Water insecurity in 3 dimensions: An anthropological perspective on water and women's psychosocial distress in Ethiopia

Abstract

Water insecurity is a primary underlying determinant of global health disparities. While public health research on water insecurity has focused mainly on two dimensions, water access and adequacy, an anthropological perspective highlights the cultural or lifestyle dimension of water insecurity, and its implications for access/adequacy and for the phenomenology of water insecurity. Recent work in Bolivia has shown that scores on a water insecurity scale derived from ethnographic observations are associated with emotional distress. We extend this line of research by assessing the utility of a locally developed water insecurity scale, compared with standard measures of water access and adequacy, in predicting women's psychosocial distress in Ethiopia. In 2009–2010 we conducted two phases of research. Phase I was mainly qualitative and designed to identify locally relevant experiences of water insecurity, and Phase II used a quantitative survey to test the association between women's reported water insecurity and the Falk Self-Reporting Questionnaire (SRQ-F), a measure of psychosocial distress. In multiple regression models controlling for food insecurity and reported quantity of water used, women's water insecurity scores were significantly associated with psychosocial distress. Including controls for time required to collect water and whether water sources were protected did not further predict psychosocial distress. This approach highlights the social dimension of water insecurity, and may be useful for informing and evaluating interventions to improve water supplies.

Introduction

Globally, 884 million people drink water from unimproved sources (JMP, 2010). Disparities in the availability of safe water constitute one of the primary underlying determinants of global health inequalities. Sixty percent of child diarrhea deaths are attributable to unsafe water, sanitation, and hygiene (WASH) (Boschi-Pinto, Velebit, & Shibuya, 2008; Prüss-Ustün, Kay, Fewtrell, & Bartram, 2004), and the quality and quantity of water supply contribute to malnutrition and vector-borne diseases (Fewtrell, Prüss-Ustün, Bos, Gore, & Bartram, 2007). Water also has indirect influences on health: where water is collected from sources distant from the home, time and effort expended on water collection constrains income generating activities, contributing to vicious cycles of poverty (Blackden & Wodon, 2006; Krishna, 2010). Recognition of this has inspired the Millennium Development Goal to halve the number of people without sustainable access to improved drinking water. It has also led to a focus on water insecurity (UNDP, 2006) – which, in parallel with food insecurity, has been defined as “insufficient and uncertain access to adequate water for an active and healthy lifestyle” (FAO, 2004; Hadley & Wutich, 2009: 451).

The 3 dimensions of water insecurity – adequacy, access, and lifestyle – have received varying amounts of attention in research to date, with adequacy and access being studied largely by public health researchers (Billig, Bendahmane, & Swindale, 1999; Ford, 1999; Gleick, 1996) and the lifestyle or cultural component studied by anthropologists. The cultural dimension of water use has implications both for access/adequacy and for the phenomenology of water insecurity. Historical and ethnographic accounts demonstrate diversity in water regulation and use across cultures (e.g. Lansing, 1987; Little & Leslie, 1999; Reisner, 1993; Thesiger, 2007 [1954]), implying different expectations and requirements for water. Ethnographic work also points to culturally specific understandings of water insecurity, such as the “suffering from water” documented by Ennis-McMillan (2001) in Mexico.

Following an approach that has proven useful in research on food insecurity (Frongillo & Nanama, 2006; Frongillo, Nanama, & Wolfe, 2004; Wolfe & Frongillo, 2001), some scholars have pointed to the value of developing water insecurity scales from the ground up, beginning with qualitative research on water use in a particular cultural context, and then adapting findings to the form of survey questionnaires, with answers scored as a metric of water insecurity (Hadley & Wutich, 2009). Rather than relying exclusively on proxy measures such as health indicators (e.g. incidence of child diarrhea or prevalence of child growth stunting (Checkley et al., 2004; Hasan et al., 1989)) or measures of physical access to water (e.g. time to source, quality of source, or quantity consumed (Whittington, Mu, & Roche, 1990)), locally grounded research can generate experience-based measures of water insecurity, reflecting local idioms of stress and suffering. The advantages of this approach are that it measures the experience of water insecurity relatively directly, and it takes account of the social context of water use. The validity of these measures can be evaluated by the extent to which they reflect (1) variability in water supply within communities in terms of quality, quantity, and access, (2) division of labor of water collecting within households, such as between women and men, and (3) independent measures of individuals' psychosocial distress.

This approach to water insecurity has been pioneered by Wutich, who in a series of studies in urban Bolivia showed how ethnographic evidence on water insecurity could be used to create a locally grounded scale of water insecurity. Wutich demonstrated that households with greater water insecurity as measured by a 9-point Guttman scale also had worse access to water; women – who bore the majority of the burden for collecting water – reported greater water insecurity than men; and water insecurity, but not per capita water use as recorded in diaries, was significantly associated with scores on a measure of emotional distress that included symptoms of anger, bother, fear, and worry (Hadley & Wutich, 2009; Wutich & Ragsdale, 2008). Taken together with ethnographic evidence (Wutich, 2009a), these findings suggest that water insecurity is determined not only by physical access and adequacy of water supplies, but also by the stresses inherent in negotiating with inequitable systems of water regulation.

In this article we advance understanding of the social dimension of water insecurity by developing a new scale of water insecurity and evaluating its relationship to an internationally accepted measure of psychosocial distress. Our assumption is that culturally specific norms and expectations regarding water use, as well as physical access constraints and adequacy of supply, inform the experience of water insecurity. We illustrate this approach through a case study in rural sub-Saharan Africa, an area of the world where water insecurity is of great concern, and where gendered division of labor in relation to water collection is widespread (Munguti, 2002; Ray, 2007; White, Bradley, & White, 1972). The research design included a mixture of qualitative and quantitative methods: qualitative methods for exploring the pathways connecting water and psychosocial distress in the study population, and quantitative methods for building a water insecurity scale and assessing its relationship to psychosocial distress. The hypothesis addressed by the study is that water insecurity, as measured by a locally developed scale, is independently associated with psychosocial distress, after accounting for food insecurity, quantity of water collected, distance from water source, and unprotected water sources.