If “Water Is Life,” Shouldn’t We Know How to Measure It?

An anthropologist sets out to create a cross-culturally valid household water insecurity scale.

We all know that fieldwork can entail the unexpected, and often these surprises can delay and frustrate: missed flights, faulty equipment, stalled research permissions. While in western Kenya in 2013 with my six-month-old daughter, Aurora, I was acutely conscious of the unexpected. We had a lot to accomplish in a short period: meetings to be held, enumerators to be trained, and formative data to be collected—data that would ultimately inform my larger study examining the determinants of maternal and child health in the contexts of food insecurity and HIV. To my surprise and joy, all went according to plan. Little did we know that the unexpected was waiting for us in the results from that fieldwork.

A Kenyan woman fetches water. Sera L. Young

One of the activities we set in motion that week was photo elicitation interviews. For this, we gave cameras to mothers in and around the city of Kisumu and asked them to photograph influences on their ability to access food. I anticipated photos of crops and livestock (many in the region are agro-pastoralists), along with stories about traditionally cited barriers to accessing sufficient and diverse foods, such as lack of money or inadequate social support. I was bewildered when the women returned with photo after photo of water instead.

One mother of an eight-month-old infant returned a photo showing a jug of filthy brown water. “This is the water we use for cooking sometimes; it comes from the prison called Kodiaga. The prison people let the sewage drain into it, but we still have to use it,” she explained.

Lack of money can make it difficult to cook for the baby and family at large. Sometimes you might have money for food but no water in the house, so you get torn between buying water or buying food. In a way, this makes the baby suffer because the money that ought to be used for buying her food ends up buying water; on the other hand, when the food is bought, that means that there is no water for cooking.

Water or food? It’s an impossible dilemma, and, as it turns out, not one faced uniquely by this woman. As the interviews progressed, other participants returned photos of water and shared similar narratives. Without sufficient water, preferred foods like githeri (a bean and maize mixture that takes a long time to cook) could not be prepared. Without clean water, mothers could not clean their bodies to breastfeed their infants. Without clean water, households drank dirty water that made them sick. These women were describing the extreme manifestations of water insecurity.

I will use this water in washing utensils for them to be clean, I will use it in cooking, I will use it to wash my clothes, and the cattle will drink it.”
As we began to refine the questions that would be used in the survey portion of our observational pregnancy cohort study, it became clear that we needed to measure water insecurity. We already had the cross-culturally validated nine-item Household Food Insecurity Access Scale, to measure exposure to our original interest, food insecurity. However, based on what we learned in the formative interviews, I wanted to also include an analogous measure of experiences with water insecurity. I was dismayed to discover that such a tool did not exist. In fact, there was not even a universal definition of water insecurity.

It was clear, however, that regular access to sufficient and safe water is a major problem. Worldwide, two-thirds of the population—four billion people—experience severe water scarcity for at least one month of the year. However, the burden is not equally distributed. Of the 748 million people who do not have access to clean water, nearly half (325 million) live in sub-Saharan Africa. In Kenya specifically, 43 percent of the rural population obtain drinking water from an unimproved source—unprotected dug wells or springs—meaning their water is at greater risk of contamination with pathogenic substances. While these macro-level indicators were a welcome starting point, they did not capture household or individual experiences, which was our preferred level of measurement. Without this more granular measurement, we could not explore how water insecurity impacts physical health, psychosocial well-being, and food security. So, my team and I decided to develop and validate a household water insecurity scale for the Kenyan context.

In 2015, with support from the National Institutes of Health, we returned to Kisumu to investigate water insecurity among pregnant and postpartum women using a range of qualitative techniques methodologies, as a first step to scale development. These data revealed complex connections between uses of water for both biological needs and the cultural practices that define the human experience. Women discussed not having enough clean water for religious ceremonies (ablutions, baptisms), household cleaning, personal hygiene, food preparation, agricultural production, and taking medications. Without water for cooking, some mothers skipped meals or prioritized food for their children. As one participant noted, “When there is no water, there is no life—because water is life. I will use this water in washing utensils for them to be clean, I will use it in cooking, I will use it to wash my clothes, and the cattle will drink it.”

Sera and baby Aurora. Sera L. Young

As for water acquisition, Kenyan participants talked about this as both a physiological and psychosocial stressor. They described its many opportunity costs (fetching water instead of tending to crops or going to school, for example), and the fact that many men believe that a lack of water in the house is sufficient grounds for physical violence against their female partners. We also queried international experts using the Delphi method in order to identify other facets of water insecurity.

A preliminary set of questions that set out to capture all of these experiences was developed based on these data and other scholarly work on water insecurity. Indeed, we benefitted greatly from studies of water insecurity in other settings, including Ethiopia (led by Jed Stevenson and Craig Hadley), Bolivia (Amber Wutich), and the Mexico/Texas border (Wendy Jepson). It was around this time too that we began to critically evaluate how water insecurity had been conceived (Jepson et al. 2017). This was also informative in developing the scale items. Our initial scale included 29 questions that asked about experiences of water insecurity in the past four weeks. Such experiences included worry about having enough water, drinking water believed to be unsafe, and going to sleep thirsty.

In 2016, the scale was implemented among 241 Kenyan mothers to test its validity at three time points: 15, 18, and 21 months postpartum. By looking at responses across time, we were able to reduce the scale to only 20 questions using a series of statistical procedures. Although we have yet to investigate the relationships between water insecurity and health outcomes, formative work has revealed that 77.3 percent of our participants felt “somewhat or strongly concerned” for their physical safety during water acquisition; 64.1 percent reported drinking unsafe water; 65.3 percent reported worrying about accessing sufficient water; and women without water in their compound spent a mean of 4.5 (±6.7) hours per week acquiring water (Krumdieck et al. 2016). These early findings underscore the fact that women disproportionately bear the burden of water insecurity, and that it has far-reaching consequences.

As an anthropologist, I am not satisfied to only understand how water insecurity in western Kenya affects, and is affected by, the health and well-being of women and children. I’d like to compare experiences and sequelae of water insecurity across populations. I became certain that we needed a cross-culturally valid household-level water insecurity scale that could measure the water security status of any household in the world. We discovered other scientists were also thinking critically about this issue, and we have come together to investigate water security both quantitatively and qualitatively. Our collaborative research network, the Household Water Insecurity Experiences (HWISE) Consortium,  includes over 36 members from across 20 institutions worldwide. Currently, we have collected data from 3,891 households in 13 sites and anticipate survey implementation in another 9.

We intend for the final, cross-culturally valid scale to be available for broad dissemination and use by the end of 2018. Then, for the first time, policymakers, NGOs, and scientists will be able to measure water insecurity at a granular level and meaningfully compare their findings. With these data, we can know the prevalence and severity of water insecurity; investigate its relationships with social, economic, and health phenomena; better target limited resources to those with greatest needs; and measure the impact that policy changes or engineering innovations have on water security (see Wutich et al. 2017). Our ability to measure household food insecurity has transformed our understanding of a range of indicators of health and well-being, from HIV-transmission to school performance. I am hopeful that the measurement of household water insecurity will do the same.

This work is supported by The National Institutes of Health (NIMH K01 MH098902) and a Competitive Research Grant to Develop Innovative Methods and Metrics for Agriculture and Nutrition Actions (IMMANA Grants). IMMANA is funded with UK aid from the UK government. Study registered at NCT02974972.

Sera L. Young is an assistant professor of anthropology and global health at Northwestern University. Methodologically, she draws on her training in medical anthropology, international nutrition, and HIV infection to take a biocultural approach to understanding how mothers cope to preserve their health and that of their families (www.serayoung.org).

Joshua D. Miller is a research study coordinator in the Young Research Group at Northwestern University. His research interests include pica, as well as water (in)security, food (in)security, and their interactions.

Cite as: Young, Sera L., and Joshua D. Miller. 2018. “If ‘Water is Life,’ Shouldn’t We Know How to Measure It?” Anthropology News website, March 12, 2018. DOI: 10.1111/AN.796


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