is linked to poor mental health through intrapersonal, relational and community-based stressors. We examined water insecurity and depression among refugee youth in Bidi Bidi, Uganda.

METHODS

We conducted a cross-sectional survey and multivariable ordinal logistic regression to examine associations between water insecurity and depression severity, adjusting for gender, resilience, social support and food insecurity.

RESULTS

Among participants (n=115; mean age: 19.7 y, SD 2.3), 80.0% reported water insecurity and 18.3% had moderate/severe depression symptoms. Water insecurity was independently associated with higher levels of depression severity (adjusted OR: 5.61; 95% CI 1.20 to 26.30; p=0.03).

CONCLUSIONS

Findings suggest water insecurity was commonplace and associated with depression. Water insecurity could be integrated in refugee mental health promotion by policymakers and community-based programmers.

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

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

Using Water Intake Dietary Recall Data to Provide a Window into US Water Insecurity

BACKGROUND

In the United States, problems with the provision of safe, affordable water have resulted in an increasing number of adults who avoid their tap water, which could indicate underlying water insecurity. Dietary recalls provide critical nutritional surveillance data, yet have been underexplored as a water insecurity monitoring tool.

OBJECTIVES

This article aims to demonstrate how water intake variables from dietary recall data relate to and predict a key water insecurity proxy, that is, tap water avoidance.

METHODS

Using 2005-2018 NHANES data from 32,329 adults, I examine distributions and trends of mean intakes of total, plain (sum of tap and bottled water), tap, and bottled water, and percentage consuming no tap and exclusive bottled water. Second, I use multiple linear and logistic regressions to test how tap water avoidance relates to plain water intake and sugar-sweetened beverage (SSB) consumption. Next, I use receiver operating characteristics (ROC) curves to test the predictive accuracy of no plain water, no tap, and exclusive bottled water intake, and varying percentages of plain water consumed from tap water compared with tap water avoidance.

RESULTS

Trends indicate increasing plain water intake between 2005 and 2018, driven by increasing bottled water intake. In 2017-18, 51.4% of adults did not drink tap water on a given day, whereas 35.8% exclusively consumed bottled water. Adults who avoided their tap water consumed less tap and plain water, and significantly more bottled water and SSBs on a given day. No tap intake and categories of tap water intake produced 77% and 78% areas under the ROC curve in predicting tap water avoidance.

CONCLUSIONS

This study demonstrates that water intake variables from dietary recalls can be used to accurately predict tap water avoidance and provide a window into water insecurity. Growing reliance on bottled water could indicate increasing concerns about tap water.

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

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

Does Irrigation with Treated and Untreated Wastewater Increase Antimicrobial Resistance in Soil and Water: A Systematic Review

Population growth and water scarcity necessitate alternative agriculture practices, such as reusing wastewater for irrigation. Domestic wastewater has been used for irrigation for centuries in many historically low-income and arid countries and is becoming more widely used by high-income countries to augment water resources in an increasingly dry climate. Wastewater treatment processes are not fully effective in removing all contaminants, such as antimicrobial resistant bacteria (ARB) and antimicrobial resistance genes (ARGs). Literature reviews on the impact of wastewater irrigation on antimicrobial resistance (AMR) in the environment have been inconclusive and mostly focused on treated wastewater. We conducted the first systematic review to assess the impact of irrigation with both treated or untreated domestic wastewater on ARB and ARGs in soil and adjacent water bodies. We screened titles/abstracts of 3002 articles, out of which 41 were screened in full text and 26 were included in this review. Of these, thirteen investigated irrigation with untreated wastewater, and nine found a positive association with ARB/ARGs in soil. Out of thirteen studies focused on treated wastewater, six found a positive association with ARB/ARGs while six found mixed/negative associations. Our findings demonstrate that irrigation with untreated wastewater increases AMR in soil and call for precautionary action by field workers, their families, and consumers when untreated wastewater is used to irrigate crops. The effect of irrigation with treated wastewater was more variable among the studies included in our review, highlighting the need to better understand to what extent AMR is disseminated through this practice. Future research should assess factors that modify the effect of wastewater irrigation on AMR in soil, such as the degree and type of wastewater treatment, and the duration and intensity of irrigation, to inform guidelines on the reuse of wastewater for irrigation.

Understanding Rural Women's Domestic Work Experiences (DWE) in Ibadan, Nigeria: Development of a Measurement Tool Using Confirmatory Factor Analysis

Gender norms prescribe domestic labor as primarily a female's responsibility in developing countries. Many domestic tasks depend on access to water, so the physical, emotional, and time demands of domestic labor may be exacerbated for women living in water-insecure environments. We developed a set of domestic work experience (DWE) measures tailored to work in rural areas in developing countries, assessed rural Nigerian women's DWE, and examined relationships among the measures. Interviewer-administered survey data were collected between August and September from 256 women in four rural Nigerian communities. Latent factors of DWE were identified by analyzing survey items using confirmatory factor analysis. Pearson's correlation was used to examine relationships among latent factor scores, and multivariate linear regression models were used to determine if factor scores significantly differed across socio-demographic characteristics. The DWE measures consisted of latent factors of the physical domain (frequency of common domestic tasks, water sourcing and carriage, experience of water scarcity), the psychosocial domain (stress appraisal and demand-control), and the social domain (social support). Significant correlations were observed among the latent factors within and across domains. Results revealed the importance of measuring rural Nigerian women's DWE using multiple and contextual approaches rather than relying solely on one exposure measure. Multiple inter-related factors contributed to women's DWE. Water insecurity exacerbated the physical and emotional demands of domestic labor DWE varied across age categories and pregnancy status among rural Nigerian women.

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.

Indigenous Community-Led Programs to Address Food and Water Security: Protocol for a Systematic Review

The connection between indigenous peoples and Country (a multidimensional concept including land and water) enabled communities to thrive and survive over millennia. This has been eroded by colonisation, dispossession and increasing food and water insecurity due to climate change and supply constraints. Globally, indigenous peoples experience a disproportionate burden of chronic disease and poor nutrition is a major risk factor. Indigenous leaders have been advocating for community-led solutions. The primary aim of this systematic review is to determine what community-led programs have been undertaken to address food and/or water security globally. A comprehensive search of peer-reviewed literature will be performed in EMBASE, CINAHL, PsycINFO, PubMed, Scopus, LILACs, Informit and Business Source Premier. The grey literature search will include grey literature databases, customised Google search engines, targeted websites, and consultation with experts. The search strategy will consist of four concepts, combined as follows: (1) indigenous peoples AND (2) community program AND (3) food security OR (4) water security. Covidence will be used for study screening and data extraction by two authors. A deductive thematic analysis using indigenous-informed methodologies will be used to synthesise data. This review seeks to provide insight on models and mechanisms to encourage action and metrics for quantifying success of indigenous community-led programs to improve food and water security.

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

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

Our Relationship to Water and Experience of Water Insecurity among Apsáalooke (Crow Indian) People, Montana

Affordable access to safe drinking water is essential to community health, yet there is limited understanding of water insecurity among Native Americans. Therefore, the focus of this paper is to describe Apsáalooke (Crow Indian) tribal members' experiences with water insecurity. For Apsáalooke people, local rivers and springs are still vitally important for traditional cultural activities. We interviewed 30 Native American adults living on the Crow Reservation in Southeastern Montana. Participants answered six open-ended interview questions about their water access, costs of obtaining water and changes in their domestic and traditional water uses. Participants emphasized how the use of water has changed over time and described the complex challenges associated with addressing water insecurity in their community, including the importance of considering the spiritual and cultural impacts of water insecurity on health. Water insecurity is a growing global problem and more attention and efforts are needed to find appropriate and affordable solutions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Qualitative Examination of Water Access and Related Coping Behaviors to Understand Its Link to Food Insecurity among Rural Households in the West Region in Cameroon

Food insecurity is a significant public health issue, since it causes malnutrition and engenders millions of deaths every year. A significant association is found between water and food insecurity. However, it remains unclear what are the pathways through which water shortage impacts food insecurity. Hence, a qualitative study was conducted in rural areas in Cameroon to (1) examine water access, its management, and its daily use and (2) investigate common behavior changes and coping strategies adults used in managing limited water availability in their households. Three rounds of focus group discussions and six key informant interviews were conducted with men and women. The results demonstrated that water access was limited, involving long walking distances and making several trips to the water sources. The household size, number of adults vs. children, and presence of storage containers affected water availability and its daily use. To manage limited water, coping behaviors included skipping drinking, changing cooking plans, and recycling water. In conclusion, limited water access increases food insecurity through several pathways. Governments, policy makers, and international organizations should recognize the interwoven link between water and food security. Joint actions and collaborative efforts are needed to improve success and reduce tradeoffs in achieving Sustainable Development Goals # 2 and # 6.

Prioritizing Water Security in the Management of Vector-Borne Diseases: Lessons From Oaxaca, Mexico

Changes in human water use, along with temperature and rainfall patterns, are facilitating habitat spread and distribution of Aedes aegypti and Aedes albopictus mosquitoes, the primary vectors for the transmission of Dengue, Chikungunya, and Zika viruses in the Americas. Artificial containers and wet spots provide major sources of mosquito larval habitat in residential areas. Mosquito abatement and control strategies remain the most effective public health interventions for minimizing the impact of these vector-borne diseases. Understanding how water insecurity is conducive to the establishment and elimination of endemic mosquito populations, particularly in arid or semiarid regions, is a vital component in shaping these intervention strategies.

A Systematic Literature Review on Water Insecurity from an Oregon Public Health Perspective

This paper systematically reviews existing United States-based water insecurity literature with the goal of understanding the evidence base for developing public health water insecurity intervention strategies in Oregon. The authors conducted the systematic literature review using an adjusted PRISMA reporting checklist to document the review process. Results find 11 public health-related water insecurity interventions including surveillance practices and indicator and policy development. Research on water insecurity health impacts and solutions is still an emerging field. Nevertheless, state agencies perceive a risk to communities from inadequate safe water and are taking steps to assess and reduce these risks. From the review, strategies include improving water affordability, carrying out community education events, documenting drought risk and water loss, and tracking improvements in safe drinking water compliance. The review finds opportunities to take varied approaches that are community-specific, partnership-based and culturally relevant. Recommendations for Oregon include characterizing communities experiencing water insecurity, assessing community needs, tracking regional water scarcity and recognizing the human right to water in Oregon.

"If there is no water, we cannot feed our children": The far-reaching consequences of water insecurity on infant feeding practices and infant health across 16 low- and middle-income countries

OBJECTIVES

Infant feeding plays a critical role in child health and development. Few studies to date have examined the link between household water insecurity and infant feeding, and none in a cross-cultural context. Therefore, we examined the perceived impact of household water insecurity in four domains: breastfeeding, non-breastmilk feeding, caregiver capabilities, and infant health. Our research was conducted as part of the Household Water Insecurity Experiences (HWISE) study.

METHODS

We interviewed respondents from 19 sites in 16 low- and middle-income countries (N = 3303) about the link between water insecurity and infant feeding. We then thematically analyzed their open-ended textual responses. In each of the four domains (breastfeeding, non-breastmilk feeding, caregiver capabilities, infant health), we inductively identified cross-cultural metathemes. We analyzed the distribution of themes across sites quantitatively and qualitatively.

RESULTS

Water was perceived to directly affect breastfeeding and non-breastmilk feeding via numerous pathways, including timing and frequency of feeding, unclean foods, and reduced dietary diversity. Water was perceived to indirectly affect infant feeding through caregiver capabilities by increasing time demands, exacerbating disease, undernutrition, and mortality, and requiring greater efficacy of caregivers. Respondents made connections between water challenges and infant health, for example, increased risk of infectious diseases, undernutrition, and mortality.

CONCLUSIONS

These findings suggest that water presents many, and sometimes unexpected, challenges to infant feeding. By systematically investigating biocultural pathways by which water impacts infant and young child feeding, it will be possible to understand if, and how, water security can be leveraged to improve child nutrition and health.

Status on the Scale Development to Measure Water Insecurity Experiences at the Household Level: A Narrative Review

Adequate and safe water is critical in promoting all 3 pillars of food security. Hence, ensuring availability of water for all is one of the 2030 Sustainable Development Goals. To monitor progress of this goal and understand the role of water in addressing food insecurity, development of a household-level water insecurity scale has become very critical. As such, using the following concept of water insecurity: inconsistent access to sufficient amount of safe and clean water for active and healthy life, several scale development studies have been conducted to measure water insecurity experiences at the household level. Hence, in this review, the science literature was evaluated to 1) describe the scale development process; 2) assess the validity results by comparing scale measurements results with the established 4 United Nations (UN) water standards on water access; and 3) examine key water- and food-related dimensions covered by the scales in measuring water insecurity at the household level. Eight published studies were identified from the following scientific databases: EBSCO, PubMed, Google Scholar, and JSTOR. Five of the 8 selected studies were conducted in sub-Saharan Africa, 2 were conducted in North and South America, and 1 was conducted in South Asia. A majority of the studies were conducted with women and included preliminary qualitative/ethnographic phases to identify scale items. Of the 4 UN water standards, the amount of water used/stored was commonly used to test the scale results. However, no consistent results were found in its association with water insecurity. In a rural setting, distance to water source was positively associated with water insecurity. Psychosocial distress/anxiety and reduced water use for hygiene were key dimensions of scale in all the studies. Rigorous research is needed to establish various levels of water insecurity, its scoring scheme, and its association with daily intake of water-an essential nutrient.

Assessment of the relationship between water insecurity, hygiene practices, and incidence of diarrhea among children from rural households of the Menoua Division, West Cameroon

The objectives of a cross-sectional, semi-quantitative study were to: i) assess the prevalence of water insecurity and its association with water access-related behaviors such as time, distance, and sources of water; ii) identify major themes of concern raised in reference to anxiety, water quality/quantity, and perceived health risk domains of water insecurity, and; iii) examine the relationship between water insecurity, hygiene practices, and diarrheal incidence among children in rural areas of the Menoua Division in the Western Region of Cameroon In-person interviews were conducted with 18 years or older women living with at least one child between 2 and 5 years old (n=134). Participants spent on average 17±12 minutes walking to a drinking water source. Prevalence of water insecurity was 58%, and it was associated with a lower hygiene score among caretakers, i.e., hygiene score of water secure: 9.2±1.2 vs. insecure:8.2±2.2, F_{(1, 132)}=8.096, P<0.01). Overall, the incidence of diarrhea among children was 18%, and it was significantly higher among water insecure households (79%) compared with secure households (21%, P=0.02). In conclusion, access to improved sources of water is an issue in rural areas. Addressing water insecurity is critical in promoting optimal health and development of children due to its association with poor hygiene practices among caretakers.

Household water sharing: a missing link in international health

Water insecurity massively undermines health, especially among impoverished and marginalized communities. Emerging evidence shows that household-to-household water sharing is a widespread coping strategy in vulnerable communities. Sharing can buffer households from the deleterious health effects that typically accompany seasonal shortages, interruptions of water services and natural disasters. Conversely, sharing may also increase exposure to pathogens and become burdensome and distressing in times of heightened need. These water sharing systems have been almost invisible within global health research but need to be explored, because they can both support and undermine global public health interventions, planning and policy.

Climate change, uncertainty and allostatic load

CONTEXT

Humans constantly respond to environmental stressors challenging their somatic stability. Allostasis, an evolved neuroendocrine/physiological stressor response system, is our main pathway for doing so. Effective allostasis returns somatic systems to their current optima; over a lifetime of stressor responses, related systems fail, effectiveness declines, and physiological dysregulation (i.e. allostatic load) increases. Global Climate Change (GCC) multiplies environmental stressors on human populations and is likely to increase allostatic load.

OBJECTIVES

As a population-level stressor, GCC increases risks for multiple stressors, including sociocultural instability and food and water insecurity, while also motivating migration. We predict GCC increases risk for elevated allostatic load. Here, we review pathways by which GCC increases climatic and social stressors contributing to greater stress and allostatic load.

METHODS

Based upon published sources and primary ethnographic case studies, this review examines how GCC, by multiplying climate-related stressors, likely increases social instability, food and water insecurity, and migration. Thereby, it is proposed that GCC contributes to allostatic load.

RESULTS

GCC multiplies stressors on local populations. Those experiencing social insecurity related to GCC during growth and development are expected to show the largest influences on their lifetime allostatic load. Similarly, as GCC increases food and water insecurity, it likely will increase allostatic load in those affected and is likely to propel migrants to seek improved living circumstances. These stressors may be continued among their descendants via historical trauma or epigenetic responses.

CONCLUSION

GCC accentuates effects of environmental and sociocultural stressors on human populations. Those exposed to GCC are likely to show lifelong elevated allostatic load.

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.

'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.

Toilet Talk: Eliminating Open Defecation and Improved Sanitation in Nepal

Globally, 2.4 billion people lack adequate sanitation, and open defecation remains common. In this article, I present the qualitative findings from an evaluation of a water, sanitation, and hygiene intervention in remote, mid-West Nepal. The evaluation, conducted in 2014, involved villagers from eight wards in Kotgaun Village Development Committee. Drawing on the concept of the "toilet tripod," I argue as follows: multi-scalar political will provide an important foundation for construction and sustained use of toilets, proximate social pressures contributed significantly to toilet adoption and efforts to eliminate open defecation, and water insecurity constrained improved sanitation and hygiene.

Household water insecurity, missed schooling, and the mediating role of caregiver depression in rural Uganda

BACKGROUND

School attendance rates in sub-Saharan Africa are among the lowest worldwide, placing children at heightened risk for poor educational and economic outcomes. One understudied risk factor for missed schooling is household water insecurity, which is linked to depression among women and may increase children's water-fetching burden at the expense of educational activities, particularly among children of depressed caregivers. In this study conducted in rural Uganda, we assessed the association between household water insecurity and child school participation and the mediating pathways behind these associations.

METHOD

We conducted a population-based, cross-sectional study of female household heads (N = 257) and their children ages 5-17 (N = 551) in the rural regions surrounding the town of Mbarara, in southwestern Uganda. We used multivariable linear regressions to estimate the association between water insecurity and missed schooling. We then assessed the extent to which the association was mediated by caregiver depression.

RESULTS

Among children, water insecurity had a statistically significant association with the number of missed school days (a standard deviation increase in water insecurity resulted in 0.30 more missed school days in the last week). The estimated association was partially mediated by caregiver depression. When stratified by sex, this mediating pathway remained significant for boys, but not among girls.

CONCLUSIONS

Water insecurity is a risk factor for missed schooling among children in rural Uganda. Caregiver depression partially mediated this relationship. Also addressing caregiver mental health in water insecure families may more fully address the needs of sub-Saharan African families and promote educational participation among youth.

Household water insecurity is associated with a range of negative consequences among pregnant Kenyan women of mixed HIV status

Water insecurity (WI) is a serious and worsening problem worldwide, but its role in health outcomes among people living with HIV or pregnant women is unknown. We assessed experiences of WI in a cohort of 323 pregnant Kenyan women of mixed HIV status. The majority (77.7%) had at least one experience of WI in the previous month; it was associated with negative economic, nutrition, disease, and psychosocial outcomes. A standardized cross-culturally valid household WI scale would facilitate assessment of the prevalence and consequences of WI, and increased attention to WI could reveal an overlooked, but modifiable, cause of adverse HIV outcomes.

Population-based study of intra-household gender differences in water insecurity: reliability and validity of a survey instrument for use in rural Uganda

Hundreds of millions of people worldwide lack adequate access to water. Water insecurity, which is defined as having limited or uncertain availability of safe water or the ability to acquire safe water in socially acceptable ways, is typically overlooked by development organizations focusing on water availability. To address the urgent need in the literature for validated measures of water insecurity, we conducted a population-based study in rural Uganda with 327 reproductive-age women and 204 linked men from the same households. We used a novel method of photo identification so that we could accurately elicit study participants' primary household water sources, thereby enabling us to identify water sources for objective water quality testing and distance/elevation measurement. Our psychometric analyses provided strong evidence of the internal structure, reliability, and validity of a new eight-item Household Water Insecurity Access Scale (HWIAS). Important intra-household gender differences in perceptions of water insecurity were observed, with men generally perceiving household water insecurity as being less severe compared to women. In summary, the HWIAS represents a reliable and valid measure of water insecurity, particularly among women, and may be useful for informing and evaluating interventions to improve water access in resource-limited settings.

The Effects of Water Insecurity and Emotional Distress on Civic Action for Improved Water Infrastructure in Rural South Africa

The South African constitution ratifies water as a human right. Yet millions of citizens remain disconnected from the national water infrastructure. Drawing on data collected in 2013-2014 from women in northern South Africa, this study explores "water citizenship"-individual civic engagement related to improving water service provision. Literature indicates that water insecurity is associated with emotional distress and that water-related emotional distress influences citizen engagement. I extend these lines of research by assessing the connection that water insecurity and emotional distress may collectively have with civic engagement to improve access to water infrastructure.