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The Household Water InSecurity Experiences (HWISE) Scale: development and validation of a household water insecurity measure for low-income and middle-income countries
  1. Sera L Young1,
  2. Godfred O Boateng1,2,
  3. Zeina Jamaluddine3,
  4. Joshua D Miller1,
  5. Edward A Frongillo4,
  6. Torsten B Neilands5,
  7. Shalean M Collins1,
  8. Amber Wutich6,
  9. Wendy E Jepson7,
  10. Justin Stoler8
  11. On behalf of the HWISE Research Coordination Network
    1. 1Anthropology, Northwestern University, Evanston, Illinois, USA
    2. 2Nutrition, Harvard University, Cambridge, Massachusetts, USA
    3. 3Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
    4. 4Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA
    5. 5Medicine, University of California San Francisco, San Francisco, California, USA
    6. 6School of Human Evolution and Social Change, Arizona State University, Tempe, Arizona, USA
    7. 7Geography, Texas A&M University College Station, College Station, Texas, USA
    8. 8Geography, University of Miami, Coral Gables, Florida, USA
    1. Correspondence to Dr Sera L Young; sera.young{at}


    Objective Progress towards equitable and sufficient water has primarily been measured by population-level data on water availability. However, higher-resolution measures of water accessibility, adequacy, reliability and safety (ie, water insecurity) are needed to understand how problems with water impact health and well-being. Therefore, we developed the Household Water InSecurity Experiences (HWISE) Scale to measure household water insecurity in an equivalent way across disparate cultural and ecological settings.

    Methods Cross-sectional surveys were implemented in 8127 households across 28 sites in 23 low-income and middle-income countries. Data collected included 34 items on water insecurity in the prior month; socio-demographics; water acquisition, use and storage; household food insecurity and perceived stress. We retained water insecurity items that were salient and applicable across all sites. We used classical test and item response theories to assess dimensionality, reliability and equivalence. Construct validity was assessed for both individual and pooled sites using random coefficient models.

    Findings Twelve items about experiences of household water insecurity were retained. Items showed unidimensionality in factor analyses and were reliable (Cronbach’s alpha 0.84 to 0.93). The average non-invariance rate was 0.03% (threshold <25%), indicating equivalence of measurement and meaning across sites. Predictive, convergent and discriminant validity were also established.

    Conclusions The HWISE Scale measures universal experiences of household water insecurity across low-income and middle-income countries. Its development ushers in the ability to quantify the prevalence, causes and consequences of household water insecurity, and can contribute an evidence base for clinical, public health and policy recommendations regarding water.

    • anthropology
    • cross-cultural
    • food insecurity
    • household water insecurity
    • scale development
    • scale validation

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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    • Handling editor Kerry Scott

    • Twitter @@profserayoung, @@Gboaten2015, @@Z_Jamaluddine, @@joshdoesscience, @@ShaleanCollins, @@AWutich, @@ProfessorJepson

    • Collaborators HWISE Research Coordination Network: Ellis Adams; Farooq Ahmed; Mallika Alexander; Mobolanle Balogun; Michael Boivin; Alexandra Brewis; Genny Carrillo; Kelly Chapman; Stroma Cole; Hassan Eini-Zinab; Jorge Escobar-Vargas; Matthew C. Freeman; Asiki Gershim; Hala Ghattas; Ashley Hagaman; Nicola Hawley; Divya Krishnakumar; Kenneth Maes; Jyoti Mathad; Jonathan Maupin; Hugo Melgar-Quiñonez; Javier Moran; Monet Niesluchowski; Nasrin Omidvar; Patrick Mbullo Owour; Amber Pearson; Asher Rosinger; Luisa Samayoa-Figueroa; E. Cuauhtemoc Sánchez-Rodriguez; Jader Santos; Marianne V. Santoso; Roseanne Schuster; Sonali Srivastava; Chad Staddon; Andrea Sullivan; Yihenew Tesfaye; Nathaly Triviño-León; Alex Trowell; Desire Tshala-Katumbay; Raymond Tutu; Felipe Uribe-Salas; and Cassandra Workman.

    • Contributors SLY, GOB, TBN, AW and WEJ designed the study. SLY, ZJ, JDM, SMC, AW, WEJ, JS and HWISE RCN members collected data. SLY, GOB, ZJ, JDM, EAF, TBN and JS analysed and interpreted the data. SLY, GOB, ZJ, JDM, EAF, TBN, SMC, AW, WEJ and JS drafted the article. All authors critically reviewed and approved the final draft of the manuscript.

    • Funding This project was funded with the Competitive Research Grants to Develop Innovative Methods and Metrics for Agriculture and Nutrition Actions (IMMANA). IMMANA is funded with UK Aid from the UK government. This project was also supported by the Buffett Institute for Global Studies and the Center for Water Research at Northwestern 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 Miami; the National Institutes of Health grant NIEHS/FIC R01ES019841 for the Kahemba Study, DRC. We also acknowledge the National Science Foundation's HWISE Research Coordination Network (BCS-1759972) for support of the collaboration. SLY was supported by the National Institutes of Health (NIMH R21 MH108444; NIMH K01 MH098902). WEJ was supported by the National Science Foundation (BCS-1560962). Funders of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. Authors had full access to all study data and had final responsibility for the decision to submit for publication.

    • Map disclaimer The depiction of boundaries on the map(s) in this article does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval Study activities received necessary ethical approvals from institutional review bodies relevant to each site.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon reasonable request.