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    Household Water Insecurity Will Complicate The Ongoing COVID-19 Response - Evidence From 29 Sites in 23 Low - and Middle-Income Countries - Elsevier Enhanced Reader

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    Marcos Santiago

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    Ineratinal Joumal of Hygiene and Environmental Health 234 (2021) 113715 Contents ists available a SeienceDiret =| International Journal of Hygiene and Environmental Health ELSEVIER Journal homepage: www elsevier.comilocatelijheh a ® Household water insecurity will complicate the ongoing COVID-19 sae response: Evidence from 29 sites in 23 low- and middle-income countries Justin Stoler®*”, Joshua D. Miller", Alexandra Brewis‘, Matthew C. Freeman’, Leila M. Harris", Wendy Jepson ', Amber L. Pearson", Asher Y. Rosinger ', Sameer H. Shah", Chad Staddon’, Cassandra Workman’, Amber Wutich ‘, Sera L. Young “, Household Water Insecurity Experiences Research Coordination Network (HWISE RCN) * unr of tant, coval Gales, FU ® mest of Noh Caan at Cpe, Chapel HL NCA < Asana Sate Une Tene AZ USA © Emory Ue daa, 8 USA {ony of mak alba, Vanco 6, Conta Meg Sate Unt, Ea Lae MUSA Pomayat Ste Unter, Une ar, BA, USA “Caper of he Wet f Egan Bot OF "Dna North Carat Cabra, rear, NG, USA ARTICLE INFO ApsTRACT ower | Match 2020, the World Health Organization (WHO) issued a set ofpublegudelies for Covonaviws Disease ome 2019 (COVID-19) prevention measures that highlighted handwashing, pyscal dianing, and houschold ‘leaning. These heath behaviors ae severely compromise in parts ofthe worl hat lack secure water suplis, Datculauy in low and mide ineome cousses (LNCS). We used enpiseal data gatered ln 2017-2018 fom, 18,207 households in 29 sites across 23 LMUICS to adavess the poeatialiplieations of water insecuty fr COVID 19 prevention and response, These data demonstate how bousehold water insecurity presents cuay pathways foc limiting personal and enstonmental yen, impeding physical distancing and exacerbating existing sia nd health vulnerabilities that ean led to move severe COVID-19 atcontes In the four week Prior suvey Implementation, 45.9% of households in our sample ether were unuble to wash their hands ot epoted ottonrng water trom others, which may undermine typlene and physical distancing, Fue, 70.0% of households experienced one or moe wate-telated problems that poenilly undermine COVID-19 contr! strateges or disease cretment, including insuffelent water for bathing, Inundeting, of taking medication; dunking unsafe water; going to slep thst; or having litle-o-no draking wae. These Hangs help deny lwhese water provision is most elevaat to managing COVID-19 speed and outcomes. hal bah 1. Introduetion (WHO, 2020). Globally, over four billion people experience water scarcity atleast one month per year (Mckonnen and Hoekstra, 2010), @ ‘The global response to COVID-19 has emphasised basic infeesion reality that may make it difieult co enact COVID-19 control messes contol strategies, such as self-quarantine, handwashing and physical with far-reaching consequences across continent (Stacdox etal, 2020; distancing, to “laten the epidemiological curve" in many contexts Soler et sl, 2020). Water Inseeurity (and mote broadly, inadequate * onesponding author. 1300 Campo Sano Ave, Cov Gables, FL, 23146, USA, Ematl adress solet@nianises' CG. Sle), jochsniler@uneed) (ID, Mile, alexinewik@asnedy A, Brewis), nathea:Aeemangemnor:eds (OC. Free), Ibaris@ires bec (LM, Hats), wicpmon@tannt CW, Jepson, apcatson@insecs (AL Pearson), 20579@pss.eca (AY. Rosngen, ser Sahlaluni ube.ca (SH Shah), chad stdon ue. scuk (. Staddoo), clworkins@ung.edu (C. Workmas), amber wutich@asuedu (A. Wale}, sera young ouhuestnneat (SA. Youn). ups /éolor/10.2016/)ueh.2021.115715 Received 3 Noveniber 2020; Received in vevise form 25 January 2021; Accepted 11 Febuary 2021 ‘Availabe online 19 Febniny 2021 1438-4539/6 2021 sever Gobi. Al ight eserved ‘water, sanitation, and hygiene [WASH]) already contributes to the global disease burden (Pris Ustin etl, 2018), and has fond out asa potentially significant suliplier of COVID-19 tsk, compounding the paucity of other healheare resourcesespectally test kts, personal protective equipment, oxygen and veotilaors—that has plagued many nations (Hopman etal, 2020). Identifying the likely location of relevant ‘water insecurity hotspots and clarifying the pathways by whieh water insecurity adés to the burdens of COVID-19 are potentially vital to ‘ongoing prevention and treatment, especially in low- and middle-income eountries (LMICS), Persistent household water insecurity is defined as the inability to ‘access and Benet from affordable, adequate, reliable ad safe water (epson el 2017. The links between water insecurity and COVID-19 ‘are only beginning to emerge. One ealy stady from Indonesia noted positive association between household water reuse and COVID-19 transmission (Siisfoho et a, 2020), It aso renvains unclear whether urban slums, whieh tend to house many of dhe most vulnerable, are being sufficiently targeted by national COVID-19 testing and acing ‘programs (Molla and Islam, 20205 Monteiro de Oliveira etal, 2020), ‘overcrowding and Inck of basic services in urban shins are believed to ‘contribute to the pandemic in some regions, sich asin Latin America (Gurls, 2020), while other regions thought tobe particularly vulnerable ‘such as sub-Saharan Ares (Fkunish ets, 2020), have responded wel (\lakon!, 2020). For example, many African nations have avoided catastrophic COVID-19 outcomes through advance planning and public ‘adherence 1 preventive measutes, and because of younger popslation structure (Makoni, 2020). But, evolving SARS-CoV2 variants and recurTing waves of infections in late-2020 clarified that many pandemic recovery timelines would be extended ‘The World Health Organization's guidance for COVID-19 prevention, inchides: 1) frequent handwashing; (2) physical distancing: (3) avoid. ing touching one’s face; (4) practicing respiatory hygiene; (5) seeking medical care for eough, ever ne difiulty breathing: and (6) following advice from one’s healtheare provider (WI10, 2020). tn addition, the United States Centers for Disease Control and Prevention (CDG) also recommends regulary cleaning and disinfecting household surfaces (€0C, 2020), Water is thus critical for stemming the sprend of COVID-19 In healt facilities and households (USAID Water Leadership Coune!, 2020), ‘Many organizations have noted the inherent confers between these ‘guidelines and the realities of widespread water insecurity around the world. Among many other examples, WaterAid, one ofthe langest non. governmental. implementers of WASH solutions for the poor and marginslized, has had to change hove they work in the midst of this pandemic with increasing focus on water insecurity asa key element of ther response (Casey, 2020). Household level COVID-19 control strategies are complicated by many factors beyond limits to handwashing and cleaning Sioler et, 2020). Physical distancing is les feasible when it impedes access to ‘water, as has been noted with shared sentation facilites (Caruso and ‘Freeman, 2020), Over a billion people collet water fom sources outside ‘of their home (WHO/UNICEE, 2017), which often requires traveling significant distances and queuing for long periods in close proxin ‘with others. Households also frequently cope by sharing water, an un derappreciated global phenomenon (til etal, 2018) that typically involves shared physial spaces or physical comtact sith water cou tainers. Households may also inetease water storage to avold fetching, ‘Dut improperly stored water increases vulnerability co viral and bacte ial illneses. Informal water vendors who are not officially deemed ‘essetial services may cease operation out of fear of ines, resulting in significant supply disruptions to informal water markets, The manage rent of these water related tradeoffs and lstuptions—on top of feats about COVID-19—wil likely increase stress, anxiety, and interpersonal violence. All of these factors are exacerbated by the realities of resource poor settlements that are home to close co one billion people (Corburn et al, 2020). ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 (Our analysis highlights the challenges that many living with house: hold water insecurity may experience in following international COVID- 19 contol guidelines, many of which hamper their ability to protect themselves, their households, and their communities. Our global data se also allows us f speak with more precision about the magnitude of some of these effects. We use empirical data collected in 2017-2018 from 8,297 households in 29 sites across 2 LMICs to demonstrate how household level water insecurity not only severely nits handwashing, clesning, and disinfection of household surfaces, but also greatly com plieates physical distancing. We also ilstrate how conforming t0 cur Fent COVID-19 control measures may, in some scenarios, lead to cascading Death risks beyond COVID-19, including how water insec rity incerseets with other resource constraints sue food nd seit ‘don insecurity. Finally, we explore other contextual vulnerabilices that, tore broadly, may hinder compliance with WHO guidance, and conclude with considerations for COVID-19 contto in tesouee-Lnited sectings. 2, Material and methods 21. Stuy data Data were drawn from the Household Water Insecurity Experiences (GHWISE) study, which primarily aimed 10 develop and validate a eoss culturally equivalent household water insecurity scale (S. L. Young o£ aly 2019; 20298), Crossseetional survey data were collected be ‘necen 2017 and 2018 from samples of 101-574 households in each of 29 sites neross 28 countries (Fs. 1). Sites were selected to mieximize het erogeneity by climatic region, predominant water infrastructure, and types of water problems. In most sites, households were selected using simple rasvdom sampling, with the exceptions of purposive sampling used in Singida, Tanzania; Kempala, Uganda; and Upolu, Samoa; and parallel assignmient in Pune, India. Adults were considered eligible re spondents if they “Were knowledgeable about their household's water situation” (5. L. Young etal, 2010) These survey data provided amore detailed view of household water insecurity than other common household surveys such as Demographic and Health Surveys or Multiple Indicator Custer Surveys. Enumerarors used paper and table based surveys to collect data on sociodemographics and experiences with water availability, access bility, reliabiliy, and use, which ate core components of houseliold Water insecurity (Jepson otal, 2017). The survey items elicited the frequency of 34 hotsehold experiences related to water in the four weeks prior ro survey implementation, and responses were categorized 1s follows: never (O times), rarely (1-2 times), sometimes (3-10 times), ‘fen (11-20 times, or alwys (more than 20 thes). This paper presents data from the $4question survey module to highlight pathways drough Uwhich differen dimensions of water insecurity complicate COVID-19 prevention and control. Data collection occurred in to waves be- ‘weeen 2017 and 2018, The total sample size available for this analysis was 8.297 households across 29 sites. All participants provided verbal or written informed consent in the respective local language. Study aetviies were reviewed and approved by all relevant ethical review boards (SL. Young etal, 20190), 22, Statistical analysis ‘We assessed the frequency of affirmation foreach survey item related to handwashing, ability to enact physical distancing, and cleaning and disinfecting household surfaces 10 demonstrate heterogeneity across sites. We used a deseripive rather than infereatil, approach de 1 the current lack of reliable COVID-19 prevention ar ease data in the HWISE study sits thae would otherwise help us extrapolate risk to other areas Our objective was to present the breadth of water insecurity experiences that ave implications for COVID-19 prevention ad contro nour analysis of socioeconomic status, we categorized HWISE study Seer a ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 Fig. 1. The 20 HOVSE study sites showing the percent of households in each site hat experienced one or more water prolensin the pir Four weeks that potentially “undermine COVID-19 contol stratepes or disease rete participants’ responses fo the MacArthur Seale of Subjective Social examined their relationship with seleet water insecurity Items using ‘Status, «selEreported measure of one’s perceived social standing inthe chi-square tests and two-sample tests of proportions, All analyses were ‘community Clee, 2007), Ito high, meu, an low tertiles, and conducted using Stata 14.0 (StataCorp, College Station, TX, USA). 0% 25% 50%. 75% 100% Unable to wash hands due to problems with water in prior month (N=29 sites, n=8081) Unable to wash hands of children due {o problems with water in prior month oe . e (N=29 sites, n=7541), Unable to bathe due to problems with ‘water in prior month ee lee owl ee (N=29 sites, n=8125) Unable to wash clothes due to as. problems with water in prior month cose ee mee (N=29 sites, n=7759) ‘ig. 2. Distribution by study ste of peeent of households thar expesienced incentupsios ohyene Behavior in the tir four weeks due to problems with water ‘own percent gets all sites in be. 2. Results Froquency statistics for responses to individual water insecurity items among the 8,297 study households are presented in Figs. 2-8. We report these results in sub-groups as they pertain to hygiene, physical distancing, and additional contextual vulnerabilities. Overall, 45.9% of households reported being unable to wash their hands of reported borrowing waterin the four wocks prior to completing the survey, which confounds comipliance with WHO's first ro guidelines for COVID-19 control (fequent handwashing and physical distancing). We also considered households’ ability to engage in @ broader range of water: related activites that may serve as proximal and distal determinants to COVID-19 outeomes: drinking unsafe water, going to sleep thirsty, having n0 water oF less water for deahking, nnd lacking water to take medications, bathe, Ininder clothes, or prepare foods, in addition to handwashing of borrowing water, We found that 70.9% of households ‘experienced atleast one ofthese water-related problems that can ‘ermine COVID-19 contol strategies or intensity disease progression, SL. Hygiene 1.1. Handwashing and bathing Frequent handwashing with soap and water is critical for reducing, the spread of communicable diseases, including COVID-19. Soap de- sroys the lipid bilayer that envelopes SARS-CoV-2 and water washes ‘away the exposed, Inactivated virus (Sidon ets, 2020), Yet nearly ‘one in four households (23.0%) in our study reported that they were “unable ro wash their hands in the prior four weeks aftr dirty activities” (e.g, defecating, changing diapers) due to problems with water (ig. 2). ‘Of households with children, 23.6% reported being unable to wash their young children’s hands aud fees because of problems with water. Over ‘third (83.7%) of households reported being unable to wash thee bodies, varying widely from 4.19% of sampled households in Honda, Colombi, 0 94.8% of honsehoids in Punjab, Pakistan, ‘Sometines washing was limited or ipossible because water was not ‘vailable insufficient quantities, For exsapl, when water was linited ‘de to shutoff, some households reported that they prioritized water for drinking and cooking over hygiene. Other households reported that there was water available, but thet the quality was too low for hand- ‘washing or bathing. Although water does not need to meet drinking Water standards for hygienic purposes (WHO/UNICEF, 20204), ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 handwashing with severely contaminated water can be unacceptable, lnrcae the skin and create open sores, or expose individuals to «variety of water-washed diseases (Bartram and Hunter, 2015), ‘The frequency with which households are unable to wash hands dive ‘o problems with water is likely to inerease during the pandemic. As hand hygiene messaging spreads, individuals may wish to increase handwashing Dut may be unable ro do so due to competing water de sands. For instance, water may become more difficult to access because of physical distancing recommendations or the need to divert greater ‘quantities of water to other household tasks that have increased in fe quency due ro sheltering in place, such as eooking, cleaning, or caring for dhe il. Women and girls typically experience water inadequacy even more acutely (siasfield, 2020). This ean be due to unequal access within households, oF specific needs related 10 menstrual or sexta hygiene While there is currently no evidence that COVID-19 affeets the men. strual eyele or can be spread by blood or semen, the concomitant sess tnd anxiety are nonetheless important o consider (UNICEE, 2020). 31.2. Howsohold cleaning and discon ‘SARS-CoV-2, the virus that emnses COVID-19, ean tavel in droplets fd land on common household surfaces, where the viris can remain Viable for hours to days, depending on the surface material (e, the virus survives longer on plastic and wond compared to eopper surfaces) (an Dorenalen el, 2020), Regular disinfection of household surfaces fs therefore recommended ro reduce the risk of trnsmission (CDC, 2020). Best practices include laundering soft, porous surfaces (ea clothing) with hot water and non-porous surfaces (tables) with soap rnd water or bleach diluted with water. These preventative practices are Aifcult or impossible when a household experiences water preblems, ‘Acros all sites, 45.9% of households were unable to wash clothes due to problems with water inthe prior four weeks (Pig. 2). Further, 59.196 ofhouseholds worried tha they would not have enough water for all of their needs and 27.9% reported they had no useable water, including for chores suchas cleaning surfaces. As the price and avail: ability of water fluctuates throughout the pandemic, households may reduce waterintensive chores and reserve limited water for higher priority activities, sueh as direct consumption. Indeed, in a previous study in western Kenya, respondents prioritized Water for drinking, ‘aking medications, and cooking over other activities such as washing clothes (Collins et, 2019), The 2018 dough in Cape Towa, South Avia, also shovted how households can severely reduce water use o% 26% 50% 76% 100% Borrowed water in prior month bial (ie20 shes, nerrag) | Oc cre epee s@ opm oo | oe 1% Loaned watorin rir month ale (N=22 sos, n=5805) | © - : ‘Thought of moving dwellings due to 212% ‘problems with water in prior month (N=29 sites, n=8098) ses oO me Fig. 3. Disubution by study se of pescen of households tat boned or loaned water in the plo our weve, aswell those who considered moving dv 0 bles sh water (with peseene avo al sts in bol, Solero ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 0% 25% 50% 75% 100% Roundtrip time to primary water source 185% 's at east one hour wee ie eee ° Complete 21 or more trips to primary 9.0% water source each week Que eee © (Nes sites, 1=6832) Fig. 4. Disubution by study sc of round cp ie wo painary water sowce and ups made co water Souuce per week (vith pevcent axes al sts in bold o% 25%. 50% 75% 100% Water situation impacted cultivation of 307% ‘crops in prior month Gre ese 8 oh e (N=29 sites, n=4603) Water situation impacted raising of a0% Tivestock in prior month he 2 le . e (N=29 sites, n=5240) Problems with water prevented one from 349% ‘earning money in prior month Pee ole ow e (N=29 sites, n=7430) Problems with water meant children ayy missed school or went late in prior 5 eal cf i ae ‘month (N=29 sites, n=6808) 5. Distibution by sty ste of peicent of houses that experienced vetoed or ediational opportnity oss ia the prior four weeks eto problems with ‘water wth pescen acsos al sites in boa. ‘during an emergency—ehange that was largely driven by policy Increased sharing potentially rings people into greater direct physical discourse, social norms, and perceived threats toone'slifestyle(Booysens contact with each other, It ean also bring people ito greater contact etal, 20195 Enqvist and Ziervogel, 2019) with shared objects like water jugs that may then inerease transmission risks of infectious disease (Stoler el, 2019) Frequency’ of borrowing water in the prior month ranged berween, 4.0and 85.49% of households across all 29 sites, and lending ranged from 5.2 10 85.8% across the 2 sites with ending data (9s, 5)-OF the 3.078 hhowselolds thar borrowed water, 54.2% also reporced loaning water. OF the households that loaned water, 66.0% also eported borrowing di ing the prior four weeks. Taken together, this suggests substantial transactional movement of water (and the containers used to haul it) 3.2, Physical distancing 8.2.1. Waner sharing If people cannot readily access community water supplies when, physical distancing, water sharing between neighboring households right inrease asa coping strategy (Wutih etal, 2018) dis common adaptation his been observed in many LMICs (Rosinger etal 2020). Worried there would not be enough ‘water for household needs in prior ‘month (N=29 sites, n=7436) Unable to wash clothes due to problems with water in prior month (N=29 sites, n=7059) Unable to wash hands due to problems with water in prior month (N=29 sites, n=7379) Unable to wash hands of children due to problems with water in prior month (N=29 sites, n=6919) Unable to bathe due to problems with water in prior month (N=29 sites, n=7425) ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 15% 30% 45% 60% 75% ec @ oc @ e eo eoe e eo lowes @ = moderate Ses igh SES ‘of perceived socoeconomie sats relative t ote in thereon both in and out of households ‘The ypes of water containers sed and che method of exchange may be important risk factors of COVID-19 transmission, given that SARS- ‘CoV.2 survival varies across surfaces. While the HWISE study did not collect data on the types of water containers used during water ex ‘changes, plastic jerryeans are 8 common water storage container in many water insecure communities. Jerycans may pass from one per son's hands to another during the filling process, thus inereasing transiuission risk asthe virus ean survive on plastic for upto 724 (oan Dotenialen et 9, 2020). Both Individuals involved in the water ex ‘lange should ideally wash thelr hands prior to exchanging water, and the surface ofthe container shouldbe sanitized afterward. This assimies adequate water for liandwashing (see Section 9.1.1), although house holds often participate in water sharing specifically because ofa lack of ‘eces 10 water—includng for handwashing, 8.2.2. Water ftching Water fetching often involves Jong queues at water kiosks and borehole pumps (Gecre and Covtobius, 2017). Spending extended time in close proximity with others is inconsistent with physica distancing 6. Pexent of households across al sudy ses that word about problems with wate or experienced iteryptions to hygiene in dhe prot fur weeks by tele sidelines In the HWISE sample, we obtained data on the frequency of| Ups to collect water per day. We also collected data on the amount of time spent obtaining water per day (which includes queue tite). We found tha 18.59 of households had & roundtrip water collection tine equal 10 oF over 1h (ig. 1). Also, 8.9% of households made more than 21 trips to their water sonree each week and 23.4% teported spending at least 7 hyweek fetching water. I is also well documented that there are frequently gender dffeences with respec ro water fetching (Geers and Contbius, 2017), potentially leading to diferential disease exposure. ‘When households are unable to fetch water, or if Fetching presents, {oo large of an opportunity cost in terms of tne spent, individuals may be forced to resort ro higher-priced or lower-quality water from tankers, cats, and other forms of water vending, or use nearby suuface water (Suiley and Stoles, 2020). For lower-income households, higher water costs may present tradeoffs for other household priorities, particularly health care for il family menubers oF COVED-19 preveative eae sc as asks, loves, disinfectant, soap, detergent and hand sanitizer. Physical distancing guidelines would also seemingly discourage water fetching in groups, which eliminates way of maintaining social eapital and an important safety buffer for women and children, who Changed foods being prepared due to robe wah wet nrc men 9 sites, n=8093) Drank water that looked, tasted, or ‘smelled bad in prior month (N=28 sites, n=8030) Drank water thought to be unsafe in prior month (N=29 sites, n=8116) Not enough water in household to drink a liked in prior month (N=29 sites, n=8121) 116% Wnt to stop thirsty in por month thee noe sites, n=8113) 130% on es "Not enough water to take medications in prior month (N=16 sites, n=4146) No useable or drinkable water in the household in the prior month (N=29 sites, n=8127) 25% ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 50% 75% 100% s27% “o | ao9% Org we cele 35.0% once Fig. 7. Disutbution by study site of percent of houssholds chat experienced water problems in the pir four weeks tha could undermine physical or nuiional Ist (with perent aes lites old frequently suffer harassment, assault, and accidents while fetching ‘water (Collins et al, 2019; Venkataramanan eta, 2020). This reality ‘an shape water-related decision making and cause wonten fo ake risks, sch as sing alterative inferior water sources or navigating physically dangerous terrain to obtain water elsewhere (Smiley and stoler, 2020), 12% Mobility ‘Because human mobility facilitated rapid transmission of COVID.19 from the star of the outbreak (Kraenir etal, 2020), many nations and rninicipalities have enforeed self quarantine in order to reduce spend ‘and flatien the epidemiological curve, Some lockdowns have been ‘vigorously enforced by police and even military forces (nas Rights Watch, 2020). in many regions, lockdown restrictions have had the unintended consequence of triggering mobility, aS many struggled co our home inthe absence of work opportunices and public transport. ‘The HWISE study asked how frequently households had considered moving their dwelling due to their water situation in the prior four weeks. We found that for most sites, at least some households had considered moving in the past four weeks, with an average of 21.8% cross all sites (ig. 3). In San Bora, Bolivia, 66.896 of households considered moving due to problems with water. When eater insecurity drives relocation, the introduction of COVID- 19 into new locatons is possible, Further, households often seek out more desirable water sources that ea be chained to their comme and ray therefore increase the risk of transmission to new neighbortoads i this source i outside their daily aedvty space (Sniley ad Stole, 2020). Such dynamies may be further complicated If hese destinations are ilbequipped to support aew arrivals safely. Comion forms of circular migration, such ss commuting or agrieultural migrant labor travel pat tems, also present opporninities 10 spread COVID-19 to origin ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 0% 25% 50% 75% 100% Worried there would not be enough on water for household needs in prior le ee le month (N=29 sites, n=8143) Felt upset or angry about water aro situation in prior month | ethene oe we (N=29 sites, n=8128) Felt ashamed about water situation in 344% prior month | oe ese (N=13 sites, n=3884) Problems with water caused difficulties ned with community members in prior ore . . month (N=29 sites, n=8024) Problems with water caused difficulties 0% within household in prior month oo sew e (N=29 sites, n=8065) Fig. 8. Disbution by study ste of perear of househols thar experienced pt ‘water Goth percent esos al sitesi be. ‘communities, movement induced by wate insecurity is migratory and ‘COVID9 is introduced, there is even greater potential for hostility in host destinations 8.8, Contextual mnerailtes Many underlying biocultural and socio-economic vulnerabilities, render water-inseeure households even more susceptible 10 COVID-19 Infection and at higher risk of severe disease. Context matters and can magnify wulnerbilities in communities with high poptlation density and poverty, particularly paces where seFisolation is impractical, uel, 2 informal settlements (Corburn etal, 2020) and refugee camps (a ‘al aye Kesson, 2020). For instanee, in Beirut, Lebanon, we found "hat houscholds inside urban refxgee camps had higher water insecurity scores than nearby households outside the camps (enn 4 sd, 10.2-£6.9 W5.5.5.£65, P< 0.0001) ‘Water insecurity isshaped by water systems and the use and availability ‘of tferemt water sources. Water insecurity also intersects wth iveinoods, socivecononmie satus, and gender, as well as the sociomedical reaites oF food insecurity, thirst and dehydration, and mental health We summarize the effects ofeach ofthese contextal factors in cua, 9.3.1, Water systems ‘The HWISE study evaluated the myriad configurations of how ceived sues o Interpersonal confer in the prot four weeks due to problems wth households collet, convey, and access water for domestic needs. We used these data to examine the variation in primary drinking water sources—one of the key metres of the WHO Joint Monitoring Pro gnanime for Water Supply, Sanitation, and Hygione—and assess how Piped, collected, or delivered water may contribute to COVID-19 vulnerability Almost @ quarter of surveyed households (24.39) accessed water though & community water system (eg, on-premises piped wate) While the HWISE study id not collec data on shared eonnections across fr among homesteads, overall these households are expected to face fewer risks of COVID-19 exposure unless they are selling water others Other important primary driuking water sources included dug wells (protected orunprotected) and boreholes, sed by 17.98 of households Only 1.8% of households engaged in raninater collection ns primary drinking water source, though many sives were interviewed in the dry senson, Taken together, these water sources—comminity water sys tems, wells, and rainwater collection, used by 44% of house hholés—provide mechanisms of obtaining needed water for basic needs rnd hygiene thet are generally compatible with physical distancing Ahongh community water systems depend on a labor foree that may oF ray not be able to maintain systems during the height of quarantine, public systems and their workforce ate stil generally sported in ways that Limi water service intermittency (On the other hand, over half of our stay households accessed water in ways that potentially place people at an ineeased risk of COVID-19 transmission, Water provisioning is & profoundly social activity that requires considerable physical labor and social relations to fetch or collect waver (Gere sid Combis, 2017). Water fetching, as noted ‘earlier, frequently involves queuing in close proximity and spending significant ime waiting fr one's tum or for water tobe available. Inthe HIE study, 27.496 of households reported cha their primary drinking water source was a spring (3.58), surface water (6.6%), or public standpipe (17.4%). COVID-19 exposure may occur while collecting oF fetching water at any one of these sources throigh person-to-person ‘contact. At springs of surface water Sources, increased risk may resi from proximity to others when there are lilted safe fetching locations. AAC public standpipes, increased risk may oecur with contact of eomion Water points that are not disinfected The HWISE study also reported that almost 119% of surveyed households depended on drinking water delivery services. Over 799 of households reported thet their primary drinking water source was delivered by tanker tick, and another 3.996 received waterfront 8 ‘suallseale vendor. Similarly, over 15% of households depended on bottled or sachet water. Although not all modes of water delivery necessarily come directly (households, neasy all involve person-to- person conveyance and payments. Water delivery services have vary ing praecees of contaet with water concsners that do not guarantee lisinection, During a public health emergeney, dependence on informal ‘water vendors carries additional risk of service disruption, as the informal workforce may cease operations in the name of physical distancing or due to other pandemic riven government mandates, 413.2, Livelihoods Livelihood impacts ean be divided into two basic categories: nom monetary and monetary (Scoones, 2009). Non-monetary impacts involve aspects ofthe dontestic economy that are not diretly part ofthe ‘ash economy, such 8s household task linked to the socal reproduction of labour including child-rearing, domestic maintenance, and subsis tence food production. Monetary economic inipacts are those that are dlitectly linked tothe earning or spending of cash income, such as day labouring, cading or commodity agriculture. In practic, households are likely robe involved ina complex range of monetary and non-monetary ‘economic activities, all of which cou be impaeted by the COVID-19 pandemic. We first present data about non-monetary livelihood sm. pacts before tuming to impacts on cash dimensions of livelihood strategies. The HWISE study revealed that, prior (© COVID-19, a significant numberof houscholds borrowed (39.79) and loaned (81.59%) water as part of their regular livelihoods (Fig. 3). The variability in hese in dicators across sites was high, with respondents in sites like Arua, Uganda, suggesting that they slmost never borrow/loan water, while those in other sites such as Cartagena, Colombia, very frequently do. Depending on specific lockdosen policies, sich non-monetised ex ‘changes of water could be significantly affected n Uganda, for ecample, the military was used to police the nationwide lockdown, and research partners reported feeling like “prisoners” inthe homes, often unable to _g0 out even to secure basic necessities (nian Rights Wateh, 2020), More indirect consequences could ensue if any of the borrowed loaned waters used for other sors of productive activites, such as etop or livestock rising. In the HWISE study, 30.796 and 31.0% of house holds reported a lek of sufficient water for raising crops or livestock, respectively (Pig. 9). Moreover, 34.99 of respondents reported that problems with water prevented them from earning money, and 23.9% reported that water problems prevented children from attending schoo Ie is plausible that suppression ofthe losning/borrowcing of water be ‘noeen vulnerable households could have damaging effects on income: generating activities (Wich el, 2018). With respect to the monetary economy, there was considerable ‘variability among the 29 sites: in Kisum, Kenya, 74.7% of households ‘experienced water problems that impacted their ability to earn money ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 twherens only 0.806 of houssholds in Cear, Brazil, reported this. Many who reported significant impact were day laborers, andthe esalation of water related obstacles to income generation may produce eatastrophic efeets on households ability to earn needed cash. AS we have seen in Peru, India, and elsewhere, lockdown polices triggered ant exodus of poorer people from the cities, presumably since returning to home towns and villages offered mote immediate access to non-commodity subs tence production (Stadion et al, 2020). Even in smaller towns, as ‘earning potential decreased, households decamped to even smaller vil lages and rural areas in order to be eloser to their mgrisural elds (World Bank, 2020) The sudden severe curtailment of informal markets has dsproportonately hindered poorer lowseliolds’ ability 10 satisfy even basic needs. ‘Acros al sites, there was evidence that these impacts are exper enced differently neross socio demographic groups. For example, in southvwestera Uganda, minority Batwa communities reported. more restrictive lockdown policing than in majority Bufimbira comunities (Gideon e& al, 2020). Indeed, as with many communicable disease Doubreaks, socioeconomic stats (SES) and gender disparites have ‘considerable implications for COVID-19 risk and outcomes. 4.3.3. Socioeconomic status ‘The uneven distribution of resources, power, and voice by historic! and current social and economic systems affects houschold water se curity Jepson et al, 2017). The U.S. burden of COVID-19 has dispro portionately fallen upon those of lower SES and eommunites of colour, ntersecting with existing structural vulnerabilities, neath comorbid Ines, and differential capacities for everyday mitigation efforts (Dorn ca 2020) that has led tout shutoffs and evietions (Melia ea, 2020). These patterns are likely to be further magnified in LMICs (Giopman eta, 2020). We analysed the relationship between household SES tertile (Le, relative low =1, medium=2, and high =) and the affirmation of several water insecurity experiences related to in terruptions in household hygiene: (1) being wortied that there woul not be enough water for their neds, (2) unable to wash clothes, (3) ‘unable ro bathe due to water-related problems, (4) unable to wash their hands, and (5) unable to wash their children's hands. A higher per centage of low- and medium SES households affirmed these water Insecurity experiences than high-SES households (i. 0). Fst, SES tertile was negatively associated with whether a household affirmed being worried that there would not be sufficient water fr their needs (72: 98.20, P< 0.01). Using # two-sample test of proportions {adjnsted for multiple comparisons), we found tat 54.2% of high SES howseholds afirsed vester worry, a lower percentage than low SES (64.556; P<0.01) and middle-SES (65.69%; P < 0.01) households Second, SES tertile was negatively associated with whether # household affirmed the inability to wash clothes (2: 72.48, P< 0.01) and bathe (72: 99.69, P-<0.01) in the prior four weeks. High SES households reported being unable to wash their elothes (40.5%) and body (28.490), at lower frequencies than low SES (51.29% and 40.5%; both P<0.01) and mediun-SES (50.196 and 36.896; both P< 0.01) households. Third, SES tertle was negatively associated with whether & house: hold affirmed the inability to wash their hands (2:39.00, P< 0.01) and Wash the hands of their children (2: 36.14, P-<0.01). High-SES households affirmed being unable to wash their hands (19.79) and elilren’s hands (19.895) at fower frequences than low-SES 26.8% and 28.9%; both P<0.01) and medium-SES (24.6% and 25.4%; both P< 0.01) households. Overall, a higher percentage of medium. and low SES households affirmed water insecurity experiences compared with high SES house hhoks, but che overall percentages across eres were lg, ranging from approximately 20-60%. This underscores the need for effort at al scales to improve household water security across multiple dimensions of human well-being, particularly minimizing risks associated with COVID- 19 transmission, morbidity, and mortality. Such efforts will require Improved water service provision as well as effort to reduce potential socioeconomic baries to sufficient water access through government subsidies or other policies, ‘The HWISE study sso recorded the sex ofthe household head, and we found that female-headed low-SES households most commonly affirmed ‘water insecurity experiences related to aspects where higher quantities of ‘water are required, such as aot being able to bathe (49.3%) or wash thet lothes (58.63) inthe prior four weeks. COVID-19 clearly presents spe cif risks for womten, including challenges for menstral hygiene (UN ‘CEE, 2020), and serious economic impacts given potential for lower ‘earnings and savings, higher exposure COVID-19 through occupa Uousl work (women comprise 70% of the global healthcare workforce), additional unpaid work sich a8 caring for sick children or elders, and _gender based violence resulting from poliey measuresdesigned toreduce the transmission of COVID-19 (United Nations, 2020), 3.4, Food insecuriy Household food insecurity often eo occurs with water insecurity. In the WISE sandy, the overall correlation between food and water ins ceurity scores wes 0.37 (P< 0.001), with correlations aniong study’ sites ranging from ~0.02 to 0.74. Srewis el, (2020) also tested multiple sub-dimensions of water insecurity (need, quality, water worry) using the same HWISE dataset, and found all to be associated with greater household food insecurity. In site-specific regressions, greater water need was positively associated with food insecurity for 24 of 27 sites. ‘The only exceptions were Acatenango, Guatemala (the site with the smallest sample), Punjab, Pakistan (die most water insecure site), and Pune, Indi he most water secure and also one ofthe most food seeure sites) (Brewis etal, 2020), ‘Theoretically, there is reason to expect that water insecurity is & diver of food insecurity rather than the other way around, particularly because water is needed to grow erops, fed livestock, and prepare and ‘cook adequate safe foods buc nor the converse (Brewis et sl, 20205, ‘yutieh aod Brewis, 2014). For example, water is needed co irrigate household gardens and maintain ania, prepare food safely, ad many ‘of the most really available cereals, tubers, and grains (ec, ava) specifically require treatment with water to make thea digestible ‘and safe. Note chat many sites reported higl levels of “having to cage foods being prepared” (Fg, 7) and “water situation impacted livestock” ‘and “water situation impacted crops” (P. °) ‘The observation ofa strong and consistent association between food ‘and water insecurity sero many of the global sites, with water nse ceurity asa potential driver, has implications for COVID-19 in several dimensions based on elevation of isk of food insccurity. There are many mechanisms by which household food insecurity might potentially Impact COVID-19 risk to individuals, households, and communities, and we would then expect water insecurity to elevate these. Fes, Is well ‘established that acute aid chronic mdernutrivion creates additional sks for infeetion (Calder and Jackson, 2000). Undernutrtion un ‘dermines barter Function, allowing easier entry ofinfectiousagents, and italso weakens immune function, making it harder to recover fom in feetions. Also, water security appears to be important for mothers’ ea pacity and decisions about how they Cheastfeed thelr ciléren (Coli fer al, 2019; Schuster etal, 2020), an additional way in which water may be hypothesized to affect ehiéren’s immune funetion. Third, under low resource conditions, money, assets, or social capital deployed to deal with water (or fond) insecurities ean undermine household budgets ‘or ther means co cope with health challenges, including healthcare nd ‘other spending relevant to the prevention and treatment of infectious disease (Brewis tal, 2020) 8.3.5. Thirst and defydraron (One of the most common recommendations that patients with res piratory infections receive from doctors, isto “drink plenty of fluids (Guppy &¢ aly 2004). This recommendation is given 0 reduce risk of dehydration through insensible water loss and account for potential ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 lower water intake, as well as reduce mucus thickness (Guppy et al, 2004), Boor water aceessbility and reliability may make i dificult co et this recommendation. Lacking access to water while in a ‘dehydrated condition increases anxiety and can change decision Dractices (H. A. Young eal, 2019), whieh may inerease transmission Fisk of COVID-19, ‘Actos ll HWISE study sits, 17.69 of households reported going (0 sleep thirsty atleast once inthe last four weeks, At every site, some households reported water problems-so severe that they reported at least ‘one night of going to slep thirsty, ranging From 0.49% i Ceara, Bell, co 67.996 in Kahemba, DRC (Fg, 7). In addition, 27-996 of all households had no useable or drinking water at east once in the prior month; 40.5% drank water that looked, tasted, or smelled Dad and 40.89% drank water though tobe unsafe. We would wo expect any of these experiences to be sssorited with optiniin hydration, ‘Our results indicate that a large proportion of households would not be able to meet the treatment recommendation of “drink plenty of ‘uids” iF they were to contraet COVID-19, While dehydration was not expliily measured in the HWISE study, from a physiological perspec tive, thirst can be indicative of dehydration (Weinberg eta, 1995)-Ieis likely that some proportion of the individuals in these households are also dehydrated, which can negatively affect cognitive performance and led to confusion, particularly among older adults, as well as lead to higher risk of Kidney stones (Popkin et al, 2010; Weinberg et wl, 1995). “Therefore, prevention atid at-home treatment of COVID-19 may be ore challenging under these conditions 3.6. Mental heat Water insecurity is strongly Linked to mental dl-health, Early exploratory research found high rates of worry, anger, shame, and conflict among people experiencing water insecurity (Salen, 20115 \Watich and Ragsale, 2008) Reeent researc finds that water inseeurity Is associated with symptoms of anxiety and depression (Wusliav eta 2070). Seven key mechanisms appear to produce water-elated mental itbhealth: (1) worry about ilaess and heslth problems, (2) conic in households and communities, (8) status loss or social flute, (4) loss of connection to meaningful places, (5) reduced autonomy or opport nities, (6) poverty, deprivation and certainty, and (7) unjust or unaie treatment (Watch tl, 2020) Cis Hikely that COVID-19 will intensify ost, if not all, ofthese pathways. We highlight chree likely dynamies: worry about illness and health problems, conflict in households and ‘onmmunities, ad stans loss oF socal fare Water insecurity puts people at higher rsk of contrating COVID-19,, nd ths fs distrossing. Past research shows that people fel significant worry over the risks of drinking contaminated water, de physica risks of water fetching, and thirst and hunger borne of water inseeurity (Watch etal, 2020). Our date indicate that 59.1% of households re ported tha at least one member experienced worry that dhey would not have enough water in the last four weeks (Pig. 8). This is likely to Intensify as people worry about contracting COVID-19 at water fetching Points, contamination of stored water, and the necessiy of drinking lesssafe water if cash becomes. short and water-points. become ingccessible Water insecurity precipitates significant conflicts both within households and across communities. Within households, confits tend to center on financial worries and water shortages, with women often bearing the brunt of blame sud experiencing higher risk of intimate paruner violence (hiowhry et al., 2020). Within communities, water insecurity produces confit as people argue over access to water Sources (Sultana, 2011. In the HWISE study, 28.0% of households reported intr-household difficulties over water, and 21.5% reported extra household difficulties over water (Fs. 8). As the stakes of water insecurity increase during a COVID-19 outbreak, we would predict seh conflict would also increese—for example, if people are unable to meet physical distancing expectations while queuing for water. ‘Water insecurity can create status loss, especially for households that, ‘are impoverished, unable to maintain hygiene norms, or are perceived a too dependent on others (Witt and Brevis, 2014). This can be ‘particularly true for households that lean more heavily on water sharing ‘arrangements when water becomes searce (Wut ets, 2018). Shame ‘and anger are conimon entional responses to the threat of status loss (Gmycer et al, 2016). In our sample, 47.086 of households reported ‘anger/upset and 34.4% reported shame over water (Pi. 8). AS com: tuninities experience economic and social disruptions related to ‘COVID-19, people wil likely find it increasingly ficult to conform to social norms and expectations (Such as hygiene noms) and may expe rience anger aad shame over status loss as result 8.3.7. Household sanitation Thadequate sanitation snd water fnsecurty are mstualy reinforcing, 1 the inability to effectively separate human waste more readily in troduces pathogens into the domestic environment. Recent evidence indicates gut involvement of SARS-CoV-2, with prolonged viral shed ding found in both sympromitie and non symptomatic patients (0 ‘Cal, 2020), Alhough the HWISE study didnot ask about water use for sanitation, the gut invalvement of SARS-CoV-2 poses several impli ‘ons for WASH-insecure households Gastrointestinal symptoms require increased attention to fecal management when sick individuals inerease se of bathrooms, latrines, ‘or chamber pots. Evidence is also emerging for fecal-oral transmission of the virus (Yeo eal, 2020), with implications for WASH insecure areas Even if fecal-oral transmission proves uncommon, sanitation security nonetheless is critical, Shaved sanitation facilities, such as ntrines, are oft experience high use and thus present isk (Caruso and Freeman, 2020). We may see increases in droplet and fomite transmission of COVID-19 if facilities aze inadequately cleaned. Effective management of diserhes requires sufficient quamtties of safe water for cleaning as well as for hydration, and hygiene, and caregiving. Second, inadequate sanitation is a key driver of environmentally mediated transmission of enteric infections, As COVID-19 spreads to ‘countries with high burdens of enteric infections, enteric infections may ‘emerge as important comorbidities that shape epidemic trajectories ‘given the noted effects of infeetion with SARS-CoV-2 in the gastrin testinal tract. 4. Conclusion ‘Water isa erica component of human well-being and development, (Gepsonetal., 2017), and household water insecurity presents an array of ‘complications for COVID-19 prevention aud control, Although the pandemic is exacerbating soeio-medical inequalities in high-income na Hons (Dome 2020), water insecurity is experienced everywhere, and lus effets aze especially salient in LMMICs, Our analysis of eniptieal data from 8,297 howseliolds across 29 LMMIC sites illustrate how the WHO ‘guidelines for COVID-19 control are dificult to meet given the everyday realities faced by billions of people. For example, 71% ofhouseholds had ‘ocently experienced a water-related problem that has the potential ro ‘undermine COVID-19 contol strategies or intensity lsease progression, ‘and 46% faced specific challenges with handwashing and physical distancing, both core elements of WHO's guidelines for COVID-19 pre vention and control. night of nes, tore infectious strains of COVID-19 like 8.1.1.7 Galloway eta, 2021), prevention strategies sich as mask lng and physeal distancing ate even mote importa iven inital delays to vaccine deployment. Although our study saruple is not representative ‘ofall LMIGsor communities in the counties sample, the water problen documented here clearly exemplify the range of substantial issues ‘endured by waterinsecure households across diverse rural and urban ‘contexts. While water istes alone cannot forecast COVID-19 intensity, these data suggest some practical means to identify where particular and layered rsk for COVID-19 are located within LMICs: those communities with particularly high levels of water insecurity ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 (Our analysis has imitations. The date do not include information beyond households, and nonhousehold water sources could be an important and effective means for households to obtain water. Nearly ‘wo billion people depend on healthcare fciitfes without baste water services, which ineteases COVID-19 isks for patients and health eare workers (WHO/UNICEF, 20206). Additionally, over 30% of schools slobaly lack access to an onsite water point and 36% have no hygiene facilities. These institutions are more likely to be found in comsunities with poor household water security, multiplying the risks to people living there, especially during the pandemic. This pandemie necessitated legislation of economie stinulus and relle packages in high- and middle income nations Although the cost of| achieving Sustainable Development Goal (SDG) 6 would require & sig nificant inerease over our eurrent global investment, the cost of achieving universe basie WASH services has been estimated at US$28.4 billion per year from 2015 t 2030 (Le, US$426 billion, now. discounted), oF 0.1086 of global GDP (Hutios and Varughese, 2016) n March and April 2020 alone, the United States committed USSS. trillion ina series of four economic relief packages, and the European Union committed €540 billion, with significant additional relief legis lation pending on both continents. Other countries have followed sui, such as Japan's USS992 billion stimulus package, China's USS500 billion seal stinmus, and India's US8260 billion COVID.19 relief package. Compared co what the world will ultimately end wp spending fn emergency economic measures, the cost of universal basic WASH looks lke bargain, something we have known for year (Hon el, 2007), We emphasize that while these issues are most acute in situations such asthe eurrent pandemic, basie WASH services have implications for tuany other key considerations ranging from mitigating the global burden of disease to improving education outcomes and improving gender equity. WASH service coverage has long been a presing global concern; COVID-19 has made its importance more visible and urgent. In the short term, the COVID-19 ersis should trigger increased in vestments an attention fo WASH issues by LMICS and the development community as seen after the 2014-16 Ebola outbreak in West Aftica (Cooper, 20208). Eleven Afhican nations announced diferent forms of free water forthe urban poor and other groups for exaniple paying users billsin some areas in Ghana (Anankivas and Aupratyrun, 20205 Suiley cal, 2020), providing water for vulnerable communities and informal sectlements in Kenya, and the World Bank supporting 20 new water Points for poor communities in Democratic Republic of the Congo sup plied by uility-ovned water tankers (Cooper, 2020). Government stinmals programs may also nowd to directly address publie private partnerships (PPP) that have historically played crucial role in WASH service provision. These partnerships may have the physleal and social infrastructure to immediately improve water access for many vulnerable communities. Bur the pandemic his ereated Financ sess for PPPs across industries globally and threatens widespread project failure from logistical disruption and new budget constraints, including the Ioss of revere from regional lockdowns (Baxter and Casady, 2020; (Casa ancl Banter, 2020), PPP engagement requires caution, as goals tnd accountability are not sways well-sligned between partners, and profit imperatives ean clash with equity and other priorities, {As policymakers and program implementers scale-up the immediate Aistbution of emergency WASH supplies, we encourage deeper consideration of hor these activities can be tasitioned into targeted, sustainable, long-term WASH Investments. High-resolution geospatial rapping of water and sanitation access, ike dhose predced by the Lacel Burden of Disease WaSH Collaborators in 2020, can provide sub- national guidance on priority regions (Deshpanie et al 2020). Although solutions should be tailored to local neds and constraints, iis clear thar most communities will benefit from improventents in both water infrastructure and water governance, and also the way water managers distribute water and remain responsive to theneeds of diverse users, Ultimately, such strategies have the potential to greatly improve the overall healt of communities aud increase their resilience to future shocks, including another pandemic. Housing and utility policies may help deter COVID-19 transmission a well: in the US and Iran, oratoria ‘on eviction and electricity and water shutofis have helped contain dis ‘esse spread, although the eeonomie impacts on landlords and utilities remain unclear Clowes eta, 2020; Seidight eal, 2020), Strengthening household water security is critical for preventing and mitigating the effects of future pandemics in underserved communities ‘around the world (Cooper, 20201), The world was already off track to ‘achieve SDG 6 before the COVID-19 pandemic, and innovations in water ‘economics, engineering, and management will be eritieal to accelerate the pace of progress (of etl, 2020). In the meantime, adequate and affordable WASH services can mitigate the potentially compounding effets of COVID-19 and funure pandemics with the traditional burde ‘of water insecurity, especially in the most historically marginalized hosseholds and communities, WISE RCN Co-Authors lis Adams, University of Notre Dame, South Bend, IN, USA. Farooq, ‘Alimed, Quaid Azam University, Islamabad, Pakiscn. Malika Alex ‘ander, Jolins Hopkins University-Byranyjee Jeejeebhoy Medical College Clinica Trials Unit, Pune, bids. Gershim Sik, Affiean Population and Health Research Genter, Nairobi, Kya. Mobolanle Balogun, College of Medicine of the University of Lagos, Lagos, Nigeria. Michael J. Bolin, Michigan State University, Eas Lansing, MI, USA. Genny Carrillo, Texas ASM University, College Station, TX, USA. Kelly Chapman, University ‘of Flora, Gainesville, FL, USA. Strona Cole, University of Westminster, London, UK. Shaleaa MI. Collins, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA. Hassan Elnt- Zinab, Shahid Beheshti Univesity of Medical Sciences, Tehran, Iran. ‘Jorge’ Escobar Vargas, Pontificia Universidad Javeriana, Bogoti, CColombis. Hala Ghats, American University of Beirut, Beirut, Lebanon, Monet Ghorbani, Arizona State University, Tempe, AZ, USA. Ashley Hageman, Yale University, New Haven, CT, USA. Nicola Hawley, Yale University, New Haven, CT, USA. Zeina Jamaluddine, American Uni versity of Beirut, Beirut, Lebanon. Divya Krishnakumar, Anode Gover nance Lab, Bengaluru, India. Kenneth Maes, Oregon State University, Corvallis, OR, USA. Jyoti Mathad, Weill Cornell Medicine, New York, NY, USA, Jonathan Maupin, Aeizona State University, Tempe, Az, USA. Patrick Mbullo Owuor, Northwestern University, Evanston, Il, USA. Hugo Melgar-Qulfionez, McGill University, Ste-Anne de Bellevue, ‘Quebec, Canada. Milton Marin Morales, Universidad Auténoma del Beni José Ralivién, Trinidad, Bolivia, Javier Moran, Antonomous University ‘of Conhuila, Coahile, Mesico. Nastin Omidvar, Shahid Behesht Uni versity of Medical Sciences, Tehran, Iran, Sabrina Rasheed, International ‘Centre for Dirroesl Disease Research Bangladesh, Dhska, Banglades Lisa Seiayon-Figueros, McGill University, Ste-Anne de-Bellevne, ‘Quebec, Canada. Emesto C. Sénches- Rodriguez, Hospital Agustin ‘O'Horan, Métide, Yucatan, Mexico, Marianne V, Santoso, Northwestern, niversity, Evanston, IL, USA. Roseanne C. Schuster, Arizona State hiversity, Tempe, AZ, USA. Mahdleh Shelkhi, Shahid Beheshe Uni versity of Medical Seiences, Tehran, tran. Sonali Srivastava, Anode Governance Lab, Bengaluru, India, Andrea Sulivan, University of Miami, Coral Gables, FL, USA. Yihenew Tesfave, Oregan State Univer sity, Corvallis, OR, USA. Nathaly Triviio, Poutiieia Universidad Jav cerita, Bogoti, Colombia. Alex Trowell, University of Amsterdam, ‘Amsterdam, The Netherlands, Desire Tshala-Karumbay, Oregon Health ‘& Science University, Portland, OR, USA. Raymond Tu, Delaware ‘State University, Dover, DE, USA. credit author statement Justin Stoler: Conceptualizetion, Funding Acquistion, investiga tion, Project Administration, Resourees, Writing - Original Draft, Writing - Review & Editing Joshua D. Miller: Conceptualization, Formal Analysis, Investigation, Project Administation, Resources, ‘rao! Jour! of Hn and Emel Heth 234 (2021) 135715 Visualization, Writing ~ Original Draft, Writing - Review & Editing Alexandra Brewis: Conceptualization, Punding Acquisition, lnvestige tion, Resources, Writing - Original Drat, Writing - Review & Editing Matthew C. Freeman: Funding Acquisition, Investigation, Resourees, Writing - Original Draft, Writing - Review & Editing Leila Hare Conceptualzation, Writing - Original Draft, Writing - Review & Editing Wendy E. Jepson: Conceptualization, Funding Acquistion, Investig: tion, Resources, Writing - Original Drat, Writing - Review & Editing ‘Amber 1. Pearson: Concepruslization, Funding Aequsition, Investig: Udon, Resources, Writing - Original Drat, Writing - Review & Editing Asher ¥. Rosinger: Conceptualization, Funding Acquistion, invest gation, Resources, Writing - Original Draft Writing - Review & Baiting Sameer H. Shah: Writing - Original Dri, Writing - Review & Baiting Chad Staddon: Concepiaizaton, Funding Acquistion, investigation, Resouces, Writing - Original Draft, Writing - Review & Editing Cas. sandra Workman: Funding Acquisition, Investigation, Resources, Writing - Original Draft, Writing - Review & Editing Amber Wutieh: Coneepmuslization, Funding Acquistion, Investigation, Resourees, Writing - Original Draft, Writing - Review & Editing Sera L. Young: CConcepmualization, Funding Acquistion, avestigation, Resources, Wilting - Original Draft, Writing - Review & Editing MWISE REN: Funding Acquistion, Investigation, Resources. Dectarati ‘of competing interest ‘This research does nor contain any conflict of interests, Acknowledgments ‘The authors acknowledge the suppor of the Household Water Tnse curity Experiences Research Coordination Ne«work (HWISE RCN) fa ded by National Science Foundation grant number BCS-1759972. The FHWVISE study was funded with the Competitive Research Grants to Develop Innovative Methods aud Metrics for Agriculture and Nutrition Actions (IMMANA). IMMANA is funded sith UK Aid from the UK gov ferment. This projeet was aso supported by the Buffett Institue for Global Studies and the Conter for Water Research at Nortivestern University; Arizona State University’s Center for Global Health at the School of Human Evolution and Social Change and Decision Center for a Desert City (National Science Foundation SES-1462086); the Office of the Vice Provost for Research of the University of inal; and the Na- onal Institutes of Health grant NIEHS/FIC ROLESDI9841 for the Kahemiba Study, DRC. SLY was supported by the National nsticutes of Health (NIMH R21 MH108444; NIMH KOT MH1098902). WES was sup: ported by the National Science Foundation (BCS-1560962) and the ‘Texas ASM University CONACYT Resenrch Collaborative Grant. CS vas supported by the Lloya’s Register Foundation. Funders of che study’ ad no role in study design, data collection, data analysis, date interpreta ‘don or writing ofthe report. 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