Beyond WASH: Testing Additional Connections Between Household Water Insecurity and Child Nutrition Outcomes in Multi-Country Contexts.

This study identifies multiple pathways connecting household water insecurity with child nutrition. Using nationally representative samples for 18 countries, we examine the mediating role of child's dietary diversity as a function of household water status, while also accounting for sanitation. We construct a latent household water insecurity score (HWI) and use Structural Equation approach to model underlying pathways. HWI affected child's HAZ score and hemoglobin both directly and indirectly, with a mediation from child feeding alongside effects from sanitation. Broadening the conception of household water insecurity and accommodating the indirect effects of water could improve explanations of child under-nutrition.

Maternal and household factors affecting the dietary diversity of preschool children in eastern Ethiopia: a cross-sectional study.

OBJECTIVE: Investigate the association between the dietary diversity of preschool children and proximate factors including household food insecurity, maternal food choice, preferences, khat use, and levels of depressive symptoms. DESIGN: Cross-sectional survey of randomly selected households. SETTING: Haramaya Health and Demographic Surveillance site in Eastern Ethiopia, predominantly smallholder farming households. PARTICIPANTS: 678 preschool children (24-59 months) and their mothers. METHODS: The key outcome, the adequacy of dietary diversity of preschool children, was calculated using a 24-hour parental dietary recall. Binary logistic regression was then used to identify maternal and household factors associated with dietary adequacy versus inadequacy. RESULTS: The majority (80.53%) of surveyed children had low dietary diversity (mean Dietary Diversity (MDD)) score of 3.06±1.70 on a 7-point scale). Approximately 80% of households exhibited food insecurity. Households with greater food security (adjusted OR (AOR)=1.96, 95% CI 1.19 to 3.23), healthier maternal food choice (AOR=2.19, 95% CI 1.12 to 4.31) and broader maternal food preferences (AOR=4.95, 95% CI 1.11 to 21.95) were all associated with higher dietary diversity of their preschool children (p≤0.05). Other covariates associated with adequate child dietary diversity included improved household drinking water sources (AOR=1.84, 95% CI 1.16 to 2.92) and family planning use (AOR=1.69, 95% CI 1.00 to 2.86). Despite predictions, however, maternal depression and khat consumption were not identified as factors. CONCLUSIONS: The dietary diversity of preschool children is extremely low-a pattern observed in both food-secure and food-insecure households. Key factors include maternal selection of food for convenience and ease, preferences that do not include animal protein or healthier food choices, and lack of access to improved drinking water sources. Interventions around maternal food choice and preferences could improve preschool children's nutritional health.

Men's household water fetching in India: Gender inequity is associated with greater responsibility and related risks.

INTRODUCTION: Household water fetching elevates physical and emotional harms, and these are generally assumed to accrue to women due to gendered labor assignments. But even in cases like India where fetching remains a highly feminized task, there are households where the primary responsibility is assumed by men. METHODS: We test the proposition that men's responsibility for water fetching is predicted by greater gender equity, reflected in measures of wives' empowerment. We used an extremely large, nationally representative Demographic and Health Survey dataset from India (2019-2020), narrowed to only households in which spouses co-reside with off-plot water sources (N = 10 616), and applying a multinomial regression approach. RESULTS: In >20% of households, men are the primary fetchers. They are more likely to have primary responsibility when water is more distant, privately purchased, or transported by vehicle. Contrary to predictions, men assume greater responsibility for household water fetching as their wives' empowerment measures decrease and when they want to control their movement. CONCLUSION: Married men in India sometimes assume responsibility for water fetching, but this is not explained by greater household gender equity. The findings also suggest that when men are responsible for fetching they have heightened risk of some forms of physical trauma but less relative psychological harm. Detailing why men fetch water matters for identifying and mitigating the physical and emotion harms of bearing responsibility for water labor, with implications for how gender should be conceptualized in water interventions intending to improve health and well-being.

Adolescent breakfast skipping is associated with poorer academic performance: a school-based study from Hidhabu Abote District, Ethiopia.

BACKGROUND: Breakfast is regarded as "the most important meal of the day," suggested to positively affect learning in children and adolescent in terms of cognitive and school performance. Yet, studies in LMIC settings are few and show very inconsistent results. OBJECTIVE: To assess the prevalence and correlates of breakfast skipping and its association with school performance among randomly selected in-school adolescents in Hidhabu Abote Wereda, North Shewa Zone, Central Ethiopia. METHODS: A cross-sectional study was conducted from November to December 2020. A total of 422 participants were selected randomly from high schools of Hidhabu Abote Wereda. Data were entered in to Epiata version 3.1 and exported to SPSS version 24 for analysis. Bivariate and multivariate binary logistic regression analysis identified factors that were significantly associated with the breakfast skipping. Odds ratio along with 95% Confidence interval was estimated to measure the strength of the association and level of statistical significance declared at p-value less than 0.05. RESULTS: The magnitude of breakfast skipping was 41.3%, (95% CI (36.6-46.0)]. There was statistically significant association between breakfast skipping and overall academic performance [AOR: 5.18, 95% CI (1.54-7.46)], mathematics performance (3.88, 95% CI (1.34-11.22)], and English language performance scores [2.92, 95% CI (1.38-7.58)]. Being female [AOR = 1.857, 95% CI (1.05-3.27)], household food insecurity [AOR: 2.478, 95% CI (1.36-4.51)], and less maternal education [AOR 1.89, 95% CL (3.38-7.77)] were independently associated with breakfast skipping. The primary reasons given for breakfast skipping were lack of time, lack of appetite in morning, and concerns around weight gain. CONCLUSION: Nearly half of in-school adolescents were skipped breakfast meals, and reportedly in most cases for reasons unrelated to lack of food access. Students who skipped breakfast had lower levels of school performance.

Managing menstruation with dignity: Worries, stress and mental health in two water-scarce urban communities in India.

An emerging body of literature examines multiple connections between water insecurity and mental health, with particular focus on women's vulnerabilities. Women can display greatly elevated emotional distress with increased household water insecurity, because it's them who are primarily responsible for managing household water and uniquely interact with wider water environments. Here we test an extension of this proposition, identifying how notions of dignity and other gendered norms related to managing menstruation might complicate and amplify this vulnerability. Our analysis is based on systematic coding for themes in detailed semi-structured interviews conducted with twenty reproductive-age women living in two water insecure communities in New Delhi, India in 2021. The following themes, emerging from our analysis, unfold the pathways through which women's dignity and mental health is implicated by inadequate water: ideals of womanhood and cleanliness; personal dignity during menstruation; hierarchy of needs and menstruation management amidst water scarcity; loss of dignity and the humiliation; expressed stress, frustration and anger. These pathways are amplified by women's expected roles as household water managers. This creates a confluence of gendered negative emotions - frustration and anger - which in turn helps to explain the connection of living with water insecurity to women's relatively worse mental health.

Weight stigma after bariatric surgery: A qualitative study with Brazilian women.

Prior studies suggest that one anticipated benefit of bariatric surgery is the achievement of a thinner body, one that is less subject to perceived negative judgment and condemnation by others. However, additional analyses also indicate that stigma may persist even with significant post-surgery weight loss. To investigate the stigma-related perceptions and experiences of women who have undergone bariatric surgery and the resulting body transformations, we conducted individual, semi-structured interviews with thirty Brazilian women (15 aged 33-59 and 15 aged 63-72). The resulting text was then analyzed using thematic analysis. We found that some form of weight stigma persisted for our participants, regardless of weight loss. Ongoing experiences of stigma were also evidenced by the constant internal and external vigilance reported by the women, as well as their articulated efforts to distance themselves from their previous bodies. Additionally, participants reported being judged for choosing an "easy way out" to lose weight. Those in the older group reported that weight stigma was entangled with ageism: older participants received mixed messages underscoring the ways that weight and age may interact in doubly stigmatizing ways. Family and close peers were especially powerful sources of stigma experiences. Collectively, these results show that weight stigma persists even when people undergo a procedure to lose substantive weight and that the degree and types of stigma experiences are influenced by gender and age. Our study suggest future research should explore whether a targeted approach might be more effective, for example, an approach that would emphasize the importance of developing coping strategies with respect to experiences of stigma and discrimination after surgery.

Frontiers of household water insecurity metrics: severity, adaptation and resilience.

The measurement of household-level and individual-level water insecurity has accelerated over the past 5 years through innovation and dissemination of new survey-based experiential psychometric scales modelled after food insecurity scales. These measures offer needed insight into the relative frequency of various dimensions of water problems experienced by households or individuals. But they currently tell us nothing about the severity of these experiences, mitigating behaviours (ie, adaptation) or the effectiveness of water-related behaviours (ie, resilience). Given the magnitude of the global challenge to provide water security for all, we propose a low-cost, theoretically grounded modification to common water insecurity metrics in order to capture information about severity, adaptation and resilience. We also discuss ongoing challenges in cost-effective measurement related to multidimensionality, water affordability and perception of water quality for maximising the impact and sustainability of water supply interventions. The next generation of water insecurity metrics promises better monitoring and evaluation tools-particularly in the context of rapid global environmental change-once scale reliability across diverse contexts is better characterised.

Individual interviews versus focus groups for evaluations of international development programs: Systematic testing of method performance to elicit sensitive information in a justice study in Haiti.

Focus group discussions (FGDs) and individual interviews (IIs) with community members are common methods used in evaluations of all kinds of projects, including those in international development. As resources are often limited, evaluators must carefully choose methods that yield the best information for their particular program. A concern with FGDs and IIs is how well they elicit information on potentially sensitive topics; very little is known about differences in disclosure by methodology in the domain of justice. Using FGDs (n = 16) and IIs (n = 46) from a USAID project in Haiti, we systematically coded responses based on a shared elicitation guide around access to and engagement with the formal and informal justice systems and performed thematic and statistical comparisons across the two methods. We introduce the continuous thought as the novel standard unit for statistical comparison. Participants in IIs were statistically more likely to provide themes relevant to genderbased violence. Importantly, sensitive themes extracted in IIs (e.g., related to sexual violence, economic dimensions, and restorative justice) did not emerge in FGDs. Given these results and other limitations to the FGD, prioritizing interviews over focus group modalities may be appropriate to guide targeted, effective programming on justice or other socially sensitive topics.

Parental khat use and early childhood growth status in Eastern Ethiopia.

BACKGROUND: Adult chewing of the stimulant plant khat (Catha edulis) has an unclear relationship with child growth outcomes. Contradictory study conclusions because habitual khat chewing covary with increased household income from khat production. AIM: Disentangling the association of parental khat use, household khat production, and child nutritional status and growth markers. METHODS: Bayesian analysis was applied to survey data for 2340 households containing 2760 children aged 24-60 months in a population-representative geographic sampling of two districts in Eastern Ethiopia, a khat chewing and producing region. RESULTS: Stunting effects were more evident than wasting; the negative child growth effect of khat chewing persisted regardless of household khat production; maternal chewing particularly mattered for child growth delays. CONCLUSIONS: This exploratory analysis suggests that future studies should target the interactions of khat chewing practices with gendered performances of child care/feeding responsibilities.

Status, social norms, or safety? understanding intended and reported bottled water use in Urban Mashhad, Iran.

Personal plastic-bottled water use is highly commodified, raising an array of cost and environmental concerns, and continues to grow globally. Studies in lower-income nations suggest safety as a primary motivation for such water purchases, but studies in high-income nations with greater relative affordability suggest it is more tied to socially situated consumer decisions like status and aesthetics. Here, we consider what motivates bottled water use in an urban city (Mashhad) in a middle-income predominantly Muslim country (Iran), where there is a likely intersection of safety (due to contamination), social norms, and status concerns. Surveys were collected with a random population-representative sample of resident adults from discrete households (n = 970). Structured equation modeling testing the relative effects on reported bottled water intentions and use shows that all these factors are shaping people's decisions. Both higher- and lower-income residents' responses suggest that status and social norms considerably influence intentions to use. Overall, even despite real safety issues with tap water, social norms and status concerns seem to weigh more heavily on residents' decisions to drink bottled water.

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.

Water Insecurity, Water Borrowing, and Psychosocial Stress Among Daasanach Pastoralists in Northern Kenya.

This article quantifies Daasanach water insecurity experiences in Northern Kenya, examines how water insecurity is associated with water borrowing and psychosocial stress, and evaluates if water borrowing mitigates the stress from water insecurity. Of 133 households interviewed in 7 communities, 94% were water insecure and 74.4% borrowed water three or more times in the prior month. Regression analyses demonstrate water borrowing frequency moderates the relationship between water insecurity and psychosocial stress. Only those who rarely or never borrowed water reported greater stress with higher water insecurity. The coping mechanism of water borrowing may help blunt water insecurity-related stress.

Water Sharing Is a Distressing Form of Reciprocity: Shame, Upset, Anger, and Conflict Over Water in Twenty Cross-Cultural Sites.

Anthropological theories of reciprocity suggest it enhances prestige, social solidarity, and material security. Yet, some ethnographic cases suggest that water sharing-a form of reciprocity newly gaining scholarly attention-might work in the opposite way, increasing conflict and emotional distress. Using cross-cultural survey data from twenty global sites (n=4,267), we test how household water reciprocity (giving and receiving) is associated with negative emotional and social outcomes. Participation in water sharing as both givers and receivers is consistently associated with greater odds of reporting shame, upset, and conflict over water. Water sharing experiences in a large, diverse sample confirm a lack of alignment with predictions of classic reciprocity theories. Recent ethnographic research on reciprocity in contexts of deepening contemporary poverty will allow development of ethnographically informed theories to better explain negative experiences tied to water reciprocity.

Teorías antropológicas de reciprocidad sugieren que ésta mejora el prestigio, la solidaridad social y la seguridad material. Sin embargo, algunos casos etnográficos sugieren que compartir el agua ­una forma de reciprocidad que esta ganando atención académica recientemente­ puede funcionar de forma opuesta, incrementando el conflicto y la angustia emocional. Utilizando información de una encuesta intercultural de veinte sitios globales (n=4,267), evaluamos cómo la reciprocidad de agua en hogares (dar y recibir) esta asociada con resultados emocionales y sociales negativos. La participación en el compartir de agua como dadores y recibidores esta asociada consistentemente con mayores probabilidades de reportar culpa, malestar y conflicto sobre el agua. Las experiencias de compartir agua en una muestra amplia y diversa confirman una falta de alineación con las predicciones de las teorías clásicas de reciprocidad. Investigación etnográfica reciente sobre reciprocidad en contextos de profundización de la pobreza contemporánea permitirá el desarrollo de teorías informadas etnográficamente para explicar mejor las experiencias negativas ligadas a la reciprocidad del agua.

Health impacts of water and sanitation insecurity in the Global North: a scoping literature review for U.S. colonias on the Mexico border.

U.S. border colonias are peri-urban settlements along the U.S.-Mexico border. Residents often face substandard housing, inadequate septic and sewer systems, and unsafe or inadequate household water. As of 2015, an estimated 30% of over 5 million U.S. colonia residents lacked access to clean drinking water, suggesting health complications. This scoping review identifies a very limited existing set of research on water and sanitation insecurity in U.S.-Mexico border colonias, and suggests value in additional focused research in this specific context to address health challenges. Preliminary health data indicates that due to water insecurity, colonia residents are more likely to contract gastrointestinal diseases, be exposed to carcinogenic compounds from contaminated water, and experience psychosocial distress. These widespread health issues in colonias are exacerbated by historical and ongoing socioenvironmental injustices in the U.S.-Mexico border region and their relation to the poor health outcomes.

Fat Is All My Fault: Globalized Metathemes of Body Self-blame.

Norms valorizing not-fat bodies appear to have spread around the world, combined with a globalizing belief that thinness is the result of individual management of self and hard work. We examine themes of blame and felt responsibility for weight and "fat" in four distinct geographic and cultural locations: peri-urban Georgia, United States; suburban Osaka, Japan; urban Encarnación, Paraguay; and urban Apia, Samoa. Use of a novel metatheme approach that compares and contrasts these four distinct places characterized by different population-level prevalences of obesity and by specific cultural histories relevant to body norms and ideals provides a flexible toolkit for comparative cross-cultural/multi-sited ethnographic research. We show that self-blame, marked by an articulated sense of individual responsibility for weight and a sense of failing in this responsibility, is present in every field site, but to varying degrees and expressed in different ways. [fat, obesity, metatheme, stigma, self-blame].

The Harm Inflicted by Polite Concern: Language, Fat, and Stigma.

Understanding language as a social action draws attention to the ways in which fat stigmatizing discourses do social harm. Drawing on interviews and experiences situated in Osaka, Japan and north Georgia, US, this paper looks closely at the ways in which fat stigma is expressed across the two sites, both blatantly and through more subtle language use. We identified four key themes in people's narratives around localized ideas about fatness. These themes are: (1) expressed pity or concern for fat people; (2) reported experiences of indirect stigma in public settings; (3) reported experiences of direct stigma in private settings; and (4) robust and repeated associations between fat and other conditions that had locally relevant negative connotations in each site. We further identify the expressed concern and pity articulated in the first theme as a form of cloaked, "dressed up" stigma and as such, we argue that it enacts social harm, especially when it co-occurs with more blatant forms of stigma. Linguistic niceties around caring actually, at least in these contexts, reify symbolic connections between fat bodies and their social failure.

Localizing syndemics: A comparative study of hunger, stigma, suffering, and crime exposure in three Haitian communities.

Theoretically, disease syndemics are hyper-localized in the forms they take, but little empirical data show how localization manifests. We present a comparison across three sites in Haiti, from data collected in June-august 2017 testing for localizations of risks across three communities: rural farming, border town, and in a high gang-activity urban zone. First, we modeled survey responses collected from heads of 4055 geographically-sampled households via linear regression, considering additive and interaction effects of food insecurity, crime exposure, and discrimination on depression and anxiety levels. Exposure to food insecurity, crime exposure, and discrimination were each associated with more depression and anxiety symptoms. For those living in the urban zone, there was weak evidence of possible interactional risks between the three vulnerabilities, suggesting little meaningful localized syndemic patterning. Second, we conducted thematic and word-based semantic network analysis to identify if people themselves cognitively connected vulnerabilities of hunger/poverty, crime, and suffering/discrimination using 7321 text blocks from 95 semi-structured interviews/focus groups. Network visualization suggested people commonly connect these domains. While the patterns were localized, crime concerns were central to all networks. The domain connections expressed through people's own words were more complexly inter-related than was evident from the modeled survey data, and suggested counter-intuitive influences. The quantitative approach to modeling syndemic interactions suggests no apparent practical benefits to layering or combining local anticrime, anti-hunger, and anti-discrimination programming. However, the qualitative network analysis suggests that programming could none-the-less leverage the perceived connections across domains for more meaningful and effective interventions. For the broader study of syndemics, incorporating novel qualitative approaches clarifies that constituent processes are not just potentially localizing suffering, but are also extremely important in how people cognitively understand and organize their everyday lives.

Body norms and normative bodies in Highland Guatemala.

OBJECTIVES: The concept of bionormalcy highlights the potential tensions between bodies defined clinically as normal or healthy, bodies that are normative (frequent) within a population, and bodies defined within a given social context as abnormal or devalued. Theories of resource scarcity predict preferences for larger bodies should deviate from what is biologically normative (i.e., most frequent) or clinically defined as healthy. Using the case of adult women in a Guatemalan community with chronically low food security, we test how food scarcity shapes individual views of smaller, larger, and clinically categorized normal bodies. METHODS: Participants were 102 women from a community in the Central Highlands of Guatemala. Using the Stunkard figure scale and a word elicitation task, participants attributed positive and negative characteristics to male and female silhouettes clinically defined as underweight, normal, overweight, mildly obese, and obese. Mixed-effects models were used to compare attribution scores for figures relative to the clinically normal silhouette. RESULTS: Silhouettes deviating from the clinically defined normal BMI category on both sides are stigmatized to varying degrees. Food insecurity exacerbates the degree of stigma, while also relatively preferencing overweight bodies. CONCLUSIONS: In this pilot study, women exhibit a preference for body sizes that fall within the clinical normal and overweight categories and stigmatize bodies outside this range, but in distinct ways. We suggest the attachment of stigma to small and large bodies are not mirror processes, and require more detailed testing to untangle the likely complex ecological and social explanations.