Concurrence of water and food insecurities, 25 low- and middle-income countries

Interacting Water Insecurity and Food Insecurity: Recent Advances in Theory and Application

Brewis, Workman et al. (2020) provided a basis for significant subsequent advancement in understanding the interplay between household water insecurity and food insecurity across diverse global contexts. This commentary reflects on the subsequent evolution of research and its application in the 5 years since the study's initial online publication in AJHB, highlighting dynamic mechanisms that link water insecurity and food insecurity and the implications for human health. Newer studies suggest that water insecurity may drive food insecurity more significantly than vice versa, with localized case studies revealing the diversity and complexity of multi-scalar factors that contribute to these relationships. Future research priorities include more refined water insecurity measurement tools and further testing of potential mechanisms in theorized causal pathways linking water insecurity and food insecurity to each other and health outcomes.

Food and Water Insecurity and Functional Disability in Adults

Importance

Evidence from diverse global populations suggests that household food insecurity (HFI) is associated with adult disability, but the association between household water insecurity (HWI) and disability remains understudied. Examinations of the joint association of dual HFI and HWI with disability are lacking.

Objective

To explore independent and joint associations of HFI and HWI with functional disability in Ecuadorian adults.

Design, Setting, and Participants

This cross-sectional study used data from the 2018 Ecuadorian National Health and Nutrition Survey, a nationally representative, population-based survey conducted in Ecuador. The study included adults (aged 18-99 years) with information on sociodemographic characteristics, household food and water security, and functional disability status. Data were collected in 2 waves of the survey, from November 2018 to January 2019 and June to July 2019. Statistical analysis was performed from May to December 2024.

Exposures

HFI, WFI, or both.

Main outcomes and Measures

The primary outcome was self-reported functional disability, assessed using the Washington Group Short Set on Functioning, a tool that uses a set of 6 questions to measure activity limitations.

Results

Among 42 071 participants (mean [SE] age, 48.0 [0.1] years; 31 683 male [75.3%]; 1840 African descendant [4.4%], 5184 Indigenous [12.3%], and 35 047 Mestizo ethnic majority group [83.3%]), most lived in urban areas (26 164 participants [62.2%]). Exposure to HFI only was associated with an increased risk for any functional disability (adjusted relative risk [aRR], 1.44; 95% CI, 1.37-1.52), as well as sensory (aRR, 1.43; 95% CI, 1.35-1.52), physical (aRR, 1.56, 95% CI, 1.42-1.72), and cognitive (aRR, 1.78; 95% CI, 1.61-1.98) disabilities. HWI exposure only was associated with increased risk for any functional disability (aRR, 1.12; 95% CI, 1.06-1.20), as well as sensory (aRR, 1.17; 95% CI, 1.09-1.25), physical (aRR, 1.15; 95% CI, 1.05-1.26), and cognitive (aRR, 1.17; 95% CI, 1.03-1.34) disabilities. Exposure to dual HFI and HWI was associated with a greater increase in risk than HFI or HWI alone of any functional disability (aRR, 1.61; 95% CI, 1.50-1.72), as well as sensory (aRR, 1.65; 95% CI, 1.52-1.79), physical (aRR, 1.72; 95% CI, 1.59-1.87), and cognitive (aRR, 2.01; 95% CI, 1.76-2.29) disabilities.

Conclusion and Relevance

In this study, dual exposure to HFI and HWI was associated with a greater increase in risk of any and specific functional disabilities compared with independent contributions of HFI and HWI alone. These findings highlight the importance of addressing HFI and HWI jointly rather than independently when conducting research on disability and other health outcomes and in designing policies and programs to protect at-risk adults and their households.

Mental health, water, and food: Relationships between water and food insecurity and probable depression amongst adults in Mexico

BACKGROUND

Water and food insecurity often co-occur, and have independently been identified as potential risk factors for poor mental health. Their interlinkages are only just beginning to be explored; even less is known about how the relationships vary by gender. Understanding the independent associations of water and food insecurity with mental health, as well as their joint effects, can help identify which interventions might be most appropriate for improving health.

METHODS

We explored how probable depression covaried with water and food insecurity using nationally representative data from the Mexican National Health and Nutrition Survey 2021 (ENSANUT 2021, n = 13,126). Cross-sectional data were collected on household water, food insecurity, and probable depression amongst adults. We used multivariable logistic regression models to examine the association of water insecurity and food insecurity with moderate-to-severe probable depression, and we stratified the models by sex.

RESULTS

Household water insecurity was associated with higher odds of probable depression amongst women (1.37 OR, CI: 1.13-1.66) and men (1.30 OR, CI: 0.92-1.83). When controlling for household food insecurity, the association between probable depression and water insecurity was no longer important, however, household food insecurity was associated with higher odds of probable depression. Those experiencing joint water and food insecurity had the highest odds of probable depression (2.70 OR, CI: 2.13-3.40). The associations between water insecurity, food insecurity and mental health did not differ by sex.

CONCLUSION

Concurrent water and food insecurity increase the likelihood of probable depression amongst both men and women. Strategies to mitigate both resource insecurities could improve mental health.

Household water security is a mediator of household food security in a nationally representative sample of Mexico

OBJECTIVE

Explore the relationship between water insecurity (WI) and food security and their covariates in Mexican households.

DESIGN

A cross-sectional study with nationally representative data from the National Health and Nutrition Survey-Continuous 2021 (in Spanish, ENSANUT-Continua 2021), collected data from 12 619 households.

SETTING

WI was measured using the Household Water Insecurity Experiences (HWISE) Scale in Spanish and adapted to the Mexican context. Food security was measured using the Latin American and Caribbean Food Security Scale. A generalised path model was used to produce two simultaneous logistical regression equations - WI (HWISE ≥ 12) and moderate-to-severe food insecurity (FI) - to understand key covariates as well as the contribution of WI to FI.

PARTICIPANTS

The head of the household, an adult of >18 years of age, consented to participate in the survey.

RESULTS

Households experiencing WI were more likely to experience moderate-to-severe FI (OR = 2·35; 95 % CI: 2·02, 2·72). The odds of WI were lower in households with medium (OR = 0·74; 95 % CI: 0·61, 0·9) to high (OR = 0·45; 95 % CI: 0·37, 0·55) asset scores. WI also depended on the region of Mexico. FI is more prevalent in indigenous people (OR = 1·29; 95 % CI: 1·05, 1·59) and rural households (OR = 0·42; 95 % CI: 1·16, 1·73). Notably, wealth and household size did not contribute directly to FI but did so indirectly through the mediating factor of WI.

CONCLUSIONS

Our study shows that there are structural factors that form part of the varied determinants of WI, which in turn is closely linked to FI.

Household food and water insecurity and its association with diarrhoea, respiratory illness, and stunting in Ecuadorian children under 5 years

Household food and water insecurity has been previously associated with adverse health consequences in children. However, these relationships are understudied in middle-income Latin American populations such as in Ecuador, where a high prevalence of food and water insecurity has been reported. Using cross-sectional data from 2018 Ecuadorian National Health and Nutrition Survey, we examined the association of household food insecurity (HFI), household water insecurity (HWI), and concurrent HFI-HWI with diarrhoea, respiratory illness (RI), and stunting in 20,510 children aged ≤59 months. HFI was measured using the Food Insecurity Experience Scale. HWI was defined when households responded negatively to one or more of four drinking water indicators. Maternal caregivers reported on child diarrhoea and RI episodes during the previous 2 weeks. Measured length or height was used to assess stunting. We constructed log-binomial regression models to estimate the associations of HFI, HWI, and concurrent HFI-HWI with child outcomes. Moderate-severe HFI was associated with a higher prevalence of diarrhoea (PR = 1.39; 95% CI: 1.18, 1.63) and RI (PR = 1.34; 95% CI: 1.22, 1.47), HWI with a higher prevalence of RI (PR = 1.13; 95% CI: 1.04, 1.22), and concurrent HFI-HWI with a higher prevalence of diarrhoea (PR = 1.30; 95% CI: 1.05, 1.62) and RI (PR = 1.45; 95% CI: 1.29, 1.62). Stunting was not associated with HFI, HWI nor concurrent HFI-HWI. These findings suggest that HFI and HWI can independently and jointly act to negatively affect children's health. Policies and interventions aimed at alleviating both food and water insecurity are needed to bring sustained health improvements in Ecuadorian children.

Predicting poor mental health among older Syrian refugees in Lebanon during the COVID-19 pandemic: a nested cross-sectional study

INTRODUCTION

The COVID-19 pandemic has worsened pre-existing vulnerabilities among older Syrian refugees in Lebanon, potentially impacting their mental health. The study aims to describe the evolution of poor mental health over time and to develop and internally validate a prediction model for poor mental health among older Syrian refugees in Lebanon.

METHODS

This prognostic study used cross-sectional data from a multiwave telephone survey in Lebanon. It was conducted among all Syrian refugees aged 50 years or older from households that received assistance from a humanitarian organisation. Data were collected between 22 September 2020 and 20 January 2021. Poor mental health was defined as a Mental Health Inventory-5 score of 60 or less. The predictors were identified using backwards stepwise logistic regression. The model was internally validated using bootstrapping. The calibration of the model was presented using the calibration slope (C-slope), and the discrimination was presented using the optimised adjusted C-statistic.

RESULTS

There were 3229 participants (median age=56 years (IQR=53-62)) and 47.5% were female. The prevalence of poor mental health was 76.7%. Predictors for poor mental health were younger age, food insecurity, water insecurity, lack of legal residency documentation, irregular employment, higher intensity of bodily pain, having debt and having chronic illnesses. The final model demonstrated good discriminative ability (C-statistic: 0.69 (95% CI 0.67 to 0.72)) and calibration (C-slope 0.93 (95%CI 0.82 to 1.07)).

CONCLUSION

Mental health predictors were related to basic needs, rights and financial barriers. These allow humanitarian organisations to identify high-risk individuals, organise interventions and address root causes to boost resilience and well-being among older Syrian refugees in Lebanon.

[Food insecurity and household water insecurity: a population-based study in a municipality in the Amazon River basin, Brazil]

This study analyzed food insecurity and associated factors in the urban area of a municipality in the Amazon River basin, Western Amazon. This is a cross-sectional population-based study conducted from August to November 2021 with 983 households selected by stratified probability sampling. A multinomial logistic regression model was used, adopting the following criteria: p-value < 20% in the bivariate analysis and p-value < 5% for the multivariate adjustment. The results of the analyses were described as odds ratio (OR) and 95% confidence interval (95%CI). The following variables were significantly associated with mild or moderate food insecurity: household water insecurity; number of residents ≥ 5 in the household; belonging to socioeconomic class D or E; having a father, mother or another as the head of the family; and having any resident as a beneficiary of the Brazilian Income Transfer Program. The analysis model for severe food insecurity showed that living with household water insecurity; belonging to socioeconomic class D or E; having a father, mother or another as the head of the family; age of the head of the family < 55 years; and family income lower that two minimum wages increased the chances of severe food insecurity when compared to those with food security. In conclusion, this study found a high prevalence of food insecurity in the Municipality of Itapiranga, State of Amazonas, North Region of Brazil, associated with social and economic vulnerability, lack of public services, and household water insecurity.

Water insecurity is associated with intimate partner violence among female adolescents and youth but not males in rural Tanzania: A cross-sectional study

Food insecurity increases intimate partner violence (IPV), but less is known about water insecurity (WI) and IPV. We examined the association between household WI and IPV among adolescents and youth in the Mbeya and Iringa regions of Tanzania. The cross-sectional sample comprised 977 males and females aged 18-23 years living in rural, impoverished households. We conducted multivariate logistic regression analyses to estimate the association between experiences of WI [measured by the Household Water Insecurity Experiences (HWISE-4) Scale] and physical and/or emotional IPV (measured by an adapted Conflict Tactics Scale). Overall, WI (HWISE ≥4) was associated with 74% higher odds of any IPV (marginal effects (ME) of 7.8 percentage points (pp)), compared to those not WI. Among females (but not males), WI was associated with 3-fold higher odds of any IPV (OR = 3.00; 95% CI: [1.52, 5.94]; ME  = 14 pp). Compared to non-WI females, WI females had 5- and 2-fold higher odds of IPV (ME = 30.8 and 11.3 pp) among the ever married and never married sub-samples, respectively. The association between WI and IPV among females was attenuated (OR = 1.93; 95% CI: [0.93, 3.97]) when adjusting for household food insecurity. Ameliorating water insecurity is a promising avenue for IPV reduction.

Changing climates, compounding challenges: a participatory study on how disasters affect the sexual and reproductive health and rights of young people in Fiji

Pacific youth are at the forefront of the climate crisis, which has important implications for their health and rights. Youth in Fiji currently bear a disproportionate burden of poor experiences and outcomes related to their sexual and reproductive health and rights (SRHR). There is limited information about how the increasing climate impacts may affect their SRHR, and what the implications may be for climate action and disaster risk reduction. We aimed to explore the experiences of 21 Fijian youth in fulfilling their SRHR when living through multiple natural hazards. We conducted 2 workshops and 18 individual semistructured interviews using visual and storytelling methods. Irrespective of the type of hazard or context of disasters, participants identified limited agency as the main challenge that increased SRHR risks. Through reflexive thematic analysis, we identified four themes centred around 'youth SRHR agency'; (1) information and knowledge, (2) community and belonging, (3) needs and resources, and (4) collective risks. These themes encompassed multiple factors that limited youth agency and increased their SRHR risks. Participants highlighted how existing challenges to their SRHR, such as access to SRHR information being controlled by community gatekeepers, and discrimination of sexual and gender diverse youth, were exacerbated in disasters. In disaster contexts, immediate priorities such as water, food and financial insecurity increased risks of transactional early marriage and transactional sex to access these resources. Daily SRHR risks related to normalisation of sexual and gender-based violence and taboos limited youth agency and influenced their perceptions of disasters and SRHR risks. Findings offer important insights into factors that limited youth SRHR agency before, during and after disasters. We underscore the urgency for addressing existing social and health inequities in climate and disaster governance. We highlight four key implications for reducing youth SRHR risks through whole-of-society approaches at multiple (sociocultural, institutional, governance) levels.

Mapping the global, regional, and national burden of diarrheal diseases attributable to unsafe water

Background

Diarrheal diseases are major contributors to deaths. Data on global and country-specific levels and trends of diarrheal diseases resulting from unsafe water are essential for policymakers to allocate resources.

Aims

This study aimed to describe the global, regional, and national spatiotemporal burden of diarrheal diseases resulting from unsafe water exposure.

Methods

According to the Global Burden of Disease (GBD) 2019 dataset, deaths, disability-adjusted life years (DALYs) of diarrheal diseases, and their age-standardized rates (ASRs) were analyzed by age and sex in 204 countries and territories. Moreover, the average annual percentage change (AAPC) was estimated by a log-linear regression model to reflect the time trend. The association between ASR of diarrheal diseases due to unsafe water and socio-demographic index (SDI) levels was also analyzed.

Results

From 1990 to 2019, the number of deaths and DALYs of diarrheal diseases resulting from unsafe water decreased by 50 and 59%, respectively. Moreover, the ASR of deaths and DALYs also decreased during the study period, with AAPCs of -3.69 (95% CI [95% confidence interval]: -3.91 to -3.47) and - 3.66 (95% CI: -3.8 to -3.52), respectively. High diarrheal diseases resulting from unsafe water occurred mainly in low SDI regions and Africa. Males exhibited greater diarrheal deaths attributable to unsafe water than females, which was contrary to the condition in terms of DALYs. The age-specific burden of diarrheal deaths attributable to unsafe water is concentrated in children younger than 5 years. The AAPCs of the ASR of both deaths and DALYs showed a strong negative correlation with the SDI levels.

Conclusion

The current study indicated that the global burden of unsafe water exposure-related diarrheal diseases decreased from 1990 to 2019 and varied significantly according to age, sex, and geographical location. Effective health promotion and health communication strategies and policies should be adopted to prevent and control diarrheal diseases resulting from unsafe water exposure.

Water Insecurity Indicators Are Associated with Lower Diet and Beverage Quality in a National Survey of Lower-Income United States Adults

BACKGROUND

Tap water distrust and avoidance, indicators of water insecurity, are prevalent in marginalized United States populations. As future environmental challenges stress water resources, further understanding of the scope of water insecurity and its impact on diet quality is needed, particularly in vulnerable United States populations.

OBJECTIVES

To evaluate associations between 3 potential indicators of water insecurity-1) perception of tap water safety for drinking, 2) perception of tap water safety for cooking, and 3) tap water avoidance-and dietary quality and beverage intake in lower-income United States adults.

METHODS

A cross-sectional, web-based survey was fielded to 1798 lower-income (<250% federal poverty guidelines) United States adults. Participants answered questions detailing tap water safety perceptions and avoidance, beverage intake, dietary intake (30-d prime diet quality score), and sociodemographic covariates. Sociodemographic differences in drinking water insecurity measures were evaluated using chi-square and Fisher-Freeman-Halton tests. Associations between water insecurity measures and dietary outcomes were assessed using generalized linear models adjusted for sociodemographic covariates, and effect modification by sociodemographic covariates was assessed.

RESULTS

Over half of the adults surveyed experienced some aspect of water insecurity. Measures of water security differed significantly by sociodemographic covariates (Ps < 0.05), with higher percentages of women and gender-nonconforming persons, minoritized racial and ethnic groups, lower-income groups, and food-insecure adults reporting indicators of water insecurity. Presence of any water insecurity was associated with lower diet quality (β = -1.07; 95% CI: -2.11, -0.03; P = 0.04), lower tap water intake (relative difference [RD] = 0.35; 95% CI: 1.28, 2.12; P < 0.0001), higher bottled water intake (RD = 1.64; 95% CI: 1.28, 2.12; P = 0.0001), and higher sugar-sweetened beverages intake frequency (frequency ratio = 1.13; 95% CI: 1.01, 1.27; P = 0.03).

CONCLUSIONS

Water insecurity indicators are associated with poorer diet quality and beverage intake in a population of United States adults with lower-incomes. Addressing the intersection of water insecurity, food security, environmental impacts, and nutrition may help to improve the well-being and resiliency of vulnerable populations.

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.