Results

Nineteen thousand, seven hundred and fifty-eight titles were retrieved through the electronic database searches (figure 1). Once duplicates were removed, 12 131 articles remained for further screening of abstracts and titles against the inclusion and exclusion criteria. Of these, 11 789 articles were excluded (305 remained), because the title and abstract clearly indicated that the content was irrelevant to the purpose of this review; or because health outcomes were reported only for children aged 5 years or less or for cases of infectious disease; or they reported only sanitation and hygiene practices or household water supply type without information about water source location (ie, does not indicate need for water fetching work). A further 37 papers were flagged electronically while retrieving full-text papers from the databases, identified in reference lists of retrieved papers or obtained from contacting water, sanitation and hygiene (WASH) experts.

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Figure 1

Study selection (Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009).

In total, the full text of 342 articles was obtained for review against the inclusion and exclusion criteria. Of these, 300 were excluded because they did not include data on either the work of water fetching or health of water carriers or both. Articles which focused on the health impact of physical contact with water at the point of collection, for example, reporting prevalence of schistosomiasis infection and observed or reported water contact time during water fetching activities, were also excluded because such studies do not provide information on the association between health and the work of carrying water containers home. In total, 42 articles were included in the review, which reported associations with the health of water carriers and the work of water carriage.

Twenty-six studies collected quantitative data.14 21–45 The overall methodological quality of the studies, in terms of their capacity to demonstrate a cause and effect relationship between the work of water carriage and health was rated as fair (6 studies) or poor (19 studies), only one was rated as good (table 1). The key reasons for low-quality ratings were the use of cross-sectional study design, lack of evidence to support the reliability and validity of exposure or outcome measures, lack of outcome assessor blinding and failure to include confounding factors in analyses.

Twenty-one studies reported qualitative data23 26 31 32 34 35 44 46–59 (table 2). While almost all seemed to have appropriately chosen a qualitative research design to meet their aims and provided a clear statement of research findings, there was often insufficient information reported to determine whether recruitment, data collection and analysis were appropriate and sufficiently rigorous. The influence of the researcher and ethical issues were also not clearly reported in most of the studies. We rated studies as ‘good’ if six or more of the appraisal criteria scored a ‘yes’ response, fair if four or five criteria had yes responses and poor if three or fewer had yes responses. The scoring process resulted in 12 of the studies being rated as of good quality, 5 of fair quality and 4 rated as poor quality.

The articles reported health and social outcomes including bodily pain, energy expenditure or fatigue, stress or mental well-being, perinatal health and access to healthcare services, lack of safety or discrimination related to social vulnerability and general health status. The studies reporting social outcomes of safety and discrimination were included because of the clear and likely direct impact of the reported social factors on the water carrier’s physical or psychological health. The reported health outcomes are grouped for comparison under key themes: bodily pain, energy expenditure and fatigue, stress and mental well-being, perinatal health, social vulnerability and general health.

There is moderate evidence from quantitative data and strong evidence from qualitative data of an association between water carriage and self-reported pain or injury (tables 3 and 4). Sixteen reports of 15 studies14 26 28 29 31–33 39 43 46 47 52–54 58 59 included people within their study samples whose experience of water carriage was associated qualitatively, or through quantitative analysis, with pain, injury or risk of injury (table 5). The significantly reduced distance walked and time spent for water fetching among head-loading water carriers who reported pain, compared with those who did not report pain, was interpreted by Geere et al,14 as an indication of pain-related disability. They suggested that people who experienced pain during water fetching may reduce the length of time they are exposed to the loading force, while those without pain or with lower levels of pain may be able to collect water from greater distances. Although their study was limited by a small sample size, their findings are supported by the studies including qualitative data derived from people who collect water. They are also supported by the findings of Rauniyar et al,29 who attributed a significant 5% reduction in the ‘drudgery’ of water fetching among the lowest socioeconomic group to water supply projects, and the findings of Porter et al,60 who found high proportions of children reporting pain as a direct result of load-carrying, which particularly for girls, included water carriage by head loading. However, as highlighted by Porter et al,60 61 individuals in low-income and middle-income countries carry diverse loads, and water may not be the heaviest load carried. Because none of the studies took this into account in their analyses, the effects of manual labour in addition to water carriage may confound the apparent associations between water carriage and pain.

In a recent study, Geere et al43 did not find an association between pain in the previous 7 days and history of water carriage, but did find that among people reporting pain, the area of the body in which pain was experienced was associated with a history of water carriage. Ten studies14 26 28 29 31–33 43 53 58 included some indication of the areas of the body in which water carriers experienced pain, with back and neck pain commonly reported. Geere et al43 found that participants reported multiple areas of pain, and that pain areas were correlated. Principal component analysis explained 55% of the variance in pain locations and extracted two factors correlated with patterns of pain distribution. The factor ‘axial compression’ was correlated with head, upper back, chest/rib, hands and abdomen/stomach pain. The association was proposed to indicate detrimental impacts of axial spinal loading, because participants who had previously or currently carried water had a mean increase in axial compression factor score compared with people who had never carried water, and the association was stronger among head loaders compared with those using other methods of water carriage. The factor ‘soft tissue strain’ was correlated with neck, upper limb pain, lower back and lower limb pain, and was slightly negatively associated with those having history of water carriage. While these findings may seem to contradict earlier data reporting complaints of neck and back pain during water carriage, the ‘axial compression’ pain pattern associated with water carriage was interpreted as pain referral from an underlying neck disorder.

All studies relied on self-report of pain, which is appropriate and necessary as pain is a subjective and emotional experience.62 Self-reported pain intensity scales have been shown to be valid and reliable for use in clinical trials to evaluate pain severity caused by a range of medical conditions,63–65 however, only one of the studies reported findings based on a pain intensity scale,33 and the scale was not clearly defined in the published report. No other studies qualified participants’ reports of pain in terms of its quality, severity or effect on functioning. Qualification of pain is important because it is a common phenomenon, and can range from mild intensity which does not affect functioning or quality of life to severe pain which is disabling and/or reduces quality of life. Studies should focus on whether the work of water carriage is associated with pain which is of a quality or intensity sufficient to impair functioning or reduce quality of life.66

Seven studies included qualitative reports from participants, in which they associated physical injury with water fetching,31 32 46 47 53 58 59 and four described fear of injury due to water carriage along routes or from locations frequented by dangerous animals.31 32 39 59 One study reported three cases of a child drowning at open wells or ponds,31 participants in another study reported fear or risk of being swept away or drowning during floods32 and a further study included participants who had witnessed people struck by moving vehicles while fetching water.58

There is moderate evidence of an association between fatigue or tiredness and water carriage from quantitative data (table 3) and strong evidence from qualitative data (table 4). Five of 11 studies (12 publications) reporting tiredness, fatigue or exhaustion affecting water carriers (table 6), described associations with worsened family relationships,57 poorer health status24 26 and reduced engagement with education.32 58 Two studies measured energy expenditure.25 28 As an index of total energy expenditure, Rao et al25 described drawing water as moderate physical activity, and carrying two containers on the head as heavy physical activity, while Borah et al28 categorised drawing and carrying water home as moderately to very heavy. However, the energy expenditure measurements were done on very small samples of women in India, and may not be generalisable to other populations. Together with other studies in this review, which found that rating of perceived exertion is correlated with weight of water carried and path incline,14 that energy expenditure for water carriage may be most important in food scarce regions47 and that water points which reduce water fetching increase birth rates,24 current evidence highlights that the energetic cost of water carriage has potentially detrimental effects on health and well-being, manifesting as tiredness or fatigue.

We found inconclusive evidence that water carriage is associated with stress from quantitative data (table 3) and strong evidence from qualitative data (table 4). Two rigorous qualitative studies,34 57 and one fair quality36 and two poor quality27 34 cross-sectional surveys, reported water carriage to be associated with stress (table 7). In these studies, psychosocial distress was identified as an effect of water carriage by thematic analysis, and measured using three different questionnaires and by quantification of hair cortisol content as a biomarker for chronic stress. Despite the different indicators of stress, all of the studies elucidated mechanisms by which water carriage might cause stress. These included feeling unsafe during water collection,36 having insufficient time for family members to spend with each other or discuss household issues,57 the physical difficulty of water carriage with a young child,27 risk of physical assault or rape, extremes of temperature, queueing times and inability to complete household tasks triggering arguments between married couples.34 Considering issues related to social vulnerability which are discussed below, it is plausible that water carriers experience stress related to fear of conflict or abuse.48 However, one good quality cohort study failed to find any significant association with respondents’ mental well-being or life satisfaction and connection to a piped water supply, among participants with above median time spent fetching water at baseline.30 One mixed methods study failed to find an association between emotional distress and water fetching time, even though participants found water collection to be ‘bothersome’ because of having to collect water at night.44 The findings of these studies are inconsistent with the others, however, they should be considered with some caution. The outcome measurement of mental well-being in the study by Devoto et al30 was derived from a composite score and its validity and reliability for use with the study population was not reported, and while socioeconomic status was included, other potential confounding factors which might affect mental health and life satisfaction were not included in the analyses. The average one way time to the water source in the case study by Thomas and Godfrey44 was <3 min.

There is moderate quantitative evidence that perinatal health is associated with water carriage (table 3) and strong qualitative evidence (table 4). Six studies reported different aspects of perinatal health to be associated with water carriage (table 8). Two qualitative papers reported physical strain and non-specific ‘health complications’ from carrying 20 L water containers on the head during pregnancy50 52 and one reported mothers’ views that being forced to fetch water in late pregnancy led to malnourished children.55 Quantitative studies reported reduced uptake of prenatal care services,22 six times greater odds (our calculation) of giving birth in a health facility when a husband provided help with water fetching38 and almost four times greater odds of giving birth in any given month, among women with an improved water supply closer to their home compared with those without improved water supply.24 Gibson and Mace24 described the improved water access as an ‘energy saving’ intervention which reduced distance to water and women’s time spent water fetching. They concluded that the energy saved by the technology did not translate into an improved nutritional status for women, because it supported an increase in birth rates. While the study found a negative consequence of the increased birth rate to be increased childhood malnutrition, it nevertheless indicates a potentially detrimental impact of maternal health associated with water carriage; it suggests that prior to installation of taps the exertion of water carriage affected women’s health enough to reduce birth rates, as compared with birth rates post-tap installation. While Gibson and Mace did not include nutritional interventions as possible confounding factors in their multivariable analysis, and McCray’s22 outcome measure could have been affected by recall and therefore misclassification bias, the six studies provide evidence that water fetching could be significantly associated with perinatal health outcomes through behavioural and physiological mechanisms.

There is moderate quantitative evidence and strong qualitative evidence that vulnerable people are at risk of discrimination or physical, sexual and psychological abuse while they collect water (tables 3 and 4). The studies in this review provide rich qualitative evidence in good,49 51 54 55 57 fair31 47 48 and poor quality studies32 50 58 from 31 countries, and good,30 fair31 37 or poor31 32 35 41 42 quantitative evidence from 6 countries (table 9). People may be vulnerable because of age, gender, disability, health status or ethnicity.

There is inconclusive evidence of a relationship between water carriage and self-rating of general health, because of inconsistent findings in the five studies (tables 3 and 4). There is an indication of a dose-response relationship between water carriage and self-rating of health in three21 23 26 of the five studies reporting general health of water carriers, with greater amounts of time spent water fetching linked with poorer health for both children and adults (table 10). These findings were inconsistent with those of Geere et al,43 who found that adults who currently or previously carried water, had a better (lower=healthier) mean general health rating score than adults who never carried water, while children who currently carried water reported better, and children who previously carried water reported worse health, compared with children who had never carried water. In qualitative data from an earlier pilot study, Geere et al46 found that some children linked water carriage to better health and stronger resilience to diseases such as ‘influenza’, others to meeting basic needs and some to experiencing unfair workloads.

The inconsistencies may be due to different methods used for participants to rate their general health, and differences in confounding factors incorporated into the analyses. In the three of four studies which attempted to scale or categorise health status,21 23 26 recall of occasions of illness or comparison of current to previous health status was required of respondents. This may introduce bias or error to the classification of health status, weakening internal validity of the studies and rendering the findings inaccurate.17 Self-rated health ‘today’ on a simple 5-point scale has been found to have high test-retest reliability and to be an excellent predictor of future health in some studies, however, reliability of self-rated health status has also been shown to be affected by age, income and occupation in some populations.67 Hemson’s26 findings may therefore have been influenced by recall and confounding factors, because the statistics presented are descriptive and lack analysis of the effect of variables such as age, gender and socioeconomic status. These variables were considered in the regression analyses reported by Bour,21 Foggin et al23 and Geere et al,43 with Foggin et al reporting a very strong association between increased time spent water fetching and poorer general health. However, other potential confounding factors which were not included in analyses, such as hygiene practices, access to healthcare or sanitation coverage, could have influenced the results in all studies. No studies used a longitudinal cohort design to determine a temporal relationship between water fetching and health status, and all could have been affected by confounding factors which were not included in analyses.