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

Association between water insecurity and antiretroviral therapy adherence among pregnant and postpartum women in Greater Accra region of Ghana

BACKGROUND

Adherence to antiretroviral therapy (ART) can substantially reduce morbidity and mortality among women living with HIV (WLWH) and prevent vertical transmission of HIV. However, in sub-Saharan Africa (SSA), more than 50% of new mothers discontinue ART and HIV care after childbirth. The role of water insecurity (WI) in ART adherence is not well-explored. We examined the relationship between WI and ART adherence among pregnant and postpartum WLWH in Greater Accra region of Ghana.

METHODS

Using a cross-sectional survey, we recruited 176 pregnant and postpartum WLWH on ART across 11 health facilities. We examined the association between WI (measured using the Household Water Insecurity Experience Scale, and categorized as moderate and severe WI compard to low WI) and poor ART adherence (defined as scoring a below average observed CASE index score). Bivariate analysis was performed using chi-square test followed by multivariate logistic regression models. We included all variables with p-values less than 0.20 in the multivariate analysis.

RESULTS

Most (79.5%) of the pregnant and postpartum WLWH enrolled on ART, were urban residents. Over 2/3 were aged 30 years and older. Overall, 33.5% of respondents had poor ART adherence. Proportion of poor ART adherence was 19.4% among those with low WI, 44.4% in those with moderate WI, and 40.0% among those with high WI. Respondents with moderate household water insecurity had a greater odds of reporting poor ART adherence, as compared to those with low water insecurity (adjusted Odds ratio (aOR) = 2.76, 95%CI: 1.14-6.66, p = 0.024), even after adjusting for food insecurity. Similarly, respondents with high WI had a greater odds of reporting poor ART adherence, as compared to those with low water insecurity (aOR = 1.49, 95%CI: 0.50-4.48, p = 0.479), even after adjusting for food insecurity.

CONCLUSION

Water insecurity is prevalent among pregnant and postpartum WLWH and is a significant risk factor for poor ART adherence. Governments and other stakeholders working in HIV care provision should prioritize water security programming for WLWH along the HIV care continuum.

Household water treatment practice and associated factors in Ethiopia: A systematic review and meta-analysis

The provision of potable water is crucial to ensuring the health and dignity of individuals. In many developing countries, including Ethiopia, waterborne disease has become a major public health problem. There is a significant gap in accessing comprehensive national-wide evidence on Household Water Treatment (HWT) practices and associated factors in Ethiopia. Therefore, this study aims to assess the pooled HWT practice and associated factors in Ethiopia. A comprehensive search of published studies before October 15, 2022, was identified using databases and other sources. Data were extracted using Microsoft Excel, and analysis was performed using STATA 14/SE software. A random-effects model was used to estimate the pooled proportion of HWT practices and the odds ratio of associated factors. The funnel plot and Egger's regression test were used to assess publication bias, and I2 test statistics was used to assess heterogeneity. Duval and Tweedie's "trim and fill" method was performed to adjust the pooled estimate. A subgroup analysis was also conducted to identify the sources of heterogeneity. In this study, a total of 708 articles were retrieved, and 16 eligible studies were included. The pooled proportion of HWT practice in Ethiopia was found to be 21% (95% CI: 17-24). Having a formal education (OR: 2.42, 95% CI (2.11-2.74)), being male (OR: 1.32, 95% CI (1.13-1.51)), owning radio (OR: 1.33, 95% CI (1.18-1.47)), having a higher income (OR: 1.73, 95% CI (1.41-2.04)), unimproved water source (OR: 1.71, 95% CI (1.41-2.01)), fetching water at more frequently (OR: 3.31, 95% CI (1.99-4.64)), dipping methods of water drawing (OR: 2.08, 95% CI (1.66-2.51)), and taken training of water treatment (OR: 2.15, 95% CI (1.55-2.75)) were all found to be associated with HWT practice. Based on the findings of this study, the pooled proportion of HWT practice in Ethiopia was found to be one-fifth, which indicated that it was significantly low. Therefore, the authors recommend that households could better receive adequate information about HWT practices through strengthened health education and intensive training on HWT.

Effectiveness of a water-vending kiosk intervention toward household water quality and surveyed water security in Freetown, Sierra Leone

Low-income urban residents of Freetown, Sierra Leone, have limited access to safely managed piped drinking water services. The Government of Sierra Leone, in partnership with the United States Millennium Challenge Corporation, implemented a demonstration project of ten water kiosks providing distributed, stored, treated water among two neighborhoods in Freetown. This study quantifies the impact of the water kiosk intervention by utilizing a quasi-experimental propensity score matched difference-in-differences study design. Results indicate a 0.6 % improvement in household microbial water quality and an 8.2 % improvement in surveyed water security within the treatment group. Furthermore, low functionality and adoption of the water kiosks were observed.

COVID-19 and household water insecurities in vulnerable communities in the Mekong Region

Access to sufficient clean water is important for reducing the risks from COVID-19. It is unclear, however, what influence COVID-19 has had on water insecurities. The objective of this study was to assess the associations between COVID-19 control measures and household water insecurities. A survey of 1559 individuals living in vulnerable communities in five countries (Cambodia, Laos, Myanmar, Thailand, Vietnam) showed that increased needs for clean water to wash hands or facemasks made it more likely a person was water insecure along those dimensions. Water insecurities with respect to handwashing and drinking, in turn, made adoption of the corresponding good practices less likely, whereas in the case of washing facemasks there was no association. Water system infrastructure, environmental conditions such as floods and droughts, as well as gender norms and knowledge, were also important for water insecurities and the adoption of good practices. As domestic water insecurities and COVID-19 control measures are associated with each other, efforts should therefore be directed at identifying and assisting the water insecure at high risk when COVID-19 reaches their communities.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10668-022-02182-0.

Facilitating hand hygiene in displacement camps during the COVID-19 pandemic: a qualitative assessment of a novel handwashing stand and hygiene promotion package

BACKGROUND

Handwashing with soap is critical for the prevention of diarrhoeal diseases and outbreak related diseases, including interrupting the transmission of COVID-19. People living in large displacement settings are particularly vulnerable to such outbreaks, however, practicing handwashing is typically challenging in these contexts.

METHODS

We conducted a qualitative assessment of the implementation of a combined intervention to facilitate handwashing behaviour in displacement camps and in surrounding communities in Bangladesh, Ethiopia and the Democratic Republic of Congo during the COVID-19 pandemic. The intervention comprised a 'hardware' infrastructural component (provision of the Oxfam Handwashing Station) and a 'software' hygiene promotion package (Mum's Magic Hands). We used programmatic logbooks, interviews with implementation staff and focus group discussions with crisis-affected populations to assess the use, feasibility and acceptability of the intervention.

RESULTS

Both components of the intervention were viewed as novel and appealing by implementing staff and crisis-affected populations across the study sites. The acceptability of the handwashing station could be improved by redesigning the tap and legs, exploring local supply chain options, and by providing a greater number of facilities. The implementation of the hygiene promotion package varied substantially by country making it challenging to evaluate and compare. A greater focus on community engagement could address misconceptions, barriers related to the intuitiveness of the handwashing station design, and willingness to participate in the hygiene promotion component.

CONCLUSIONS

The combination of a 'hardware' and 'software' intervention in these settings appeared to facilitate both access and use of handwashing facilities. The acceptability of the combined intervention was partially because a great deal of effort had been put into their design. However, even when delivering well-designed interventions, there are many contextual aspects that need to be considered, as well as unintended consequences which can affect the acceptability of an intervention.

Growth and growth trajectory among infants in early life: contributions of food insecurity and water insecurity in rural Zimbabwe

Introduction

Stunting or linear growth faltering, measured by length-for-age Z-score (LAZ), remains a significant public health challenge, particularly in rural low-income and middle-income countries. It is a marker of inadequate environments in which infants are born and raised. However, the contributions of household resource insecurities, such as food and water, to growth and growth trajectory are understudied.

Methods

We used the cluster-randomised Sanitation Hygiene and Infant Nutrition Efficacy trial to determine the association of household-level food insecurity (FI) and water insecurity (WI) on LAZ and LAZ trajectory among infants during early life. Dimensions of FI (poor access, household shocks, low availability and quality) and WI (poor access, poor quality, low reliability) were assessed with the multidimensional household food insecurity and the multidimensional household water insecurity measures. Infant length was converted to LAZ based on the 2006 WHO Child Growth Standards. We report the FI and WI fixed effects from multivariable growth curve models with repeated measures of LAZ at 1, 3, 6, 12 and 18 months (M1-M18).

Results

A total of 714 and 710 infants were included in our analyses of LAZ from M1 to M18 and M6 to M18, respectively. Mean LAZ values at each time indicated worsening linear growth. From M1 to M18, low food availability and quality was associated with lower LAZ (β=-0.09; 95% -0.19 to -0.13). From M6 to M18, poor food access was associated with lower LAZ (β=-0.11; 95% -0.20 to -0.03). None of the WI dimensions were associated with LAZ, nor with LAZ trajectory over time.

Conclusion

FI, but not WI, was associated with poor linear growth among rural Zimbabwean infants. Specifically, low food availability and quality and poor food access was associated with lower LAZ. There is no evidence of an effect of FI or WI on LAZ trajectory.

The dynamics of household water security and treatment practices: a population-based, cross-sectional study in Osun State, Southwest Nigeria

A minimum of basic water supply service is pertinent to improving living standards and water-dependent quality of life indices. In Nigeria, 14% have access to safely managed drinking water services, though approximately 30% of water pumps and schemes are likely to fail within 12 months of construction. This study aims to determine household water security and its predictors in Osun State, Nigeria. The cross-sectional study recruited 548 households through a five-stage sampling technique and used a semi-structured questionnaire for data collection. Results were presented by descriptive and inferential statistics, while binary logistic regression identified water-security predictors at P_ά 0.05. Hand-dug wells (27.7%) and motorized boreholes (21.2%) were the predominant household drinking water sources. A total of 43.7% of households were water-secured while 35.2% of water sources were within residential settlements. A total of 25.1% of households experienced water scarcity, and 27.2% of households treat drinking water mainly by chlorination (56.7%) and boiling (14.7%). A total of 21.2%, 64.2%, and 9% of households, respectively, have safely managed basic and limited water supply services. Drinking water sources were associated with house ownership (p = 0.001) and residence period (p = 0.025) while water treatment was associated with gender (p = 0.010) and wealth (p = 0.0001). Age (p = 0.002) and wealth (p = 0.0001) are predictors of household water security. Two-fifths of households were water-secured, highlighting the dearth of potable water supply services and the need to incorporate strategic predictors of household water security in the existing national and state-level water resources regulations.

Estimating national, demographic, and socioeconomic disparities in water insecurity experiences in low-income and middle-income countries in 2020-21: a cross-sectional, observational study using nationally representative survey data

BACKGROUND

We are facing a global water crisis. However, because most water indicators assess physical availability or infrastructure in aggregate, knowing which sociodemographic groups experience water insecurity is difficult. We aimed to assess the prevalence of water insecurity across low-income and middle-income countries (LMICs) and examine how it varies by sociodemographic characteristics and exposure to life disruptions due to the COVID-19 pandemic across and within countries.

METHODS

In this observational study, we used Individual Water Insecurity Experiences (IWISE) scale data from a cross-sectional, nationally representative sample of individuals aged 15 years and older (defined as adults) in 31 LMICs. The IWISE scale range is 0-36, and water insecurity was defined as a score of 12 or higher. We used multivariable linear regression models to assess how individual-level experiences with water insecurity related to sociodemographic characteristics in each country, region, and the pooled sample.

FINDINGS

45 555 individuals from 31 LMICs completed the IWISE module between Sept 4, 2020, and Feb 24, 2021, and were included in the 2020 Gallup World Poll (GWP) database; 45 365 individuals had sufficient data to estimate the prevalence of water insecurity. 42 918 individuals from 30 LMICs had sufficient data to assess sociodemographic characteristics associated with water insecurity, and 39 161 individuals in 29 countries had sufficient data to assess how IWISE scale scores covaried with life disruptions due to the COVID-19 pandemic. The overall prevalence of water insecurity in 2020 was 14·2%, ranging by region from 36·1% in the sub-Saharan Africa region to 9·1% in the Asia region, and by country from 63·9% in Cameroon to 3·6% in China. In the pooled model including sociodemographic and COVID-19 factors, difficulty getting by on household income (vs no difficulty getting by: β 2·76 [95% CI 2·45-3·07]), living in the outskirts of a city (vs living in a large city: 0·85 [0·29-1·41]), and being greatly affected by the COVID-19 pandemic (vs not being affected: 2·36 [1·96-2·77]) were strongly associated with higher IWISE scores. In country and regional models, the sociodemographic factors most consistently associated with higher IWISE scores were difficulty getting by on household income and life disruptions due to the COVID-19 pandemic, but the strength of these associations varied across countries and regions.

INTERPRETATION

Through extrapolation of these nationally representative data, we estimate that hundreds of millions of people had life-altering experiences with water insecurity globally in 2020, and that their sociodemographic characteristics vary by country and region. Additional individual-level measurements globally could help pinpoint the characteristics of those who are most water insecure, thereby guiding the development of context-specific policy and interventions that will best serve those most affected.

FUNDING

Carnegie Corporation, Northwestern University, and USAID.

Actual conditions of person-to-object contact and a proposal for prevention measures during the COVID-19 pandemic

This study focused on human contact behavior with objects and discussed countermeasures during the COVID-19 pandemic across 15 location types. Reducing contact with objects and disinfecting items can be implemented at a relatively low cost. We created a protocol for organizing the objects, and 1260 subjects who went outside during a day between December 3-7, 2020 in Tokyo and Kanagawa, Japan were surveyed. The participants touched 7317 objects in total; the most common objects were doors, chairs, baskets, elevator equipment, and cash. One-way analysis of variance and Scheffé's multiple comparison test showed that supermarkets had the lowest mean and median values despite having the highest number of users, contact objects, and object types. Conversely, the values for hotels were the highest, significantly higher than that for other places, excluding amusement parks, workplaces, and schools and universities. Furthermore, the long-tailed frequency distribution of the number of objects suggests that the objects touched by many individuals are limited; thus, it is important to determine the objects to be prioritized for disinfection at each location. The data and protocol could inform infection countermeasures that properly address the contact realities as they pertain to people's behavior and objects.

COVID-19 lockdowns: Employment and business disruptions, water access and hygiene practices in Nairobi's informal settlements

Host to one billion people around the world, informal settlements are especially vulnerable to COVID-19 lockdown measures as they already lack basic services such as water, toilets, and secure housing. Additionally, many residents work in informal labor markets that have been affected by the lockdowns, resulting in further reductions in access to resources, including clean water. This study uses a cross-sectional design (n = 532) to examine the vulnerabilities of households to employment and business disruptions, water access and hygiene practices during the COVID-19 lockdowns between April and June 2020 in three informal settlements in Nairobi, Kenya. We used survey questions from the Household Water Insecurity Experience Scale (HWISE) to investigate the relationship between employment and business disruptions, water access, and hygiene practices (i.e., hand washing, body washing, clothes washing, and being able to use or drink clean water). Of the sampled households, 96% were forced to reduce work hours during the lockdowns, and these households had 92% lower odds of being able to afford water than households who did not experience a work hour reduction (OR = 0.08, p < .001). Household challenges in affording water were likely due to a combination of reduced household income, increased water prices, and pre-existing poverty, and were ultimately associated with lower hygiene scores (Beta = 1.9, p < .001). Our results highlight a compounding tragedy of reduced water access in informal settlements that were already facing water insecurities at a time when water is a fundamental requirement for following hygiene guidelines to reduce disease burden during an ongoing pandemic. These outcomes emphasize the need for targeted investments in permanent water supply infrastructures and improved hygiene behaviors as a public health priority among households in informal settlements.

Stakeholder Perspectives on COVID-19 and Household Water Access in Vulnerable Communities in the Mekong Region

The COVID-19 pandemic has underlined the importance of safe access to sufficient clean water in vulnerable communities, renewing interest in water, sanitation and hygiene (WASH) programs and related targets under Sustainable Development Goal 6 (SDG 6). The purpose of this study was to better understand the obstacles to water access in vulnerable communities and identify ways they might be addressed in five countries in the Mekong Region (Cambodia, Laos, Myanmar, Thailand, Vietnam). To this end, qualitative interviews with 50 government officials and development or health experts were complimented with a quantitative survey of the experiences and views of individuals in 15 vulnerable communities. There were several key findings. First, difficulties in accessing sufficient clean water for drinking and hygiene persist in certain vulnerable communities, including informal urban settlements, remote minority villages, and migrant worker camps. Second, limited rights, high prices, and remote locations were common obstacles to household access to improved water sources. Third, seasonal differences in the availability of clean water, alongside other disruptions to supply such as restrictions on movement in COVID-19 responses, drove households towards lower quality sources. Fourth, there are multiple threats to water quality from source to consumption that should be addressed by monitoring, treatment, and watershed protection. Fifth, stakeholder groups differ from each other and residents of vulnerable communities regarding the significance of water access, supply and quality difficulties, and how they should be addressed. The paper ends with a set of program suggestions addressing these water-related difficulties.

An examination of water, sanitation, and hygiene (WASH) accessibility and opportunity in urban informal settlements during the COVID-19 pandemic: Evidence from Nairobi, Kenya

This research examines water, sanitation, and hygiene (WASH) accessibility and opportunity in Kibera and Mathare during the COVID-19 pandemic in 2021. Kibera and Mathare are two of the largest urban informal settlements in Nairobi (the capital city of Kenya) as well as Sub-Saharan Africa. Accessibility indicates how easily a person can reach WASH facilities from their home by walking. Opportunity represents how many WASH options a person has near their home. We utilize the data on water and toilet facilities collected by GroundTruth Initiative in partnership with Map Kibera Trust (local community partners) between February and April 2021 - amid the COVID-19 pandemic. By conducting quantitative geospatial analysis, we illustrate WASH accessibility and related issues that were not evident in previous studies: (1) 77.4% of people living in Kibera have limited WASH facility accessibility or opportunity; (2) 60.6% of people living in Mathare have limited WASH facility accessibility or opportunity; (3) there is a clear geographic pattern in WASH facility accessibility and opportunity; and (4) overall accessibility and opportunity is better in Mathare than in Kibera. This study is one of the first studies to examine WASH accessibility and opportunity in urban informal settlements during the COVID-19 pandemic by utilizing the current data and quantitative geospatial methods. Based on the results, we discuss important public health policy implications for people living in urban informal settlements to improve their WASH facility accessibility and opportunity during the COVID-19 pandemic.

Household water access and COVID-19 in Karoi Town, Zimbabwe

Water is a crucial resource in the fight against coronavirus disease (COVID-19), which was first discovered in late 2019 in Wuhan, China, and which has since become a pandemic. Thus, clean water unavailability constitutes a risk to people's wellbeing as the chances of contracting the disease is high without it. The World Health Organisation (WHO) prescribed hygiene as a critical measure to control the spread of this highly transmissible disease. As frequent washing of hands and observing general rules of hygiene could mitigate the spread of the disease, access to clean and adequate water supply is one of the fundamental ways of stopping the pandemic. There has, therefore, been a high demand for water across the world in a bid to address the problem. Specifically, the general lockdown and the need to frequently wash hands coupled with the obsolete water infrastructure in Zimbabwe have worsened water access problems for the citizenry. This study, therefore, assessed water access in Karoi town in Zimbabwe. Adopting a household water access conceptual framework, the study investigated six residential areas where a sample of 150 household heads were randomly selected and interviewed. Data on water access were obtained from the respondents using interview schedules. In-depth information on the subject was also obtained from four key informants working at Karoi Town Council (KTC) and Zimbabwe Water Authority (ZINWA). The results showed that households had knowledge on the importance of water availability and hygiene in relation to COVID-19 prevention, leading to an intensified high demand for water and consequently water shortage in the area. The study recommends that KTC and ZINWA need to improve on its water infrastructure and enhance the subsidization of improved water access during the COVID-19 and post-COVID-19 pandemic.

Household Water Treatment Practice and Associated Factors in Rural Households of Sodo Zuria District, Southern Ethiopia: Community-Based Cross-Sectional Study

INTRODUCTION

In Ethiopia, access to safe drinking water is very low, and even safe water at the point of distribution is subjected to frequent and substantial contamination during collection, transport, and storage. The purpose of this study was to assess the level of household water treatment practices and associated factors in rural households of the Sodo Zuria district, southern Ethiopia.

METHODS

A community-based cross-sectional study was conducted in 836 households using a multistage sampling technique. A structured and pre-tested questionnaire was used. Binary and multivariate logistic regression analysis was used.

RESULTS

The household water treatment practice was 44.1%. Households having a higher estimated monthly income, AOR = 1.5 (1.23, 3.47), older age greater than 45 years, AOR = 1.69 (1.08, 2.64), fetching water twice a day, AOR = 2.8 (1.21, 9.17), weekly washing of the water storage container, AOR = 0.3 (0.11, 0.83), and using the dipping technique to draw water from the collection jar, AOR = 1.67 (1.14, 2.42) were significant factors in the practice of household water treatment in the study.

CONCLUSIONS

The household water treatment practice was low. Higher estimated monthly income, older household heads, fetching water twice per day, washing the water storage container weekly, and dipping techniques to draw water from water storage containers were significant factors of household water treatment practices. Thus, proper hygiene of water storage, and engaging the community in income-generating activities were recommended.

A new measure of hygiene inequality applied to urban-rural comparison

Access to hygiene services remains one of the most urgent challenges facing countries, especially low-income ones. This has become much more critical in the current context of the COVID-19 pandemic. The WHO/UNICEF Joint Monitoring Program globally monitors access to hygiene service levels. As data are in three parts with a constant sum and a positive value, they are compositional data. Inequality is monitored in disaggregated data; in the urban-rural case, this is done through a simple difference between the urban and rural service levels. However, this simple form of calculation does not take into account the characteristics of the data, which can lead to erroneous interpretations of the results. Therefore, we propose an alternative measure of inequality that uses a ternary diagram and does not infringe on the data properties. The results of the new urban-rural inequality measure show spatial heterogeneity. The highest inequality occurs in Colombia, with a value of 37.1 percentage points, and the lowest in Turkmenistan, with a value of zero. Our results also show that 73 of the 76 countries evaluated have higher basic hygiene services in urban areas than in rural areas. This means that urban households have more availability of a handwashing facility on-premises with soap and water than rural households. Likewise, by subdividing the ternary diagram into ternary parcels, we could group and rank the countries based on hygiene service conditions in a hierarchical order using tripartite information. Finally, our study finds that a multivariate measure of inequality can be important for the public policies of the sector with a general vision, which underscores the value of making evidence-based decisions.

Effects of COVID-19 on the availability of clean water and sanitation

During the COVID-19 pandemic, the availability and consumption of safe water reached alarming levels. Millions of people still lack access to basic water and sanitation services, and their number is expected to increase, thus increasing the risk of virus transmission. This chapter introduces the impact of COVID-19 on water and sanitation. It starts with discussing the importance of water for health, followed by the effect of COVID-19 on the water and sanitation sectors. It then explains about Sustainable Development Goal-6 (clean water and sanitation) in the context of the COVID-19 pandemic. By the end of the chapter, lessons learned regarding the water and COVID-19 pandemic were highlighted. It was concluded that shift in the water demand, overuse of water, detection of SARS-CoV-2 RNA in wastewater, contamination of water bodies, and inability to pay water bills were the major challenges that SARS-CoV-2 posed.

Challenges to the implementation and adoption of physical distancing measures against COVID-19 by internally displaced people in Mali: a qualitative study

Background

For almost a decade now, Mali has been facing a security crisis that led to the displacement of thousands of people within the country. Since March 2020, a health crisis linked to the COVID-19 pandemic also surfaced. To overcome this health crisis, the government implemented some physical distancing measures but their adoption proved difficult, particularly among internally displaced people (IDPs). The objective of this study is to identify the challenges relating to the implementation and adoption of physical distancing measures and to determine the main mitigation measures taken by IDPs to adjust to these new policies.

Methods

An exploratory qualitative research was conducted in Bamako and Ségou, two of the ten regions of Mali. The study counted 68 participants including 50 IDPs, seven administrative and health authorities, and 11 humanitarian actors. Sampling was guided by the principle of saturation and diversification, and data was collected through semi-structured individual interviews (n = 36) and focus groups (n = eight). Analysis was based on thematic content analysis through NVivo software.

Results

The main challenges identified concerning the implementation and adoption of physical distancing measures include the proximity in which IDPs live, their beliefs and values, the lack of toilets and safe water on sites, IDPs habits and economic situation, humanitarian actors’ lack of financial resources and authority, and social pressure from religious leaders. Implemented mitigation measures include the building of new shelters or their compartmentalization, the creation of income-generating activities and food banks, psychosocial support, promoting awareness of IDPs, and nightly police patrols and surveillance to discourage IDPs from going out. Finally, a call for action is suggested for the actors involved in IDPs support and management.

Conclusions

The study demonstrates the difficulty for IDPs to follow most of the physical distancing measures and informs about the risk of disease spreading among IDPs with its potential consequences. It also shows the inability of mitigation measures to control the outbreak and suggests actions to be considered.

When usage matters: time-of-use analysis of Cape Town's Day Zero drought response

Poor resource management and infrastructure limitations make the effects of drought worse for cities in developing countries. One way to alleviate the impact without large investments is targeted demand management. This has worked well in studies that focused on some of the recent droughts, including Cape Town's 'Day Zero' drought of 2016-2018. Many studies have measured demand response to a drought at a coarse time resolution, but few have measured it at an hourly resolution or compared weekday with weekend use. In this study we evaluated households' hourly time-of-use behaviour in response to the Cape Town drought at two prominent inflection points identified by previous studies: the announcement of the Critical Water Shortages Disaster Plan in October 2017 and the introduction of Level 6B restrictions in February 2018. The first major reduction was caused by residents reducing their usage by about a third in the early morning and evening hours on weekdays, and the second, even larger, reduction was achieved in the mid-morning hours on weekdays when home owners were not at home but ensured that domestic workers used water sparingly.

The Individual Water Insecurity Experiences (IWISE) Scale: reliability, equivalence and validity of an individual-level measure of water security

Objective

The lack of a validated and cross-culturally equivalent scale for measuring individual-level water insecurity has prevented identification of those most vulnerable to it. Therefore, we developed the 12-item Individual Water InSecurity Experiences (IWISE) Scale to comparably measure individual experiences with access, use, and stability (reliability) of water. Here, we examine the reliability, cross-country equivalence, and cross-country and within-country validity of the scale in a cross-sectional sample.

Methods

IWISE items were implemented by the Gallup World Poll among nationally representative samples of 43 970 adults (>15 y) in 31 low-income and middle-income countries (LMICs). Internal consistency was assessed with Cronbach’s alpha. Equivalence was tested using multigroup confirmatory factor analysis (MGCFA), the alignment method, and item response theory. Cross-country validity was assessed by regressing mean national IWISE scores on measures of economic, social, and water infrastructure development. Within-country validity was tested with logistic regression models of dissatisfaction with local water quality by IWISE score and regressing individual IWISE scores on per capita household income and difficulty getting by on current income.

Findings

Internal consistency was high; Cronbach’s alpha was ≥0.89 in all countries. Goodness-of-fit statistics from MGCFA, the proportion of equivalent item thresholds and loadings in the alignment models, and Rasch output indicated equivalence across countries. Validity across countries was also established; country mean IWISE scores were negatively associated with gross domestic product and percentage of the population with access to basic water services, but positively associated with fertility rate. Validity within countries was also demonstrated; individuals’ IWISE scores were positively associated with greater odds of dissatisfaction with water quality and negatively associated with lower financial standing.

Conclusions

The IWISE Scale provides an equivalent measure of individual experiences with water access and use across LMICs. It will be useful for establishing and tracking changes in the prevalence of water insecurity and identifying groups who have been ‘left behind’.