Water Supply Interruptions Are Associated with More Frequent Stressful Behaviors and Emotions but Mitigated by Predictability: A Multisite Study.

Water supply interruptions contribute to household water insecurity. Unpredictable interruptions may particularly exacerbate water insecurity, as uncertainty limits households' ability to optimize water collection and storage or to modify other coping behaviors. This study used regression models of survey data from 2873 households across 10 sites in 9 middle-income countries to assess whether water supply interruptions and the predictability of interruptions were related to composite indicators of stressful behaviors and emotional distress. More frequent water service interruptions were associated with more frequent emotional distress (ß = 0.49, SE = 0.05, P < 0.001) and stressful behaviors (ß = 0.39, SE = 0.06, P < 0.001). Among households that experienced interruptions, predictability mitigated these respective relationships by approximately 25 and 50%. Where the provision of continuous water supplies is challenged by climate change, population growth, and poor management, water service providers may be able to mitigate some psychosocial consequences of intermittency through scheduled intermittency and communication about water supply interruptions. Service providers unable to supply continuous water should optimize intermittent water delivery to reduce negative impacts on users, and global monitoring regimes should account for intermittency and predictability in post-2030 water service metrics to better reflect household water insecurity experiences.

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.

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

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

Food, water, and sanitation insecurities: Complex linkages and implications for achieving WASH security.

Food, water and sanitation insecurities are complex, multi-dimensional phenomena that entail more than availability and access; food, water, and sanitation resources must be safe and culturally appropriate. Researchers and implementers concerned with these insecurities have demonstrated that there are notable interactions between them resulting in significant psychological and biological outcomes. Recent randomised controlled trials (RCTs) in Bangladesh, Kenya (WASH Benefits) and Zimbabwe (SHINE) demonstrated no effect from water, sanitation and hygiene (WASH) interventions on linear growth, and mixed evidence on enteropathogen burden and risk of diarrhoea in young children. These data suggest a need for a more comprehensive understanding of WASH security. The risks posed by multiple resource insecurities shift depending on the individual, their movement throughout their day, their economically and socially prescribed roles, and ecological features such as seasonality and precipitation. By more fully integrating food, water and sanitation security in interventions and subsequent impact evaluations, we can achieve WASH security-one that addresses myriad transmission pathways and co-occurring diseases-that ultimately would improve health outcomes throughout the world. In this critical review, we outline the complexity of combined resource insecurities as a step towards transformative WASH.

Water Security and Nutrition: Current Knowledge and Research Opportunities.

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

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

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

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

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

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

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

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

OBJECTIVES: Food and water insecurity have both been demonstrated as acute and chronic stressors and undermine human health and development. A basic untested proposition is that they chronically coexist, and that household water insecurity is a fundamental driver of household food insecurity. METHODS: We provide a preliminary assessment of their association using cross-sectional data from 27 sites with highly diverse forms of water insecurity in 21 low- and middle-income countries across Africa, Asia, the Middle East, and the Americas (N = 6691 households). Household food insecurity and its subdomains (food quantity, food quality, and anxiety around food) were estimated using the Household Food Insecurity Access Scale; water insecurity and subdomains (quantity, quality, and opportunity costs) were estimated based on similar self-reported data. RESULTS: In multilevel generalized linear mixed-effect modeling (GLMM), composite water insecurity scores were associated with higher scores for all subdomains of food insecurity. Rural households were better buffered against water insecurity effects on food quantity and urban ones for food quality. Similarly, higher scores for all subdomains of water insecurity were associated with greater household food insecurity. CONCLUSIONS: Considering the diversity of sites included in the modeling, the patterning supports a basic theory: household water insecurity chronically coexists with household food insecurity. Water insecurity is a more plausible driver of food insecurity than the converse. These findings directly challenge development practices in which household food security interventions are often enacted discretely from water security ones.

Bone density status in a large population of patients with anorexia nervosa.

Anorexia nervosa (AN) is associated with multiple medical complications. One of the rare permanent complications of AN is the deleterious effect that it has on a patient's bone mineral density (BMD). We report on the Dual-Energy X-ray Absorptiometry (DXA) findings of 336 consecutive patients with AN. Also, we investigated the effects of different factors on these DXA results. These factors included age, body mass index (BMI), percentage of ideal body weight (IBW), duration of illness, duration of amenorrhea, medications such as proton pump inhibitors (PPI) or selective serotonin reuptake inhibitors (SSRI), tobacco use and 25-hydroxy vitamin D levels. This study demonstrated a concerning high prevalence of reduced bone mineral density in patients with AN. Thus, the implication being that those involved in the care of patients with AN need to be cognizant of this serious complication and not be assuaged by the young age of this patient population.

Medical Complications of Anorexia Nervosa and Bulimia Nervosa.

Anorexia nervosa and bulimia nervosa are mental illnesses with associated complications affecting all body systems with arguably the highest mortality of all mental health disorders. A comprehensive medical evaluation is an essential first step in the treatment of anorexia nervosa and bulimia nervosa. Weight restoration and cessation of purging behaviors are often essential components in the management of medical complications of these illnesses.

Perceptions of drinking water cleanliness and health-seeking behaviours: A qualitative assessment of household water safety in Lesotho, Africa.

Despite the increased availability of improved water sources globally, enteric illnesses remain a source of significant morbidity and mortality. While the MDGs goal for safe water, i.e. improved sources, was met, substantial numbers of people still rely on unimproved sources for at least some of their water needs and contamination can occur between the source and consumption. Reviews and meta-analyses point to the need for better understanding of the cultural context for (HWT) technologies. Qualitative interviews (n = 56) conducted in the Maseru District of Lesotho (2011) addressed how people decided if their water was safe, their understanding of the linkage between water and enteric illness, and health-seeking behaviour. Respondents overwhelmingly relied on visual inspections to determine if their water was clean and not all participants linked consuming unsafe water with diarrheal disease. More than half of all respondents did not boil their water, despite believing that their primary source was not clean. People often have the knowledge necessary to ensure safe water but do not for myriad reasons, including financial constraints or habit. Data such as these are critical as the literature reveals often conflicting findings about the effectiveness of HWT and water safety takes on increasing importance in syndemic settings.

Household water sharing: A review of water gifts, exchanges, and transfers across cultures.

Water sharing offers insight into the everyday and, at times, invisible ties that bind people and households with water and to one another. Water sharing can take many forms, including so-called "pure gifts," balanced exchanges, and negative reciprocity. In this paper, we examine water sharing between households as a culturally-embedded practice that may be both need-based and symbolically meaningful. Drawing on a wide-ranging review of diverse literatures, we describe how households practice water sharing cross-culturally in the context of four livelihood strategies (hunter-gatherer, pastoralist, agricultural, and urban). We then explore how cross-cutting material conditions (risks and costs/benefits, infrastructure and technologies), socio-economic processes (social and political power, water entitlements, ethnicity and gender, territorial sovereignty), and cultural norms (moral economies of water, water ontologies, and religious beliefs) shape water sharing practices. Finally, we identify five new directions for future research on water sharing: conceptualization of water sharing; exploitation and status accumulation through water sharing, biocultural approaches to the health risks and benefits of water sharing, cultural meanings and socio-economic values of waters shared; and water sharing as a way to enact resistance and build alternative economies.

Water insecurity in a syndemic context: Understanding the psycho-emotional stress of water insecurity in Lesotho, Africa.

Syndemics occur when populations experience synergistic and multiplicative effects of co-occurring epidemics. Proponents of syndemic theory highlight the importance of understanding the social context in which diseases spread and cogently argue that there are biocultural effects of external stresses such as food insecurity and water insecurity. Thus, a holistic understanding of disease or social vulnerability must incorporate an examination of the emotional and social effects of these phenomena. This paper is a response to the call for a renewed focus on measuring the psycho-emotional and psychosocial effects of food insecurity and water insecurity. Using a mixed-method approach of qualitative interviews and quantitative assessment, including a household demographic, illness, and water insecurity scale, the Household Food Insecurity Access Scale, and the Hopkins Symptoms Checklist-25, this research explored the psycho-emotional effects of water insecurity, food insecurity, and household illness on women and men residing in three low-land districts in Lesotho (n = 75). Conducted between February and November of 2011, this exploratory study first examined the complicated interaction of water insecurity, food insecurity and illness to understand and quantify the relationship between these co-occurring stresses in the context of HIV/AIDS. Second, it sought to separate the role of water insecurity in predicting psycho-emotional stress from other factors, such as food insecurity and household illness. When asked directly about water, qualitative research revealed water availability, access, usage amount, and perceived water cleanliness as important dimensions of water insecurity, creating stress in respondents' daily lives. Qualitative and quantitative data show that water insecurity, food insecurity and changing household demographics, likely resulting from the HIV/AIDS epidemic, are all associated with increased anxiety and depression, and support the conclusion that water insecurity is a critical syndemic dimension in Lesotho. Together, these data provide compelling evidence of the psycho-emotional burden of water insecurity.