Body Composition Trajectories During the First 23 Months of Life Differ by HIV Exposure Among Infants in Western Kenya: A Prospective Study.

BACKGROUND: Infants who are HIV-exposed and uninfected have suboptimal growth patterns compared to those who are HIV-unexposed and uninfected. However, little is known about how these patterns persist beyond 1 year of life. OBJECTIVES: This study aimed to examine whether infant body composition and growth trajectories differed by HIV exposure during the first 2 years of life among Kenyan infants using advanced growth modeling. METHODS: Repeated infant body composition and growth measurements (mean: 6; range: 2-7) were obtained from 6 weeks to 23 months in the Pith Moromo cohort in Western Kenya (n = 295, 50% HIV-exposed and uninfected, 50% male). Body composition trajectory groups were fitted using latent class mixed modeling (LCMM) and associations between HIV exposure and growth trajectories were examined using logistic regression analysis. RESULTS: All infants exhibited poor growth. However, HIV-exposed infants generally grew suboptimally than unexposed infants. Across all body composition models except for the sum of skinfolds, HIV-exposed infants had a higher likelihood of belonging to the suboptimal growth groups identified by LCMM than the HIV-unexposed infants. Notably, HIV-exposed infants were 3.3 times more likely (95% CI: 1.5-7.4) to belong to the length-for-age z-score growth class that remained at a z-score of < -2, indicating stunted growth. HIV-exposed infants were also 2.6 times more likely (95% CI: 1.2-5.4) to belong to the weight-for-length-for-age z-score growth class that remained between 0 and -1, and were 4.2 times more likely (95% CI: 1.9-9.3) to belong to the weight-for-age z-score growth class that indicated poor weight gain besides stunted linear growth. CONCLUSIONS: In a cohort of Kenyan infants, HIV-exposed infants grew suboptimally compared to HIV-unexposed infants beyond 1 year of age. These growth patterns and longer-term effects should be further investigated to support the ongoing efforts to reduce early-life HIV exposure-related health disparities.

Water insecurity, self-reported physical health, and objective measures of biological health in the Peruvian Amazon.

OBJECTIVES: This study examines the associations between water insecurity, self-reported physical health, and objective measures of biological health among 225 Awajún adults (107 women; 118 men) living in the Peruvian Amazon, a "water-abundant" region. METHODS: A survey, which included multiple measures of self-reported physical health, and objective measures of biological health such as blood pressure and nutritional and immune biomarkers. RESULTS: Greater water insecurity was associated with multiple measures of self-reported physical health, including higher incidence of reported diarrhea, nausea, back pain, headaches, chest pain, fatigue, dizziness, overall poor perceived health, and "being sick." These symptoms align with the physical strain associated with water acquisition and with drinking contaminated water. A significant association between higher water insecurity and lower systolic blood pressure emerged, which may be linked to dehydration. None of the other biomarkers, including those for nutrition, infection, and stress were significantly associated with water insecurity scores. CONCLUSIONS: These analyses add to the growing body of research examining the associations between water insecurity and health. Biocultural anthropologists are well-positioned to continue probing these connections. Future research will investigate relationships between measures of water insecurity and biomarkers for gastrointestinal infection and inflammation in water-scarce and water-abundant contexts.

Perinatal Food Insecurity and Postpartum Psychosocial Stress are Positively Associated Among Kenyan Women of Mixed HIV Status.

Stress and food insecurity (FI) are associated with poor perinatal and HIV outcomes. We hypothesized that FI would increase postpartum stress among women in Kenya, and that the impact would be greater in women with HIV. Among 371 pregnant women, we identified latent FI trajectories across the perinatal period, and estimated their association with postpartum stress. Stress metrics included the Perceived Stress Scale (PSS) and hair cortisol concentrations (HCC). We identified two FI trajectories: persistent moderate FI and persistent mild FI. Moderate FI (vs. mild) was associated with higher PSS; this association was stronger among HIV-negative women. We observed a trend towards higher HCC associated with moderate FI, which did not differ by HIV status. HCC and PSS were not correlated. In summary, moderate FI (vs. mild) was associated with increased stress. The lack of PSS-HCC correlation could reflect different physiological pathways. Interventions to mitigate FI could alleviate postpartum stress.

Social Support Mitigates Negative Impact of Food Insecurity on Antiretroviral Adherence Among Postpartum Women in Western Kenya.

Food insecurity (FI), low social support, and low health-related quality of life (HRQoL) are associated with self-reported nonadherence to antiretroviral therapy (ART) among postpartum women, but these relationships have not been evaluated using objective adherence indicators. Hair samples were therefore analyzed among 83 postpartum Kenyan women living with HIV on efavirenz and nevirapine ART drug regimens in an observational cohort (NCT02974972). FI (0-27), social support (0-40), and HRQoL (8-40) in the prior month were also assessed. In multivariable models, each point increase in FI and decrease in HRQoL were associated with a 45.1% (95% CI: -64.3%, -15.6%) and 10.5% decrease (95% CI: 1.0%, 22.1%) in hair ART drug concentrations respectively, when social support was held constant. A significant interaction between social support and FI (ß = 0.02, p = 0.017) indicated that greater social support was predicted to mitigate the negative impacts of FI on ART adherence. Addressing these modifiable barriers could improve ART adherence during this critical period.

Adaptation and psychometric evaluation of the breastfeeding self-efficacy scale to assess exclusive breastfeeding.

BACKGROUND: Increasing the prevalence of optimal breastfeeding practices, including exclusive breastfeeding for 6 months, could prevent an estimated 823,000 child deaths annually. Self-efficacy is an important determinant of breastfeeding behaviors. However, existing measures do not specifically assess exclusive breastfeeding self-efficacy, but rather self-efficacy for any breastfeeding. Hence, we sought to adapt and validate an instrument to measure exclusive breastfeeding self-efficacy. METHODS: We modified and added items from Dennis' Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). It was then implemented in an observational cohort in Gulu, Uganda at 1 (n = 239) and 3 (n = 238) months postpartum ( clinicaltrials.gov NCT02925429). We performed inter-item and adjusted item-test correlations, as well as exploratory factor analysis and parallel analysis at 1 month postpartum to remove redundant items and determine their latent factor structure. We further applied confirmatory factor analysis to test dimensionality of the scale at 3 months postpartum. We then assessed the reliability of the scale and conducted tests of predictive and discriminant validity. Known group comparisons were made by primiparous status and correct breastfeeding knowledge. RESULTS: The modification of the original BSES-SF to target exclusive breastfeeding produced 19 items, which were reduced to 9 based on item correlations and factor loadings. Two dimensions of the adapted scale, the Breastfeeding Self-Efficacy Scale to Measure Exclusive Breastfeeding BSES-EBF emerged: Cognitive and Functional subscales, with alpha coefficients of 0.85 and 0.79 at 3 months postpartum. Predictive and discriminant validity and known group comparisons assessments supported its validity. CONCLUSIONS: This version of the Breastfeeding Self-Efficacy scale, the BSES-EBF Scale, is valid and reliable for measuring exclusive breastfeeding self-efficacy in northern Uganda, and ready for adaptation and validation for clinical and programmatic use elsewhere.

Schistosomiasis and hydration status: Schistosoma haematobium, but not Schistosoma mansoni increases urine specific gravity among rural Tanzanian women.

OBJECTIVES: Schistosome infections can damage organs important for water homeostasis, especially the kidneys. Urogenital schistosomiasis (caused by Schistosoma haematobium) increases protein and blood in urine and intestinal schistosomiasis (caused by S. mansoni) affects total body water. However, no data exist on how different schistosome species affect urine specific gravity (USG), a hydration biomarker. Therefore, we assessed the relationship between S. haematobium- and S. mansoni-infected and uninfected women and USG in rural Tanzania. MATERIALS AND METHODS: Surveys were conducted and stool and urine samples were collected among 211 nonpregnant women aged 18-50. S. haematobium eggs were detected using the urine filtration method. S. mansoni eggs were detected using the Kato Katz method. USG was measured using a refractometer and analyzed as both a continuous and dichotomous variable. Regression (linear/logistic) models were estimated to test the relationship between infection and hydration status. RESULTS: The prevalence of S. haematobium was 5.9% and S. mansoni was 5.4% with no coinfections. In regression models, S. haematobium-infected women had significantly higher USG (Beta = 0.007 g mL-1 ; standard error = 0.002; p = 0.001) and odds (Odds ratio: 7.76, 95% CI: 1.21-49.5) of elevated USG (>1.020 g mL-1 ) than uninfected women, whereas S. mansoni-infected women did not. DISCUSSION: Schistosoma haematobium, but not S. mansoni, infection is associated with higher USG and risk of inadequate hydration. Future work should determine whether findings are attributable to parasite-induced debris in urine or urinary tract pathologies and signs of renal damage. Human and non-human primate studies using USG in schistosome-endemic areas should account for schistosomiasis.

Geophagic earths consumed by women in western Kenya contain dangerous levels of lead, arsenic, and iron.

OBJECTIVES: Geophagy is commonly reported by pregnant women and children, yet its causes and consequences remain poorly understood. Therefore, we sought to determine if geophagy could contribute micronutrients and/or be a source of heavy metal exposure by examining the elemental composition of earths consumed in Kakamega, Kenya. METHODS: Ten samples of earths commonly consumed during pregnancy were collected by study enumerators and analyzed using inductively coupled plasma-atomic emission spectroscopy. Samples were either collected at markets or from walls of participants' homes, based on where participants reported most commonly sourcing their consumed earths. RESULTS: Based on estimated intakes (40 g/day), all samples had lead levels that exceeded the provisional maximum tolerable daily intake, and one sample exceeded the threshold for arsenic. Further, estimated intakes of iron for all samples were at least 8.9 times higher than the established threshold. Elemental concentrations were also compared by the site of sample collection (market vs. household wall); market samples had significantly higher iron concentrations and lower calcium concentrations than wall samples. CONCLUSIONS: Geophagic earths in Kakamega may be harmful because of dangerously high levels of lead, arsenic, and iron. The prevalence of geophagy among vulnerable populations underscores the importance of understanding its causes and consequences for accurate public health messaging.

Measuring exclusive breastfeeding social support: Scale development and validation in Uganda.

The World Health Organization recommends exclusive breastfeeding (EBF) for 6 months and continued breastfeeding for at least 2 years. Social support has been widely recognized to influence breastfeeding practices. However, existing scales do not measure exclusive breastfeeding social support (EBFSS), rather they assess social support for any breastfeeding. Further, they are tailored towards high-income settings. Therefore, our objectives were to develop and validate a tool to measure EBFSS in low-income settings. To develop the scale, local and international breastfeeding experts were consulted on modifications to the Hughes' Breastfeeding Social Support Scale. It was then implemented in an observational cohort in Gulu, Uganda, at 1 (n = 238) and 3 (n = 237) months post-partum (NCT02925429). We performed polychoric and polyserial correlations to remove redundant items and exploratory factor analysis at 1 month post-partum to determine the latent factor structure of EBFSS. We further applied confirmatory factor analysis to assess dimensionality of the scale at 3 months post-partum. We then conducted tests of predictive, convergent, and discriminant validity against EBF, self-efficacy, general social support, and depression. The modification of the Hughes' scale resulted in 18 items, which were reduced to 16 after examining variances and factor loadings. Three dimensions of support emerged: Instrumental, Emotional, and Informational, with alpha coefficients of 0.79, 0.85, and 0.83, respectively. Predictive, convergent, and discriminant validity of the resultant EBFSS scale was supported. The EBFSS scale is valid and reliable for measuring EBFSS in northern Uganda and may be of use in other low-income settings to assess determinants of EBF.

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.

Influence of non-directional errors in anthropometric measurements and age estimation on anthropometric prevalence indicators.

Anthropometric prevalence indicators such as stunting, wasting, and underweight are widely-used population-level tools used to track trends in childhood nutrition. Threats to the validity of these data can lead to erroneous decision making and improper allocation of finite resources intended to support some of the world's most vulnerable populations. It has been demonstrated previously that aggregated prevalence rates for these indicators can be highly sensitive to biases in the presence of non-directional measurement errors, but the quantitative relationship between the contributing factors and the scale of this bias has not been fully described. In this work, a Monte Carlo simulation exercise was performed to generate high-statistics z-score distributions with a wide range of mean and standard deviation parameters relevant to the populations in low- and middle-income countries (LMIC). With the important assumption that the distribution's standard deviation should be close to 1.0 in the absence of non-directional measurement errors, the shift in prevalence rate due to this common challenge is calculated and explored. Assuming access to a given z-score distribution's mean and standard deviation values, this relationship can be used to evaluate the potential scale of prevalence bias for both historical and modern anthropometric indicator results. As a demonstration of the efficacy of this exercise, the bias scale for a set of 21 child anthropometry datasets collected in LMIC contexts is presented.

Toward a more systematic understanding of water insecurity coping strategies: insights from 11 global sites.

INTRODUCTION: Water insecurity-the inability to access and benefit from affordable, reliable and safe water for basic needs-is a considerable global health threat. With the urgent need to target interventions to the most vulnerable, accurate and meaningful measurement is a priority. Households use diverse strategies to cope with water insecurity; however, these have not been systematically characterised nor measured. The Food Insecurity Coping Strategies Index has been insightful for targeting nutrition interventions to the most vulnerable. As a first step towards creating an analogous scale for water, this study characterises the largest empirical data set on water insecurity coping strategies and proposes guidance on measuring it using a novel toolkit. METHODS: Open-ended responses on water insecurity coping (n=2301) were collected across 11 sites in 10 low- and middle-income countries in the Household Water InSecurity Experiences (HWISE) Scale validation study. Responses were characterised and compared with behaviours identified in the literature to construct an instrument to systematically assess coping. RESULTS: We identified 19 distinct strategies that households used when experiencing water insecurity. These findings, paired with prior literature, were used to develop a Water Insecurity Coping Strategies Assessment Toolkit with guidance on its piloting to assess coping prevalence, frequency and severity. CONCLUSIONS: The widespread occurrence of water insecurity coping strategies underscores the importance of understanding their prevalence and severity. The Water Insecurity Coping Strategies Assessment Toolkit offers a comprehensive approach to evaluate these strategies and inform the design and monitoring of interventions targeting those most vulnerable to water insecurity.

Helicobacter pylori exposure among the Awajún of the Peruvian Amazon: Prevalence and environmental, social, and biological associations.

OBJECTIVES: Helicobacter pylori (H. pylori)-a gastric bacteria affecting almost 50% of the global population and leading to ulcers and cancer in severe cases-is a growing health concern among Indigenous populations who report a high burden of reported poor general health and gastrointestinal distress. We test hypothesized associations between H. pylori exposure patterns and environmental, social, and biological conditions among a sample of 212 Indigenous Awajún adults (112 males, 100 females, ages 18-65 years) living in the northern Peruvian Amazon. MATERIALS AND METHODS: Dried blood spots were analyzed for H. pylori-specific IgG using a recently developed enzyme-linked immunosorbent assay. Resulting seropositivity rates and antibody concentrations, proxying past exposures to H. pylori were analyzed in relation to relevant environmental (toilet type, floor material, reported water quality), social (household size and education level), and biological (age, sex, BMI, blood pressure, immune and metabolic biomarkers) factors using multivariable regression analyses. RESULTS: We found near ubiquitous seropositivity for H. pylori exposure in our sample (99.1% seropositive). In the regression analyses, elevations in H. pylori antibody concentrations were significantly higher among males compared to females (ß = 0.36, p = 0.01). No associations were found with any other factors. DISCUSSION: Anthropological research in the study communities suggests that the male bias in elevations of H. pylori antibody concentrations is related to cultural and biological factors. Future research is needed to further unravel these biocultural dynamics and determine whether elevations in H. pylori antibody concentrations have clinical relevance for gastrointestinal health outcomes in this population.

Pathways linking social support, self-efficacy, and exclusive breastfeeding among women in northern Uganda.

Despite improvements in infant feeding practices over the past two decades, the prevalence of exclusive breastfeeding (EBF) is below global targets. Social support can create an enabling environment for recommended infant feeding practices such as EBF, but the types of social support most important for sustained EBF and their potential mechanisms of action have not been thoroughly characterized. We therefore aimed to assess the relationship between EBF-specific social support, EBF self-efficacy, and EBF at 1 and 3 months among postpartum women in northern Uganda. Women (n = 238, 36.2% living with HIV) were recruited during pregnancy. EBF, social support, and EBF self-efficacy were assessed at 1 and 3 months postpartum. Path analysis was used to assess relationships between these factors. Most mothers exclusively breastfed to 1 (80.8%) and 3 months postpartum (62.9%). EBF-specific, but not general, social support differed by EBF status. EBF-specific social support was associated with higher odds of EBF, which was almost fully mediated by EBF self-efficacy. That is, there was evidence that social support primarily influences EBF through its association with self-efficacy. In sum, EBF-specific social support and self-efficacy likely promote EBF and are modifiable factors that can be intervened upon.

HIV-Exposed, Uninfected Infants in Uganda Experience Poorer Growth and Body Composition Trajectories than HIV-Unexposed Infants.

BACKGROUND: HIV-uninfected infants of HIV-positive women may experience worse growth and health outcomes than infants of HIV-negative women, but this has not been thoroughly investigated under the World Health Organization's most recent recommendations to reduce vertical transmission. OBJECTIVE: To determine whether HIV-exposed and -uninfected (HEU) infants whose mothers received Option B+ have higher odds of experiencing suboptimal growth trajectories than HIV-unexposed, -uninfected infants, and if this relationship is affected by food insecurity. DESIGN: Repeated anthropometric measures were taken on 238 infants (HEU = 86) at 1 week and 1, 3, 6, 9, and 12 months after delivery in Gulu, Uganda. Latent class growth mixture modeling was used to develop trajectories for length-for-age z-scores, weight-for-length z-scores, mid-upper arm circumference, sum of skinfolds, and arm fat area. Multinomial logistic models were also built to predict odds of trajectory class membership, controlling for socioeconomic factors. RESULTS: HEU infants had greater odds of being in the shortest 2 length-for-age z-scores trajectory classes [odds ratio (OR) = 3.80 (1.22-11.82), OR = 8.72 (1.80-42.09)] and higher odds of being in smallest sum of skinfolds trajectory class [OR = 3.85 (1.39-10.59)] vs. unexposed infants. Among HEU infants, increasing food insecurity was associated with lower odds of being in the lowest sum of skinfolds class [OR = 0.86 (0.76-0.98)]. CONCLUSIONS: There continues to be differences in growth patterns by HIV-exposure under the new set of World Health Organization guidelines for the prevention of mother-to-child transmission of HIV and the feeding of HEU infants in low-resource settings that are not readily identified through traditional mixed-effects modeling. Food insecurity was not associated with class membership, but differentially affected adiposity by HIV-exposure status.

HIV infection, hunger, breastfeeding self-efficacy, and depressive symptoms are associated with exclusive breastfeeding to six months among women in western Kenya: a longitudinal observational study.

BACKGROUND: Exclusive breastfeeding for the first six months of life is recommended for all infants. However, breastfeeding rates remain suboptimal; around 37% of infants are exclusively breastfed for the first six months globally. In Nyanza region, western Kenya, numerous challenges to breastfeeding have been identified, including food insecurity, hunger, depressive symptoms, and HIV infection. Yet, evidence to inform our understanding of how these problems influence women's breastfeeding behaviors across time is lacking. We therefore sought to examine these factors and how they interact to affect the initiation and duration of exclusive breastfeeding in this region. We hypothesized that women experiencing greater food insecurity, hunger, and/or depressive symptoms would be less likely to maintain exclusive breastfeeding for six months than women who were food secure or not depressed. We also hypothesized that women living with HIV would be more likely to maintain exclusive breastfeeding to six months compared to HIV-uninfected women. METHODS: Women in Pith Moromo, a longitudinal cohort study in western Kenya, were surveyed at two antenatal and three postpartum timepoints (n = 275). Data were collected on breastfeeding behavior and self-efficacy, maternal food insecurity and hunger, maternal psychosocial health, and HIV status. Cox proportional hazards models were used to identify predictors of early exclusive breastfeeding cessation. RESULTS: The majority of women (52.3%) exclusively breastfed for the first six months. In the final multivariable Cox proportional hazards model, living with HIV was associated with a 64% decrease in the rate of early exclusive breastfeeding cessation. Additionally, the rate of early exclusive breastfeeding cessation increased by 100 and 98% for those experiencing probable depression or hunger, respectively. Although there was no main effect of breastfeeding self-efficacy, the interaction between breastfeeding self-efficacy and hunger was significant, such that the rate of early exclusive breastfeeding cessation was predicted to decrease by 2% for every point increase in breastfeeding self-efficacy score (range: 0-56). CONCLUSIONS: This study contributes to previous work demonstrating that women living with HIV more consistently exclusively breastfeed and suggests that rates of exclusive breastfeeding could be increased through targeted support that promotes maternal mental health and breastfeeding self-efficacy, while reducing maternal hunger. TRIAL REGISTRATION: Study registration NCT02974972.

'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.

HIV infection and increased food insecurity are associated with adverse body composition changes among pregnant and lactating Kenyan women.

BACKGROUND/OBJECTIVES: Body composition changes markedly during reproduction. In sub-Saharan Africa, impacts of HIV infection on body composition across pregnancy and lactation in the context of Option B+ antiretroviral therapy are unknown. Therefore, we sought to evaluate the role of HIV infection on body composition during pregnancy and lactation among Kenyan women. SUBJECTS/METHODS: A cohort of pregnant women (n = 333; 50.5% HIV+, receiving ART) were enrolled at seven clinics in western Kenya. Two prenatal (mean ± SD: 23.6 ± 4.4 and 33.4 ± 2.0 weeks gestation) and three postpartum (6, 14, and 36 weeks) measurements included: individual-level food insecurity, height, weight, fat mass (FM), and fat-free mass (FFM) by bioimpedance analysis (BIA), mid-upper arm circumference (MUAC), and triceps skinfold (TSF), allowing for AMA (arm muscle area) and AFA (arm fat area) derivation. Multivariable longitudinal regression models were used to relate HIV to body composition changes. RESULTS: In longitudinal models, HIV-infected women had lower weight (ß = -3.0 kg, p = 0.003), fat mass (ß = -1.5 kg, p = 0.02), fat-free mass (ß = -1.5 kg, p = 0.01), TSF (ß = -2.6 mm, p < 0.001), AFA (ß = -3.9 cm3, p < 0.001), and MUAC (ß = -1.0 cm, p = 0.001), but not AMA (p = 0.34), across all observations. Food insecurity was inversely associated with AMA and MUAC postpartum (AMA ß-range = -0.47 to -0.92 cm3; MUAC ß-range = -0.09 to -0.15 cm, all p < 0.05). CONCLUSIONS: HIV infection was associated with lower weight, fat mass, fat-free mass, TSF, AFA, and MUAC values during pregnancy and lactation, while food insecurity was intermittently associated with body composition. This suggests that pregnant and lactating women living with HIV and food insecurity could benefit from nutritional support.

The Household Water InSecurity Experiences (HWISE) Scale: development and validation of a household water insecurity measure for low-income and middle-income countries.

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.

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.

A novel household water insecurity scale: Procedures and psychometric analysis among postpartum women in western Kenya.

Our ability to measure household-level food insecurity has revealed its critical role in a range of physical, psychosocial, and health outcomes. Currently, there is no analogous, standardized instrument for quantifying household-level water insecurity, which prevents us from understanding both its prevalence and consequences. Therefore, our objectives were to develop and validate a household water insecurity scale appropriate for use in our cohort in western Kenya. We used a range of qualitative techniques to develop a preliminary set of 29 household water insecurity questions and administered those questions at 15 and 18 months postpartum, concurrent with a suite of other survey modules. These data were complemented by data on quantity of water used and stored, and microbiological quality. Inter-item and item-total correlations were performed to reduce scale items to 20. Exploratory factor and parallel analyses were used to determine the latent factor structure; a unidimensional scale was hypothesized and tested using confirmatory factor and bifactor analyses, along with multiple statistical fit indices. Reliability was assessed using Cronbach's alpha and the coefficient of stability, which produced a coefficient alpha of 0.97 at 15 and 18 months postpartum and a coefficient of stability of 0.62. Predictive, convergent and discriminant validity of the final household water insecurity scale were supported based on relationships with food insecurity, perceived stress, per capita household water use, and time and money spent acquiring water. The resultant scale is a valid and reliable instrument. It can be used in this setting to test a range of hypotheses about the role of household water insecurity in numerous physical and psychosocial health outcomes, to identify the households most vulnerable to water insecurity, and to evaluate the effects of water-related interventions. To extend its applicability, we encourage efforts to develop a cross-culturally valid scale using robust qualitative and quantitative techniques.