"Is there anything good about a water advisory?": an exploration of the consequences of drinking water advisories in an indigenous community.

BACKGROUND: In Ontario, Canada, Indigenous communities experience some of the province's worst drinking water, with issues ranging from deteriorating water quality to regulatory problems and lack of support. When water is known, or suspected, to be unsafe for human consumption, communities are placed under a Drinking Water Advisory. Between 2004 and 2013, approximately 70% of all on-reserve communities in Ontario were under at least one Drinking Water Advisory. Despite the widespread impact of Drinking Water Advisories on health and wellbeing, little is known about First Nation individuals' perceptions and experiences living with a Drinking Water Advisory. This study presents information shared by members of a community who have lived with Boil Water Advisories on and off for many years, and a long-term Boil Water Advisory since 2017. The goal of this paper is to unpack and explore the Boil Water Advisories from the perspective of community members and provide considerations for current and future Boil Water Advisory management. METHODS: Methodological choices were driven by the principles of community-based participatory research. Two data collection methodologies were employed: hard copy surveys and interviews. RESULTS: Forty-four individuals (19.5%) completed a survey. Eight Elders and 16 key informants participated in 20 interviews. Respondents expressed varying degrees of uncertainty regarding protective actions to take while under a Boil Water Advisory. Further, 79% of men but only 46% of women indicated they always adhere to the Boil Water Advisory. Knowledge gaps that could lead to risky behaviours were also identified. Finally, Boil Water Advisories were demonstrated to have physical, financial, and time impacts on the majority of respondents. CONCLUSIONS: A direct outcome was the identification of a critical need to reinforce best practices for health protection through community education and outreach. More broadly, Chief and Council were able to use the findings to successfully advocate for improved drinking water for the community. Additionally, benefits of participatory research and community ownership include enhanced local research capacity, and increased awareness of, and desire for, research to inform decisions.

Impacts of climate change on water-related mosquito-borne diseases in temperate regions: A systematic review of literature and meta-analysis.

Mosquito-borne diseases are a known tropical phenomenon. This review was conducted to assess the mecha-nisms through which climate change impacts mosquito-borne diseases in temperate regions. Articles were searched from PubMed, Scopus, Web of Science, and Embase databases. Identification criteria were scope (climate change and mosquito-borne diseases), region (temperate), article type (peer-reviewed), publication language (English), and publication years (since 2015). The WWH (who, what, how) framework was applied to develop the research question and thematic analyses identified the mechanisms through which climate change affects mosquito-borne diseases. While temperature ranges for disease transmission vary per mosquito species, all are viable for temperate regions, particularly given projected temperature increases. Zika, chikungunya, and dengue transmission occurs between 18-34 °C (peak at 26-29 °C). West Nile virus establishment occurs at monthly average temperatures between 14-34.3 °C (peak at 23.7-25 °C). Malaria establishment occurs when the consecutive average daily temperatures are above 16 °C until the sum is above 210 °C. The identified mechanisms through which climate change affects the transmission of mosquito-borne diseases in temperate regions include: changes in the development of vectors and pathogens; changes in mosquito habitats; extended transmission seasons; changes in geographic spread; changes in abundance and behaviors of hosts; reduced abundance of mosquito predators; interruptions to control operations; and influence on other non-climate factors. Process and stochastic approaches as well as dynamic and spatial models exist to predict mosquito population dynamics, disease transmission, and climate favorability. Future projections based on the observed relations between climate factors and mosquito-borne diseases suggest that mosquito-borne disease expansion is likely to occur in temperate regions due to climate change. While West Nile virus is already established in some temperate regions, Zika, dengue, chikungunya, and malaria are also likely to become established over time. Moving forward, more research is required to model future risks by incorporating climate, environmental, sociodemographic, and mosquito-related factors under changing climates.

An ecological quantification of the relationships between water, sanitation and infant, child, and maternal mortality.

BACKGROUND: Water and sanitation access are known to be related to newborn, child, and maternal health. Our study attempts to quantify these relationships globally using country-level data: How much does improving access to water and sanitation influence infant, child, and maternal mortality? METHODS: Data for 193 countries were abstracted from global databases (World Bank, WHO, and UNICEF). Linear regression was used for the outcomes of under-five mortality rate and infant mortality rate (IMR). These results are presented as events per 1000 live births. Ordinal logistic regression was used to compute odds ratios for the outcome of maternal mortality ratio (MMR). RESULTS: Under-five mortality rate decreased by 1.17 (95%CI 1.08-1.26) deaths per 1000, p < 0.001, for every quartile increase in population water access after adjustments for confounders. There was a similar relationship between quartile increase of sanitation access and under-five mortality rate, with a decrease of 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. Improved water access was also related to IMR, with the IMR decreasing by 1.14 (95%CI 1.05-1.23) deaths per 1000, p < 0.001, with increasing quartile of access to improved water source. The significance of this relationship was retained with quartile improvement in sanitation access, where the decrease in IMR was 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. The estimated odds ratio that increased quartile of water access was significantly associated with increased quartile of MMR was 0.58 (95%CI 0.39-0.86), p = 0.008. The corresponding odds ratio for sanitation was 0.52 (95%CI 0.32-0.85), p = 0.009, both suggesting that better water and sanitation were associated with decreased MMR. CONCLUSIONS: Our analyses suggest that access to water and sanitation independently contribute to child and maternal mortality outcomes. If the world is to seriously address the Millennium Development Goals of reducing child and maternal mortality, then improved water and sanitation accesses are key strategies.

A Review of Health Risks and Pathways for Exposure to Wastewater Use in Agriculture.

BACKGROUND: Wastewater is increasingly being used in the agricultural sector to cope with the depletion of freshwater resources as well as water stress linked to changing climate conditions. As wastewater irrigation expands, research focusing on the human health risks is critical because exposure to a range of contaminants must be weighed with the benefits to food security, nutrition and livelihoods. OBJECTIVES: The goal of this paper was to review research examining health risks and exposure pathways associated with wastewater irrigation to identify research trends and gaps. METHODS: We conducted a review of the literature and identified a total of 126 studies published from 1995 to 2013. Findings were summarized based on several themes including types of exposure pathways, wastewater contaminants, methodological approaches and the geographical distribution of research. RESULTS: Only 23 studies used epidemiological methods, while most research applied alternative methods to estimate risk, such as quantitative risk assessment models or comparisons of crop contamination to established guidelines for wastewater reuse. A geographic breakdown demonstrated a focus on microbiological contaminants in specific regions such as sub-Saharan Africa and Southeast Asia, despite growing chemical risks associated with rapid urbanization and industrialization that may change the types and distribution of wastewater contaminants. CONCLUSIONS: To provide a more comprehensive understanding of the health risks of wastewater use in agriculture, future research should consider multiple exposure routes, long-term health implications, and increase the range of contaminants studied, particularly in regions heavily dependent on wastewater irrigation. CITATION: Dickin SK, Schuster-Wallace CJ, Qadir M, Pizzacalla K. 2016. A review of health risks and pathways for exposure to wastewater use in agriculture. Environ Health Perspect 124:900-909; http://dx.doi.org/10.1289/ehp.1509995.

Using Photovoice as a Community Based Participatory Research Tool for Changing Water, Sanitation, and Hygiene Behaviours in Usoma, Kenya.

Recent years have witnessed an increase in the use of community based participatory research (CBPR) tools for understanding environment and health issues and facilitating social action. This paper explores the application and utility of photovoice for understanding water, sanitation, and hygiene (WASH) behaviours and catalysing community led solutions to change behaviours. Between June and August 2013, photovoice was conducted with eight (8) women in Usoma, a lakeshore community in Western Kenya with a follow-up community meeting (baraza) in May 2014 to discuss findings with the community members and government officials. In the first part of the study, photovoice one-on-one interviews were used to explore local perceptions and practices around water-health linkages and how the ecological and socio-political environment shapes these perceptions and practices. This paper, which is the second component of the study, uses photovoice group discussions to explore participants' experiences with and (re)action to the photographs and the photovoice project. The findings illustrate that photovoice was an effective CBPR methodology for understanding behaviours, creating awareness, facilitating collective action, and engaging with local government and local health officials at the water-health nexus.

Dreaming of toilets: using photovoice to explore knowledge, attitudes and practices around water-health linkages in rural Kenya.

As part of a knowledge, attitudes, practices and empowerment (KAPE) project implemented by the United Nations University Institute for Water, Environment and Health (UNU-INWEH) in the Lake Victoria Basin, this paper reports findings from a photovoice study with women in Usoma, a lakeshore community in Western Kenya. Drawing on ecosocial and political ecology theory, findings reveal that access to water, perceptions and practices were shaped by ecological and broader structural factors. Further, collective actions to improve access were constrained by institutional and economic structures, thus (re)enforcing inequalities.

Social capital, collective action and access to water in rural Kenya.

Globally, an estimated 748 million people remain without access to improved sources of drinking water and close to 1 billion people practice open defecation (WHO/UNICEF, 2014). The lack of access to safe water and adequate sanitation presents significant health and development challenges to individuals and communities, especially in low and middle income countries. Recent research indicates that aside from financial challenges, the lack of social capital is a barrier to collective action for community based water and sanitation initiatives (Levison et al., 2011; Bisung and Elliott, 2014). This paper reports results of a case study on the relationships between elements of social capital and participation in collective action in the context of addressing water and sanitation issues in the lakeshore village of Usoma, Western Kenya. The paper uses household data (N=485, 91% response rate) collected using a modified version of the social capital assessment tool (Krishna and Shrader, 2000). Findings suggest that investment in building social capital may have some contextual benefits for collective action to address common environmental challenges. These findings can inform policy interventions and practice in water and sanitation delivery in low and middle income countries, environmental health promotion and community development.

Developing a vulnerability mapping methodology: applying the water-associated disease index to dengue in Malaysia.

The Water-associated Disease Index (WADI) was developed to identify and visualize vulnerability to different water-associated diseases by integrating a range of social and biophysical determinants in map format. In this study vulnerability is used to encompass conditions of exposure, susceptibility, and differential coping capacity to a water-associated health hazard. By assessing these conditions, the tool is designed to provide stakeholders with an integrated and long-term understanding of subnational vulnerabilities to water-associated disease and contribute to intervention strategies to reduce the burden of illness. The objective of this paper is to describe and validate the WADI tool by applying it to dengue. A systemic ecohealth framework that considers links between people, the environment and health was applied to identify secondary datasets, populating the index with components including climate conditions, land cover, education status and water use practices. Data were aggregated to create composite indicators of exposure and of susceptibility in a Geographic Information System (GIS). These indicators were weighted by their contribution to dengue vulnerability, and the output consisted of an overall index visualized in map format. The WADI was validated in this Malaysia case study, demonstrating a significant association with dengue rates at a sub-national level, and illustrating a range of factors that drive vulnerability to the disease within the country. The index output indicated high vulnerability to dengue in urban areas, especially in the capital Kuala Lumpur and surrounding region. However, in other regions, vulnerability to dengue varied throughout the year due to the influence of seasonal climate conditions, such as monsoon patterns. The WADI tool complements early warning models for water-associated disease by providing upstream information for planning prevention and control approaches, which increasingly require a comprehensive and geographically broad understanding of vulnerability for implementation.

Weather, water quality and infectious gastrointestinal illness in two Inuit communities in Nunatsiavut, Canada: potential implications for climate change.

Climate change is expected to cause changes in precipitation quantity, intensity, frequency and duration, which will subsequently alter environmental conditions and might increase the risk of waterborne disease. The objective of this study was to describe the seasonality of and explore associations between weather, water quality and occurrence of infectious gastrointestinal illnesses (IGI) in two communities in Nunatsiavut, Canada. Weather data were obtained from meteorological stations in Nain (2005-2008) and Rigolet (2008). Free-chlorine residual levels in drinking water were extracted from municipal records (2005-2008). Raw surface water was tested weekly for total coliform and E. coli counts. Daily counts of IGI-related clinic visits were obtained from health clinic registries (2005-2008). Analysis of weather and health variables included seasonal-trend decomposition procedures based on Loess. Multivariable zero-inflated Poisson regression was used to examine potential associations between weather events (considering 0-4 week lag periods) and IGI-related clinic visits. In Nain, water volume input (rainfall + snowmelt) peaked in spring and summer and was positively associated with levels of raw water bacteriological variables. The number of IGI-related clinic visits peaked in the summer and fall months. Significant positive associations were observed between high levels of water volume input 2 and 4 weeks prior, and IGI-related clinic visits (P < 0.05). This study is the first to systematically gather, analyse and compare baseline data on weather, water quality and health in Nunatsiavut, and illustrates the need for high quality temporal baseline information to allow for detection of future impacts of climate change on regional Inuit human and environmental health.