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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. 

We extend the conceptualization of the social and health burdens of household water insecurity on children beyond the traditional narrow lens of microbiological pathogens and diarrhea. The global burden of disease associated with water insecurity has traditionally focused on diarrheal disease as the most significant driver of infant and child mortality. However, there are many other pathways through which children experience adverse health and social consequences from inadequate or unsafe household water. We synthesize evidence of a broad range of health impacts, affecting children from infancy to late adolescence, across four domains: exposure to unsafe water; interruptions to growth and development through poor nutrition and hydration; negative social effects such as school absenteeism and interpersonal violence; and other non‐communicable health issues such as mental health, injuries, and reproductive health. The growing burden and urgency of these issues is implicated by forecasted increases in climate‐ and conflict‐induced water scarcity, human displacement, and environmental contamination in the decades ahead.

This article is categorized under:

Engineering Water > Water, Health, and Sanitation

Human Water > Rights to Water

 

Objective Progress towards equitable and sufficient water has primarily been measured by population-level data on water availability. However, higher-resolution measures of water accessibility, adequacy, reliability and safety (ie, water insecurity) are needed to understand how problems with water impact health and well-being. Therefore, we developed the Household Water InSecurity Experiences (HWISE) Scale to measure household water insecurity in an equivalent way across disparate cultural and ecological settings. Methods Cross-sectional surveys were implemented in 8127 households across 28 sites in 23 low-income and middle-income countries. Data collected included 34 items on water insecurity in the prior month; socio-demographics; water acquisition, use and storage; household food insecurity and perceived stress. We retained water insecurity items that were salient and applicable across all sites. We used classical test and item response theories to assess dimensionality, reliability and equivalence. Construct validity was assessed for both individual and pooled sites using random coefficient models. Findings Twelve items about experiences of household water insecurity were retained. Items showed unidimensionality in factor analyses and were reliable (Cronbach’s alpha 0.84 to 0.93). The average non-invariance rate was 0.03% (threshold <25%), indicating equivalence of measurement and meaning across sites. Predictive, convergent and discriminant validity were also established. Conclusions The HWISE Scale measures universal experiences of household water insecurity across low-income and middle-income countries. Its development ushers in the ability to quantify the prevalence, causes and consequences of household water insecurity, and can contribute an evidence base for clinical, public health and policy recommendations regarding water. 

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. 

Household water insecurity is a complex socioecological challenge with a range of consequences for health and wellbeing. Understanding individual and household‐level coping strategies, i.e., responses or adaptations to manage water insecurity, can shape future research and development practice. We therefore (a) systematically describe the characteristics and contexts of 173 studies documenting coping strategies and (b) classify the types of strategies within four domains of water insecurity: access, use, quality, and reliability. Most studies were from Sub‐Saharan Africa or South Asia. In the domain of access, the most common coping strategies were building infrastructure, and storing, purchasing, and sharing water. For use, changing food consumption, agricultural practices, and hygiene were most frequently mentioned. For quality, water treatment was the most common strategy. To ensure water reliability, people most frequently reported changing routines or relocating their homes altogether. Our review provides a useful framework to understand coping strategies, but more research is needed to address three gaps in particular. First, we recommend more representative exploration of the range of coping strategies, particularly in middle‐ and high‐income countries. Second, the links between coping with water insecurity and a range of other nutritional, social, financial, and health outcomes need to be better understood to address overall household wellbeing. Third, we recommend the development of a metric to quantify individual and household‐level water insecurity‐related coping strategies. This line of inquiry can enable practitioners to design and implement context‐specific interventions that leverage preexisting strategies to improve experiences of water insecurity.

This article is categorized under:

Human Water > Water Governance

Engineering Water > Planning Water

 

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.