Water Supply Interruptions Are Associated with More Frequent Stressful Behaviors and Emotions but Mitigated by Predictability: A Multisite Study.

Water supply interruptions contribute to household water insecurity. Unpredictable interruptions may particularly exacerbate water insecurity, as uncertainty limits households' ability to optimize water collection and storage or to modify other coping behaviors. This study used regression models of survey data from 2873 households across 10 sites in 9 middle-income countries to assess whether water supply interruptions and the predictability of interruptions were related to composite indicators of stressful behaviors and emotional distress. More frequent water service interruptions were associated with more frequent emotional distress (ß = 0.49, SE = 0.05, P < 0.001) and stressful behaviors (ß = 0.39, SE = 0.06, P < 0.001). Among households that experienced interruptions, predictability mitigated these respective relationships by approximately 25 and 50%. Where the provision of continuous water supplies is challenged by climate change, population growth, and poor management, water service providers may be able to mitigate some psychosocial consequences of intermittency through scheduled intermittency and communication about water supply interruptions. Service providers unable to supply continuous water should optimize intermittent water delivery to reduce negative impacts on users, and global monitoring regimes should account for intermittency and predictability in post-2030 water service metrics to better reflect household water insecurity experiences.

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.

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.

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.

Determinants of tap water mistrust among Phoenix, Arizona Latinx adults.

The purpose of this investigation was to characterize factors that predict tap water mistrust among Phoenix, Arizona Latinx adults. Participants (n = 492, 28 ± 7 years, 37.4% female) completed water security experience-based scales and an Adapted Survey of Water Issues in Arizona. Binary logistic regression determined odds ratios (OR) with 95% confidence intervals (95% CI) for the odds of perceiving tap water to be unsafe. Of all participants, 51.2% perceived their tap water to be unsafe. The odds of mistrusting tap water were significantly greater for each additional favorable perception of bottled compared to tap water (e.g., tastes/smells better; OR = 1.94, 95% CI = 1.50, 2.50), negative home tap water experience (e.g., hard water mineral deposits and rusty color; OR = 1.32, 95% CI = 1.12, 1.56), use of alternatives to home tap water (OR = 1.25, 95% CI = 1.04, 1.51), and with decreased water quality and acceptability (OR = 1.21, 95% CI = 1.01, 1.45; P < 0.05). The odds of mistrusting tap water were significantly lower for those whose primary source of drinking water is the public supply (municipal) (OR = 0.07, 95% CI = 0.01, 0.63) and with decreased water access (OR = 0.56, 95% CI = 0.48, 0.66; P < 0.05). Latinx mistrust of tap water appears to be associated with organoleptic perceptions and reliance on alternatives to the home drinking water system.

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.

Changing Flows: Sociotechnical Tinkering for Adaptive Water Management.

The Western United States is experiencing historic drought, increasing pressure on water management systems. Agricultural production that relies on surface water flows is therefore imperiled, requiring new innovations and partnerships in order to adapt and survive. In Arizona, some agriculture continues to rely on historic, low-tech irrigation infrastructure such as hand-dug open ditches that divert river water to flood fields. These ditch systems are managed through both formal ditch companies and informal associations. To address changing water availability and needs, ditch users regularly "tinker" with water infrastructure, experimenting and making changes beyond the original infrastructure plans. Such changes are informed and driven by local social relationships and realities of the physical infrastructure. These dynamics are critical to understanding the adaptive capacity and flexibility of the water system; however, they are challenging to recognize and record. In this paper, we apply the emerging conceptualization of sociotechnical tinkering to examine the adaptive management of irrigation ditches in the Verde Valley of Arizona. We find evidence that water users frequently tinker with their water delivery and monitoring infrastructure to respond to and anticipate changes in water availability. Viewed through the lens of sociotechnical tinkering, these interactions are understood as the material manifestations of situated practice and actor agency within a water management system. This case study contributes to literature on adaptive environmental management and the hydrosocial cycle.

MAD Water: Integrating Modular, Adaptive, and Decentralized Approaches for Water Security in the Climate Change Era.

Centralized water infrastructure has, over the last century, brought safe and reliable drinking water to much of the world. But climate change, combined with aging and underfunding, is increasingly testing the limits of-and reversing gains made by-these large-scale water systems. To address these growing strains and gaps, we must assess and advance alternatives to centralized water provision and sanitation. The water literature is rife with examples of systems that are neither centralized nor networked, but still meet water needs of local communities in important ways, including: informal and hybrid water systems, decentralized water provision, community-based water management, small drinking water systems, point-of-use treatment, small-scale water vendors, and packaged water. Our work builds on these literatures by proposing a convergence approach that can integrate and explore the benefits and challenges of modular, adaptive, and decentralized ("MAD") water provision and sanitation, often foregrounding important advances in engineering technology. We further provide frameworks to evaluate justice, economic feasibility, governance, human health, and environmental sustainability as key parameters of MAD water system performance.

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.

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.

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].

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.

Household Water Insecurity Affects Child Nutrition Through Alternative Pathways to WASH: Evidence From India.

BACKGROUND: Household water security matters greatly for child nutrition outcomes in the global South. Water's role in sanitation/hygiene, via diarrheal disease, is cited as a primary mechanism here. Yet, the relationship between Water along with Sanitation and Hygiene (WASH) and child stunting remains inconclusive. Water-related mechanisms outside of the traditional scope of WASH might assist with explaining this. OBJECTIVE: We aim to test the mediating role of reduced dietary diversity as an additional potential mechanism in linking worse household water access to increased risk of early childhood stunting, separating its effects from sanitation and diarrhea among children (as a proxy for hygiene) and taking into account regional water availability. METHOD: We use nationally representative India Demographic and Health Survey (2015-16) data for 58 038 children aged 6 to 23 months, applying generalized structural equation modelling to estimate water's direct and indirect effects (as mediated through dietary diversity and access to sanitation) on a child's likelihood of being stunted. RESULTS: Suboptimal water access is significantly associated with elevated likelihood of child stunting. More than 30% of the effect is indirect. In the context of low water access and availability, children's dietary diversity alone mediates more than 20% of its total effect on child stunting. CONCLUSION: Beyond the WASH mechanisms, household water access affects child stunting indirectly, mediated through its impacts on children's dietary diversity. These mediating effects are also moderated by regional water availability. Water interventions in low-water regions should help reduce children's risk of nutrition-related stunting in households with lowest water access.

Household water insecurity will complicate the ongoing COVID-19 response: Evidence from 29 sites in 23 low- and middle-income countries.

In March 2020, the World Health Organization (WHO) issued a set of public guidelines for Coronavirus Disease 2019 (COVID-19) prevention measures that highlighted handwashing, physical distancing, and household cleaning. These health behaviors are severely compromised in parts of the world that lack secure water supplies, particularly in low- and middle-income countries (LMICs). We used empirical data gathered in 2017-2018 from 8,297 households in 29 sites across 23 LMICs to address the potential implications of water insecurity for COVID-19 prevention and response. These data demonstrate how household water insecurity presents many pathways for limiting personal and environmental hygiene, impeding physical distancing and exacerbating existing social and health vulnerabilities that can lead to more severe COVID-19 outcomes. In the four weeks prior to survey implementation, 45.9% of households in our sample either were unable to wash their hands or reported borrowing water from others, which may undermine hygiene and physical distancing. Further, 70.9% of households experienced one or more water-related problems that potentially undermine COVID-19 control strategies or disease treatment, including insufficient water for bathing, laundering, or taking medication; drinking unsafe water; going to sleep thirsty; or having little-to-no drinking water. These findings help identify where water provision is most relevant to managing COVID-19 spread and outcomes.

Understanding Biopsychosocial Health Outcomes of Syndemic Water and Food Insecurity: Applications for Global Health.

Household food and water insecurity often co-occur, and both can lead to malnutrition, psycho-emotional stress, and increased risk of infectious and chronic diseases. This can occur through multiple pathways including poor diet and inadequate sanitation. In this perspective, we discuss the potential advantages of a syndemic approach to understanding the consequences of food and water insecurity, that is, one that makes possible the assessment of their mutually enhancing effects on health. Syndemic theory considers the concerted, deleterious interaction of two or more diseases or other health conditions, such as psycho-emotional stress, that result from structural inequities. We therefore call for an approach that links localized morbidity of individual- or household-level experiences of concurrent food and water insecurity to larger structural and contextual forces/risk environments. Such an approach permits the investigation of food and water insecurity as suites of risk, such that certain disease outcomes serve as signals for interlinked stressors. For example, the use of a syndemic perspective could help explain the persistence of conditions like diarrhea or stunting after food or water interventions; that is, existing approaches may be too narrow in scope to protect individuals from multiple and overlapping environmental and biopsychosocial stressors.

Water borrowing is consistently practiced globally and is associated with water-related system failures across diverse environments.

Water problems due to scarcity, inaccessibility, or poor quality are a major barrier to household functioning, livelihood, and health globally. Household-to-household water borrowing has been posited as a strategy to alleviate unmet water needs. However, the prevalence and predictors of this practice have not been systematically examined. Therefore, we tested whether water borrowing occurs across diverse global contexts with varying water problems. Second, we tested if household water borrowing is associated with unmet water needs, perceived socio-economic status (SES), and/or water-related system failures, and if water access moderated (or changed) these relationships. Using survey data from the Household Water Insecurity Experiences (HWISE) study from 21 sites in 19 low- and middle-income countries (n = 5495 households), we found that household-to-household water borrowing was practiced in all 21 sites, with 44.7% (11.4-85.4%) of households borrowing water at least once the previous month. Multilevel mixed-effect logistic regression models demonstrate that high unmet water needs (odds ratio [OR] = 2.86], 95% confidence interval [CI] = 2.09-3.91), low perceived SES (OR = 1.09; 95% CI = 1.05-1.13), and water-related system failures (23-258%) were all significantly associated with higher odds of water borrowing. Significant interactions (all p < 0.01) between water access, unmet water needs, and water-related system failures on water borrowing indicate that water access moderates these relationships. These data are the first to demonstrate that borrowing water is commonly used by households around the world to cope with water insecurity. Due to how prevalent water borrowing is, its implications for social dynamics, resource allocation, and health and well-being are likely vast but severely under-recognized.