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

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. 

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.

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.

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.

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.

 

Household survey data from 27 sites in 22 countries were collected in 2017–2018 in order to construct and validate a cross-cultural household-level water insecurity scale. The resultant Household Water Insecurity Experiences (HWISE) scale presents a useful tool for monitoring and evaluating water interventions as a complement to traditional metrics used by the development community. It can also help track progress toward achievement of Sustainable Development Goal 6 ‘clean water and sanitation for all’. We present HWISE scale scores from 27 sites as comparative data for future studies using the HWISE scale in low- and middle-income contexts. Site-level mean scores for HWISE-12 (scored 0–36) ranged from 1.64 (SD 4.22) in Pune, India, to 20.90 (7.50) in Cartagena, Colombia, while site-level mean scores for HWISE-4 (scored 0–12) ranged from 0.51 (1.50) in Pune, India, to 8.21 (2.55) in Punjab, Pakistan. Scores tended to be higher in the dry season as expected. Data from this first implementation of the HWISE scale demonstrate the diversity of water insecurity within and across communities and can help to situate findings from future applications of this tool.