The effects of household water insecurity on child health and well-being
Steven J. Rhue and Giulia Torrico contributed equally to this study.
Abstract
We extend the conceptualization of the social and health burdens of household water insecurity on children beyond the traditional narrow lens of microbiological pathogens and diarrhea. The global burden of disease associated with water insecurity has traditionally focused on diarrheal disease as the most significant driver of infant and child mortality. However, there are many other pathways through which children experience adverse health and social consequences from inadequate or unsafe household water. We synthesize evidence of a broad range of health impacts, affecting children from infancy to late adolescence, across four domains: exposure to unsafe water; interruptions to growth and development through poor nutrition and hydration; negative social effects such as school absenteeism and interpersonal violence; and other non-communicable health issues such as mental health, injuries, and reproductive health. The growing burden and urgency of these issues is implicated by forecasted increases in climate- and conflict-induced water scarcity, human displacement, and environmental contamination in the decades ahead.
This article is categorized under:
- Engineering Water > Water, Health, and Sanitation
- Human Water > Rights to Water
Graphical Abstract
Boys filling jerrycans in Pemba, Mozambique (photo credit: Alexandra Brewis).
1 INTRODUCTION
The global crisis of water insecurity continues to threaten human health and wellbeing and erode progress toward ensuring the United Nations' goal of clean water and sanitation for all by 2030 (United Nations, 2021; World Economic Forum, 2019). Over one billion people experience conditions of high or extremely high water vulnerability due to the inequitable distribution and management of water resources, increased water consumption related to population growth and economic development, and intensifying climate change which has led to increased human conflict and migration (UNESCO, 2019; UNICEF, 2021b). This burden includes 450 million children—1 in 5 worldwide—who face insufficient water to fulfill their everyday needs (UNICEF, 2021a).
Water, sanitation, and hygiene (WASH) interventions aiming to mitigate the impact of water-related diseases are fundamental to improving child health (Fink et al., 2011). Because over 700 children die every day from preventable diarrhea related to insufficient water, sanitation, and hygiene (WASH) (UNICEF, 2020), the existing literature has primarily focused on quantifying the morbidity and mortality associated with waterborne illness and diarrhea among children (e.g., Apanga et al., 2021; Kemajou, 2022; Prüss-Ustün et al., 2019). Yet mortality associated with reported diarrheal diseases accounted for 297,000 diarrheal deaths globally in 2016, which was <6% of all deaths in this age group (Prüss-Ustün et al., 2019). These statistics are likely to be a gross underestimate of water insecurity's total burden on child health and well-being because inadequate water compromises children's health and wellbeing via numerous, often intersecting, pathways beyond diarrheal disease. These pathways include other infectious diseases, non-communicable health issues, and social consequences of households struggling to obtain and manage household water—all issues that water insecure households regularly endure around the world (Smiley & Stoler, 2020; Venkataramanan, Collins, et al., 2020).
Unfortunately, children's experiences with water access, availability, and reliability are too often subsumed into household-level experiences or those of their parents, so we know much less about child-specific pathways (Rhue, 2021). Because few WASH interventions are designed for children—and those that do tend to focus on mitigating diarrheal diseases—interventions potentially miss other key elements of water insecurity that might more broadly support improved child health. The general importance of early interventions to improve child health is already widely appreciated (Mercy & Saul, 2009). Development efforts might therefore improve WASH interventions by tailoring certain components to support children at various life stages (e.g., infant, youth, teenager). This would require a more complete understanding of how children are affected by water insecurity through disaggregating children's experiences from those of their household, parents, or caregivers. But first we need to assess the full breadth of how water insecurity can affect child health.
This review synthesizes the interdisciplinary literature that describes the impacts of water insecurity on child health and well-being. Recognizing that water insecurity affects children through many direct and indirect pathways, we categorized child health outcomes into four broad categories summarized in Table 1. First, we describe the impact of water insecurity on exposure to unsafe water beyond gastrointestinal infections. This encompasses vector-borne and water-washed neglected tropical diseases, issues related to gut health and the microbiome, and exposure to chemical pollutants and toxicants. Second, we summarize evidence demonstrating how water insecurity can interrupt child growth and development through malnutrition and dehydration. Third, we synthesize literature illustrating various negative social effects on children related to missed education, intra-household resource insecurity dynamics, children's play, and violence. Finally, our fourth category summarizes evidence regarding other non-communicable health impacts of water insecurity on children related to mental health, injuries, and sexual and reproductive health. We hope this review serves as an input toward several objectives in the development community: (1) improving recognition of water insecurity's fundamental role for many aspects of child health, (2) envisioning and encouraging new ways to monitor and evaluate the effects of water and integrated WASH interventions on children, and (3) supporting initiatives, policies, and legislation that guarantee all children the right to water.
| Category | Pathway | Child health outcomes | Key references |
|---|---|---|---|
| Exposure to unsafe water | Limited water quantity for bathing, or ingesting, bathing, or contacting low-quality water. | Higher risk of water-washed (e.g., Buruli ulcer), water-based (e.g., schistosomiasis), and vector-borne (e.g., dengue fever) neglected tropical diseases, with concomitant increases in adverse mental health and disabilities. | Verhagen & de Groot, 2014 Knopp et al., 2013 Debacker et al., 2006 |
| Changes to the microbiome due to insufficient or low-quality water. | Adverse effects on the gut microbiota, with potential consequences for disease progression and immune function. | Piperata et al., 2020 The et al., 2018 Pop et al., 2014 |
|
| Ingestion or contact with chemically polluted water (or via breastmilk). | Developmental effects including birth defects, endocrine disruption, neurobehavioral disorders, cancers, and higher risk of asthma, obesity, diabetes, and other non-communicable health issues. | Anderko & Pennea, 2020 Pajewska-Szmyt et al., 2019 Daum et al., 2017 Meeker, 2012 |
|
| Interruptions to growth and development | Limitations on food diversity and preparation, maternal malnutrition that limited breast milk production. | Malnutrition and subsequent effects on physical and cognitive development. | Schuster et al., 2019 Collins et al., 2019 Rosinger, 2015 |
| Dehydration from insufficient water availability. | Physical limitations, reduced cognitive development, reduced heat coping strategies, increased sugary beverage consumption. | Bethancourt et al., 2021 Rosinger, 2018 |
|
| Negative social effects | School absenteeism related to water fetching or water-related chores. | Reduced health literacy, hand hygiene, nutritional outcomes. | Chard et al., 2019 Dreibelbis et al., 2013 |
| Intrahousehold buffering of risks by adult caretakers and child agency. | Disproportionate allocation of scarce food and water resources to children, often reproducing gender disparities, with consequences for growth and development. | Maxfield, 2020 Thompson et al., 2011 Barrameda, 2009 |
|
| Play in polluted or dangerous spaces, or limitations on children's play. | Adverse health effects from interaction with environmental health hazards such as toxic soils and water bodies, or adverse social and cognitive development from limitations on play due to perceived environmental risks. | Kamya et al., 2021 Eichelberger, 2018 Asaba et al., 2013 Gazzinelli et al., 2008 |
|
| Interpersonal violence from water-related conflict and anxiety. | Increased physical, emotional, and sexual abuse. | Pommells et al., 2018 Sommer et al., 2015 |
|
| Other non-communicable health issues | Water-related material deprivation, shame, anxiety about water quality, loss of connection to culturally meaningful water sources, lost school/social opportunities and low autonomy, increased interpersonal conflict, feelings of injustice, or compounded effects from other resource insecurities. | Higher rates of mental health conditions such as depression, anxiety, and post-traumatic stress disorder. | Ahmed et al., 2021 Wutich et al., 2020 Rizkalla et al., 2020 Mushavi et al., 2020 |
| Physical strain of water fetching over long distances and dangerous terrain. | Increased probability of injuries, accidental death, disabilities due to falls, musculoskeletal pain, difficulty breathing, fatigue, animal attacks, or drowning. | Asaba et al., 2013 Geere et al., 2010 |
|
| Insufficient hydration, sanitation, and hygiene that affects puberty, menstruation, and reproductive health. | Implications for girls' reproductive health (e.g., infections), safety, risk of sexual harassment, and physical and emotional well-being. | Yaliwal et al., 2020 Kayser et al., 2019 Kaur et al., 2018 |
2 METHODOLOGY
Our review began with a broad assessment of the literatures on water insecurity and child health and well-being. We define water insecurity as the inability to access and benefit from affordable, adequate, reliable, and safe water for well-being and a healthy life (Jepson et al., 2017). Given the dispersed and often incidental nature of insights about children's water insecurity experiences throughout these literatures, we conducted a narrative review, which is an unsystematic, but comprehensive, narrative synthesis of previously published literature (Green et al., 2006). Narrative reviews offer a more iterative and reflective approach to synthesizing information, allowing for greater flexibility and exploration of the literature. Keyword searches are less restricted, permiting a broader seach; the integration of relevant literature outside the primary research focus is simplified; and new literature can be identified and included at any point in the process (Pautasso, 2019).
Because we aimed to collate the literature and organize empirical findings across multiple child health issues rather than one specific well-defined outcome, the narrower approach of a systematic review was not appropriate. Additionaly, narrative reviews are particularly useful for framing future research, devising interventions (Ferrari, 2015), and synthesizing diverse bodies of information into more accessible formats (Green et al., 2006).
We used EBSCOhost, Scopus, PubMed, and Google Scholar to identify studies using a targeted set of keyword searches using the term water in combination with social and health theme keywords commonly associated with water insecurity (e.g., pollution, school, violence, hydration, anxiety) and life stage keywords (e.g., perinatal, infant, baby/babies, child/children, youth, adolescent, teenager). We then traced references and applied our professional knowledge of the water literature to branch out and identify related studies. We began in September 2021 and iteratively updated our literature review through March 2022. In-utero effects of water insecurity were considered beyond the scope of this review because they have different pathways (e.g., Cassidy-Bushrow et al., 2017; Currie et al., 2013; Rosinger, 2020) and are generally mediated via the experiences and biology of pregnant mothers (Gluckman et al., 2008). This review focuses on direct exposures and experiences of children beginning in infancy.
3 RESULTS
3.1 Exposure to unsafe water
3.1.1 Connections to neglected tropical diseases
Infectious diarrheal diseases related to water have been the primary focus of the literature on water insecurity's impact on children (e.g., Goddard et al., 2020; Wolf et al., 2022). Despite this focus, several of these diseases are considered neglected tropical diseases (NTDs) as a result of inadequate research interest and funding. Using the Bradley Classification of water-related illnesses, NTDs tend to fall into two categories: vector-borne diseases and water-washed diseases related to hygiene (Bartram & Hunter, 2015). NTDs are parasitic, viral, and bacterial diseases that disproportionately affect children globally. Control and management of NTDs are dependent upon improving water security to minimize vector breeding and to prevent exposure through bathing, irrigating crops, household chores, or contact with contaminated recreational water bodies (CDC, 2022).
Indeed, when water security is poor, children in particular, are at high risk of contracting several water-related NTDs, which can have immediate effects (e.g., skin rashes), and also lead to severe chronic disease (e.g., blindness, cancer) and disability. For example, Buruli ulcer is believed to result from the introduction of Mycobacterium ulcerans into the skin by an insect bite or open wound (Merritt et al., 2010) and disproportionately affects children under the age of 15 (Debacker et al., 2006). Buruli ulcer is associated with poor wound hygiene, which is exacerbated by water insecurity. Lesions can necrotize, leading to extensive damage to soft-tissue and bone, which can result in limb amputation.
Another example is the water-based disease schistosomiasis, which has an estimated prevalence of over 140 million cases globally (Deol et al., 2019). Schistosomiasis is an infection by parasitic worms found in freshwater bodies and, if left untreated, can lead to an enlarged liver or bladder cancer. Children are typically exposed to infected water through a range of pathways including bathing, swimming, fishing, or sourcing irrigation water, and acute or chronic infection is believed to adversely affect physical fitness, cognition and nutritional disorders (Knopp et al., 2013). Schistosomiasis' exposure pathways can be driven by water insecurity at the household-level, which can lead children to interact with unsafe water sources, or at the community-level, which can lead to dams and other water infrastructure that ecologically support the parasite's life cycle in new freshwater bodies (Sokolow et al., 2017). While school-aged children are often targeted in surveillance and treatment efforts for schistosomiasis, preschool aged children may be an important and overlooked population (Faust et al., 2020).
Dengue fever and Chikungunya, both listed by the WHO as NTDs, are exacerbated by unsafe water storage in water-stressed communities which provides breeding grounds for the primary mosquito vector, Aedes aegypti. Dengue fever is more common globally, with most cases occurring in children under 15 years of age, and with symptoms ranging from mild disease to haemorrhagic fever and dengue shock syndrome (Verhagen & de Groot, 2014). Zika virus, also transmitted by the Aedes mosquito, is shaped by the same risk factors and presents several serious and potentially long-term effects such as microcephaly and poor gross motor and communication function (Cicuto Ferreira Rocha et al., 2017). Zika is also associated with increased rates of pneumonia and urinary tract infections, as well as an 11-fold increase in mortality risk (Pereira et al., 2020).
NTDs are not only a result of water insecurity, but are comorbid with adverse mental health, developmental and psychosocial outcomes, with childhood infections producing immediate and often lifelong repercussions (Bailey et al., 2019; Pires et al., 2019; Stienstra et al., 2002). NTDs are amplified by—and consequently amplify—poverty in both high- and low-income regions (Hotez, 2014). Therefore, there have been recent calls for increased attention to epidemiologically assess the psychological sequelae of infectious disease infections including NTDs (Tucci et al., 2017). Children represent 34% of the 20 million disability adjusted life years (DALYs) resulting from NTDs, but only 17% of clinical trials (Rees et al., 2019). In particular, leishmaniasis and dengue fever stand out as water-related NTDs that require additional focus on the pathways that affect children (Rees et al., 2019).
The lasting burden of these diseases through child disability is often not included in cost-effective analyses of WASH interventions. These diseases and concomitant sequelae shape educational attainment and employment opportunities (Ochola et al., 2021). These costs are enormous; for example, the WHO estimates that universal basic WASH access would recoup billions of school days missed by children due to diarrhea (Hutton et al., 2007), and the potential reduction in school absenteeism due to averted NTDs is likely similar. Taken together, this evidence suggests that the long-term health and life opportunity costs of water-related NTDs are of global significance, yet routinely under-appreciated.
3.1.2 The microbiome
A rapidly growing body of literature demonstrates that the microbial communities that make up the myriad human microbiomes have implications for human health across the lifespan and recent work suggests that water deserves more attention in this research domain (Piperata et al., 2020; Vanhaecke et al., 2022). While this body of work is not focused on children, it does identify several pathways by which water may influence children's microbiomes, especially the microbial community in the gut. One pathway is via the physical properties of water including pH, solute, and mineral composition. Barnett and Gibson (2019), in a review of water treatment in experimental animal rearing facilities, argue that water acidification (i.e., lower pH) should be considered for its effects on gut health. One study demonstrated that water pH altered the composition of the gut microbiome of mice pups, with consequences for disease progression and immune function (Wolf et al., 2014). With respect to solutes, a study of monozygotic twins living in different households and with different water sources found that higher sodium intake from water was associated with a decrease in the species richness (a measure of diversity) of the gut microbial community (Bowyer et al., 2020). In a comparative study of US and UK households, the drinking water source (i.e., well, bottled, tap, filtered) explained a significant amount of the variation in gut microbial species diversity and composition (Vanhaecke et al., 2022). They also found compositional differences in the gut microbial species between those with high versus low daily water consumption, as measured using the Bray–Curtis Dissimilarity Index. The clinical significance of the difference is unclear. However, the authors found that high water drinkers had a lower abundance of the Campylobacter genus, which is a known cause of gastrointestinal infection. Similarly, Jha et al. (2018), in their cross-sectional study of Himalayan communities living along a gradient of agricultural dependence, found water to be a significant predictor of variation in the gut microbiome between groups. The presence of residual chlorine and other disinfecting products are also likely to influence human microbiomes and, thus, deserve further attention (Vanhaecke et al., 2022).
The microbial communities in water serve as a second pathway by which water can affect human microbiomes, including those of children. These include intrinsic microbial communities, that is, those inherent to the water source, extrinsic microbes, including pathogens, that survive in water and use it as a physical vector for transmission between hosts, and antibacterial resistant genes introduced into drinking water sources through effluent. Most research in this area has focused on waterborne enteric pathogens, especially those known to cause diarrhea. Among children, studies have considered the relationship between a diarrhea episode, which, in some cases, was associated with an enteric pathogen infection, and changes in the gut microbiota (Becker-Dreps et al., 2015; Pop et al., 2014; Solano-Aguilar et al., 2013; Subramanian et al., 2014; The et al., 2018).
Diarrhea significantly disrupts the microbial community of the gut. In a large study of West African children, the gut microbiota of those with moderate–severe diarrhea were less diverse than those of diarrhea-free controls (Pop et al., 2014). These diarrheal-induced disruptions to children's gut microbiome can be long-lasting; in a Nicaraguan study, there was no increase in phylogenetic diversity or species richness in the gut microbiota, even 2 months post recovery from a diarrhea episode (Becker-Dreps et al., 2015). Even in the absence of diarrhea, waterborne pathogen exposure has been associated with the diversity and composition of children's gut microbiomes. For example, the gut microbiota of children from households with high coliform levels in their stored drinking water, a practice common under conditions of water insecurity, were compositionally different and less diverse than those from low coliform homes (Piperata et al., 2020). The diversity and composition of the gut microbiome in children is important because it could play a pivotal role in metabolism, immune function, and mental health into adulthood.
3.1.3 Chemical pollutants and toxicants
Many children are exposed to inorganic and organic chemicals through water, both directly through ingestion and indirectly through bathing, recreation and other water-related environmental exposure pathways. Inorganic chemicals include arsenic, fluoride, and heavy metals. Organic chemicals include pesticides, industrial chemicals, persistent organic pollutants, and emerging contaminants such as pharmaceuticals and surfactants. Exposures during critical early-life phases can have long-lasting effects, including endocrine disruption (Meeker, 2012), neurodevelopmental impacts (Jurewicz et al., 2013), neurobehavioral disorders, pediatric and adult cancers, obesity, diabetes, hypertension, asthma, reproductive disorders, cardiovascular disease among others (Kearns, 2020; Kearns et al., 2019). Chemical risk is complicated by their differential impacts across developmental stages (Makri et al., 2004).
Exposure occurs in a wide variety of settings. For example, we are increasingly seeing the child health effects of drinking water contaminated with modern chemicals such as per-and polyfluoroalkyl substances (PFAS) (Anderko & Pennea, 2020). Nitrates in drinking water, typically from agricultural runoff, have been associated with type 1 diabetes, high blood pressure, acute respiratory tract infections, thyroid disease, and methemoglobinemia (Ward et al., 2018). In nations that process electronic waste with inadequate environmental safeguards, infants and children are exposed to e-waste toxins through air, dust, food, breastmilk, and water (Daum et al., 2017).
These exposures pose greater risks to infants and children due to their rapid growth and development (Sly & Carpenter, 2012). For example, infants and young children eat and drink more per body weight than adults (Meeker, 2012) increasing their exposure. Chemical toxins have been shown to cross the placenta (Bové et al., 2019) and can be introduced to infants via breast milk (Pajewska-Szmyt et al., 2019; Winans et al., 2011). Given breast milk's importance in infants' physical and cognitive development, chemicals in breast milk can have severe consequences for immune system development and inflammation response in newborns and young children (Pajewska-Szmyt et al., 2019).
3.2 Interruptions to growth and development
3.2.1 Nutrition
Water insecurity is particularly deleterious during the first 2 years of life with important implications for infant growth and development. For example, lactation intensifies the need for water in order to matain hygine and breast milk production, Water insecurity affects breast milk production via insufficient food, stress and anxiety, and longer inter-bout intervals, which further limit milk supply (Schuster et al., 2020). Insufficient water may also adversely affect breastfeeding self-efficacy as evinced by Bolivian women who expressed an association between hydration and breast milk production (Rosinger, 2015). Additionally, women may find themselves uable to wash their breasts before breastfeeding (Collins et al., 2019). The opportunity cost of water fetching can also reduce time dedicated to infant care, including delaying breastfeeding or otherwise disrupting feeding schedules (Collins et al., 2019; Schuster et al., 2019). Lower rates of exclusive breastfeeding, in turn, can increase the likelihood of child diarrhea (Apanga et al., 2021).
Even after children have weaned, breast milk—which is insufficient to meet infants' nutritional needs after the first 6 months of life (WHO/UNICEF, 2003)—has been used as a substitute when complementary foods could not be prepared due to insufficient or unclean water (Schuster et al., 2019). In one study among a nationally representative sample of households in India, suboptimal water access resulted in a failure to meet child minimum dietary diversity scores (Choudhary, Schuster, et al., 2020). Water insecurity thus can continue to affect nutritional quality for children by reducing the quality, quantity, and diversity of complementary foods. For example, caregivers may be forced to rely on poor quality water to prepare foods, unable to wash dirty foods before serving them, rely on less water-intensive foods that have lower nutritional value, or skip meals altogether (Collins et al., 2019; Schuster et al., 2020). Water insecurity thus has important nutritional implications for infants and children that often operate indirectly through physical, psychosocial, and hygienic challenges experienced by their mother or caretaker, and often intersecting with other resource scarcities.
3.2.2 Dehydration
Extreme dehydration and thirst detrimentally affect children's health, as well as impact water coping strategies. Children—especially younger children—are one of the most vulnerable groups to extreme heat and dehydration due to higher body water volume and higher body surface area to mass along with lower sweat rates and acclimatization to heat which allows for greater insensible water loss to occur (Bytomski & Squire, 2003; Suh & Kavouras, 2019). Anecdotes across several studies examine coping strategies in response to water insecurity (Achore et al., 2020). In the absence of safe drinking water, US children and young adults have resorted to sugar-sweetened beverages as alternatives (Rosinger et al., 2019).
Only two studies empirically tested how water insecurity (assessed via parental report) and ambient temperature were associated with dehydration. In the first study, which took place in the hot-humid Bolivian Amazon following a historic flood, children whose parents had a medium and/or high water insecurity were associated with 7–14 times higher odds of dehydration among children compared with children whose parents had low water insecurity. Each additional degree C above ambient temperature was associated with 43% higher odds of dehydration (Rosinger, 2018). In that study, one of the most salient items of the locally adapted water insecurity scale was that parents worried the water would make their kids sick, potentially related to parental worry regarding the water quality.
The second study examining heat and water insecurity on hydration status was a cross-cultural comparison between children in the Bolivian Amazon and semi-nomadic pastoralists in Northern Kenya. The authors found that each point increase in household water insecurity score was positively—though not statistically significantly—associated with higher odds of dehydration in both the Bolivian Amazon and the hot-arid environment of northern Kenya. Further, each 2°C increase was associated with 23% higher odds of dehydration among Tsimane' children even when controlling for the water insecurity score (Bethancourt et al., 2021). Thus, while current research offers mixed evidence that water insecurity is associated with a greater risk of dehydration, hotter temperatures were strongly associated with higher odds of dehydration for children. Overall, the combination of water insecurity and hot temperatures is likely a key health risk and vulnerability for children.
There is strong evidence that dehydration is associated with poorer cognitive performance in children and that access to water is implicated in that performance. Bar-David et al. (2005, 2009) studied the effects of dehydration on Israeli children's performance on cognitive tests. The authors found that while hydration status in the morning was not associated with test performance, poorer hydration status in the afternoon was associated with worse performance. In a follow-up randomized control study, children that received water rated themselves as less thirsty and performed better on cognitive tasks than their peers who were not offered water (Edmonds & Burford, 2009). While these studies did not measure water insecurity, it is clear that water insecurity resulting in child dehydration has implications for their cognitive performance.
3.3 Negative social effects
3.3.1 Education and school absenteeism
Water insecurity—and inadequate WASH more broadly—is known to increase school absenteeism (Cooper-Vince et al., 2017; Freeman et al., 2012), and many studies have therefore focused on WASH mitigation in schools (McMichael, 2019). School-based WASH interventions are thought to have wide-ranging effects on health literacy, hand hygiene, and nutritional outcomes (Sangalang et al., 2021). But individual and household-level factors may supersede school characteristics in determining school attendance. In a study of children aged 5 to 18, relative wealth, gender, age, distance from water source, and children's involvement in household water collection were associated with increased school absence (Dreibelbis et al., 2013). Up to age 11, there were no differences in school attendance between boys and girls. However, girls 11 years and older had a higher probability of school absence relative to boys of the same age and younger girls due to menstrual hygiene challenges (see Section 3.4.3). Similarly, Chard et al. (2019) found that expectations for children to participate in seasonal labour or household chores disrupted school attendance. Both studies identified the need to better understand and adapt WASH programs and health and education interventions to contextual drivers of key impacts and outcomes. School-based WASH interventions do not always guarantee positive health outcomes and are unfortunately prone to the same political and financial challenges that beset other development initiatives, such as variable program delivery, availability of funding, and political will (McMichael, 2019).
3.3.2 Intrahousehold buffering and child agency
The concept of biocultural buffering suggests that adults, especially mothers, can change their consumption behaviors to insulate children from the harms of household resource insecurities. That is, as household resources diminish, scarce food and water may be disproportionately diverted to children, at a possible cost to adult wellbeing (Wutich & Brewis, 2014). For example, adults may skip meals or reallocate limited available food in favor of children (Piperata et al., 2013). However, there may not always be sufficient resources to buffer child members of a household equally (Piperata & Dufour, 2021). Children's actions may also influence the reallocation of scarce resources. After measuring the diets of 51 mother–child pairs (mean child age was 9.4 years) living in food insecure Amazonian communities, Piperata et al. (2013) observed children to have direct agency over resource reallocation. Younger children cried, tugged on parent's clothing, and aggressively pleaded and begged until their mother's responded with food (see also Bernal et al., 2012; Fram et al., 2011).
Less is known about the buffering of children against water insecurity. However, the interrelated nature of food and water insecurity, and the complex interactions between them, allows for theoretical parallels to be drawn (Wutich & Brewis, 2014). For example, Maxfield (2020) traced perceived food and water adequacy in relation to intra-household allocation decisions in 200 low-income households in Jaipur, India. Male adolescents appeared more cushioned against food insecurity than females, reflecting prevailing views of their different social and economic value. In addition, female adolescents reported more severe water insecurity than their fathers, suggesting that they were not being buffered. Boys also appeared to be somewhat buffered against experiencing severe water insecurity compared with girls. The authors note that the findings may reflect gender preferences and biases around allocation rather than buffering, as actual resource allocations within the household were not directly measured.
One limit of the intra-household buffering model is that it does not necessarily account for how children may also actively manage their own food and water insecurity outside the home, including using resources that are not available to adult household members. Turkana children in Kenya have been known to make active decisions around school attendance as a means to access food through school-based feeding programs (Watkins, 2008), and children in Venezuela have been observed using multiple strategies to alleviate their food insecurity, such as seeking temporary employment, and spending personal savings to acquire food (Bernal et al., 2012). Another study in informal settlements in Mexico showed that while children similarly acquired food on their own, it did not improve their general nutritional status (Lee & Brewis, 2009). Research focused on children's extra-household management of their own water insecurity is limited, but children have been documented to rely on the water provided at schools or beg for or borrow water from other homes—options not as readily available to adults (e.g., Barrameda, 2009; Thompson et al., 2011). Whether these acts alleviate individual water insecurity or substantially improve household water insecurity status is yet to be demonstrated.
3.3.3 Children's play
Water insecurity may also undermine children's experiences of play. Play is critical to child development as children use play to explore their environment, develop relationships, foster creative problem solving, and gain cultural competence (Burriss & Tsao, 2002; Thyssen, 2003). However, play may bring them into contact with contaminated water, placing them at significant risk of exposure to pollutants and disease-causing pathogens (UNICEF, 2017). For example, Medgyesi et al. (2019) observed that children who engaged in free roaming play across multiple sites in low-income neighborhoods of Kisumu, Kenya, were at increased risk of enteric pathogen exposure via contact with contaminated soil and surface water, compared with children whose play was constrained to a single location. Additionaly, it may be all but impossible for children to avoid such hazards in water insecure environments, and caregivers may be forced to balance children's play with perceived risks to their well-being (Bartlett, 2003). In Newtok, Alaska, health concerns surrounding inadequate access to water led mothers to fear letting their children play outside (Eichelberger, 2018).
However, it can be difficult for caregivers to protect children from a contaminated environment. A child's sudden action, such as retrieving a toy or falling into a drain, is often unpreventable, and caregivers' attention may be divided among other responsibilities (Bartlett, 2003). Children may be verbally and physically reprimanded by caregivers for their purposeful or accidental play in an effort to impart the importance of avoiding unsafe water (Bartlett, 2003; Gazzinelli et al., 2008). Time spent collecting water further limits play, as children spend multiple hours traveling to and from improved/unimproved sources of water and/or wait in long queues (Nandy & Gordon, 2009; UNICEF, 2017). Yet children may also use water fetching as an opportunity to socialize and play with one another (Asaba et al., 2013; Kamya et al., 2021). Unfortunately, tensions over access to water can lead such interactions to devolve into verbal or physical altercations (Asaba et al., 2013), leaving children upset and/or injured. Overall, the dynamics and spaces of play vary greatly throughout different stages of childhood, and thus present opportunities for studying the age-related variation in exposure pathways related to water insecurity.
3.3.4 Risk of violence
Water insecure conditions place children at risk of unnecessary violence from family, peers, and strangers. Failure to collect water has been associated with experiences of violence perpetrated by parents (Mushavi et al., 2020; Pommells et al., 2018) as children become an outlet for the anxiety, stress, and frustration of water insecurity (Wutich, 2009). Acts of parental violence are sometimes driven by female caregiver fears of intimate partner violence, should water stores be insufficient to meet household needs (Mushavi et al., 2020; Pommells et al., 2018), establishing a pattern of intergenerational violence driven by water insecurity. Children may be at further risk of verbal, physical, and sexual violence from peers and adults while collecting water (Asaba et al., 2014; Kamya et al., 2021; Logie et al., 2021; Pommells et al., 2018; Sommer et al., 2015; Thompson et al., 2011). Young girls are particularly vulnerable. Several studies have indicated that, while collecting water, female children and adolescents were raped, sexually exploited, or abducted and forced into early marriage (Meyiwa et al., 2014; Pommells et al., 2018).
3.4 Other non-communicable health issues
3.4.1 Mental health
Beyond the mental health impacts of NTDs discussed above, there are at least eight proposed mechanisms for explaining the relationship between water insecurity and mental ill-health conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD) (Wutich et al., 2020). All of these mechanisms could affect children and adolescents. The first mechanism, water insecurity as a form of material deprivation, is a well-documented risk factor for mental ill-health among children (Eisenberg & Belfer, 2009). For example, there is a large literature on the experiences of refugee children, documenting how water deprivation produces trauma and related mental illnesses (Massad et al., 2017; Mollica et al., 1997; Rizkalla et al., 2020). The second is shame related to water insecurity as a form of social failure (e.g., Bisung & Elliott, 2017a). There is some qualitative data in the water insecurity literature that indicates children might experience such shame—such as the experience of attending school with unwashed clothing or bodies (Wutich & Ragsdale, 2008)—though this has not yet been explicitly linked to mental ill-health.
Third, worries over health risks due to water contamination may be linked to mental ill-health, though most evidence of this pathway is related to parents' fears about children's health and wellbeing (Bisung & Elliott, 2017b; Gaber et al., 2021; Kangmennaang et al., 2020; Tallman, 2019). There is less evidence of children experiencing such fears, but they likely do (e.g., Adams et al., 2020; Rosinger, 2018). Beyond this, children may experience health-related fear or anxiety when fetching water due to the risk of physical injuries, attacks by people or animals, or exposure to pathogens (Ahmed et al., 2021). Fourth, loss of connections to meaningful places, including bodies of water like lakes and rivers, is linked to mental ill-health. The best evidence to support this is from the large and growing literature on youth, climate change, and mental ill-health (Kameg, 2020; Majeed & Lee, 2017; Palinkas & Wong, 2020), which indicates that children can experience climate-related PTSD, anxiety, depression, sleep disorders, and substance abuse (Burke et al., 2018; Gislason et al., 2021). Climate-related displacement may also be linked to mental ill-health in children (e.g., Stoler et al., 2021).
Fifth, frustration around lost opportunities and low autonomy may explain the relationship between water insecurity and mental ill-health. Here, children commonly experience opportunity loss when they are obligated to skip school to fetch water. The literature establishes the impact of water insecurity on mothers' mental health, which negatively impacts children (Aihara et al., 2016; Bryce et al., 1989; Collins et al., 2017, 2019; Cooper-Vince et al., 2017, 2018; Mushavi et al., 2020; Schuster et al., 2020). Future research could extend these findings to study children's mental health specifically. Sixth, water insecurity is believed to affect mental health through exacerbating interpersonal conflict, such as domestic violence (see Section 3.3.4). While most of this literature has focused on women's experiences of intimate partner violence (Choudhary, Brewis, et al., 2020), children may be similarly at risk (Ahmed et al., 2021).
Seventh, experiences of institutional injustice are expected to mediate the relationship between water insecurity and mental health (Brewis et al., 2021). Relatively little is known about children's perceptions of injustice in institutions (Schües, 2016), though there is evidence that such injustices may be linked to mental ill-health in other realms (Harcourt, 2021). There is currently little evidence to support this pathway for children experiencing water insecurity as an environmental injustice. Eighth, interlocking mechanisms—including water insecurity interacting with other resource insecurities—are proposed to compound the risks of mental health for youth (Brewis et al., 2019, 2020; Maxfield, 2020; Miller et al., 2021). This is an important theorized pathway for future research.
3.4.2 Injury, accidental death, and disability
Across low- and middle-income countries (LMICs), child injuries, death, and disability associated with water insecurity are commonly related to the acquisition of water and the physical strain of fetching water over long distances and dangerous terrain (Geere et al., 2018; Venkataramanan, Collins, et al., 2020; Venkataramanan, Geere, et al., 2020). Children may slip or fall, often resulting in lower limb fractures, dislocations, and lacerations (Venkataramanan, Geere, et al., 2020), while the weight and strain of carrying water can leave children in musculoskeletal pain, cause difficulty breathing, headaches, and overall fatigue (Asaba et al., 2013; Geere et al., 2010; Kamya et al., 2021). In some circumstances water may be the heaviest load children carry (Robson et al., 2013), and prolonged water carrying is suspected to be a significant contributor to the global burden of musculoskeletal disease and long-term disability later in life (Geere et al., 2018). Injury or death may also result from traffic accidents when crossing roadways to fetch water (Robson et al., 2013; Thompson et al., 2011; Venkataramanan, Geere, et al., 2020), and children risk drowning or being swept away by flooding at bodies of water (Collins et al., 2019; Kamya et al., 2021; Robson et al., 2013; Sandford, 2017). Wild animal attacks (e.g., dogs, snakes, or crocodiles) present additional risk, and children may fear collecting water or only feel safe doing so at certain times of day (Asaba et al., 2013; Kgomotso & Swatuk, 2006; Robson et al., 2013).
3.4.3 Puberty, menstruation, and sexual and reproductive health
During puberty and periods of menstruation, adolescent girls share an increased need for water for hydration, sanitation, and hygiene (Phillips-Howard et al., 2016; Sommer et al., 2016). The lack of WASH services in households and non-household settings, such as schools, has implications for girls' health, safety, physical and emotional well-being (Kayser et al., 2019). The physiological changes experienced during puberty require proper WASH management, but inaccurate or incomplete knowledge of puberty or menstruation due to cultural norms puts vulnerable girls at a higher risk of developing vaginal infections (Kaur et al., 2018). For instance, reusable vaginal cloths need to be properly washed with soap and dried in the sun to prevent bacterial growth, yet are often dried away from sunlight to prevent them from being seen by family members; improper cleaning can lead to vaginitis, pelvic infections, and urinary tract infections (Yaliwal et al., 2020). In LMICs, non-household settings such as schools may lack basic infrastructure to ensure privacy, materials, and guidance to manage puberty and menstruation which contributes to increased harassment, decreased school attendance rates, and increased drop-out rates (Kayser et al., 2019). Girls may even feel pressured into transactional sex in order to obtain menstrual hygiene materials (Sommer et al., 2016). During menstruation, post-pubescent girls have increased daily water needs, and a lack of proper hydration can worsen menstrual cramps and discomfort. In summary, the challenges faced by girls and young women in managing menstrual hygiene exemplify the intersection of several adverse health outcomes described in this paper including infectious diseases, school attendance, gender violence, obstacles to play and social engagement, and mental health.
4 CONCLUSION
Water interventions to improve child health have typically focused on reducing child mortality and morbidity associated with microbiological pathogens and diarrheal disease. This review identified many different pathways through which improved household access to safe and adequate water may improve health and well-being outcomes across childhood. As shown in the nutrition literature, nutritional supplement (i.e., biological) interventions and social interventions produce different effects on growth and development (Prado et al., 2019). Thus, when intervention programs disproportionately focus on microbiologically oriented water quality or the general provision of water, they may miss critical opportunities to address multiple health and wellbeing outcomes by failing to consider the breath of children's water related vulnerabilities, needs, and co-existing insecurities (Bartlett, 2003; Nandy & Gordon, 2009).
Children's agency and individual coping mechanisms regarding water insecurity remain poorly understood because children's voices have largely been absent from research on water insecurity. This forces practitioners to extrapolate findings from adult experiences when targeting children in WASH interventions. The literature has also overemphasized the impacts of water scarcity, which fails to consider children's experiences in water abundant, yet water insecure, environments. Despite the ethical and practical challenges of engaging with children in research, we recommend including children's perspectives in WASH monitoring and evaluation programs. Further research in these areas has the potential to unlock new ways of improving children's lives and affirming their right to water.
AUTHOR CONTRIBUTIONS
Steven J. Rhue: Conceptualization (equal); writing – original draft (equal); writing – review and editing (equal). Giulia Torrico: Conceptualization (equal); writing – original draft (equal); writing – review and editing (equal). Chioma Amuzie: Writing – original draft (equal); writing – review and editing (equal). Shalean M. Collins: Writing – original draft (equal); writing – review and editing (equal). Andrea Lemaitre: Writing – original draft (equal); writing – review and editing (equal). Cassandra Workman: Writing – original draft (equal); writing – review and editing (equal). Asher Rosinger: Writing – original draft (equal); writing – review and editing (equal). Amber Pearson: Writing – original draft (equal); writing – review and editing (equal). Barbara Piperata: Writing – original draft (equal); writing – review and editing (equal). Amber Wutich: Funding acquisition (equal); writing – original draft (equal); writing – review and editing (equal). Alexandra Brewis: Writing – original draft (equal); writing – review and editing (equal). Justin Stoler: Conceptualization (equal); funding acquisition (equal); writing – original draft (equal); writing – review and editing (equal).
FUNDING INFORMATION
This study was supported by the Household Water Insecurity Experiences Research Coordination Network (HWISE-RCN) funded by the National Science Foundation (grant BCS-1759972).
CONFLICT OF INTEREST
The authors declare no conflict of interest.
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DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
