A Novel Tool for the Assessment of Household Water Insecurity: Scale development and Validation in Western Kenya

Household food insecurity is a powerful predictor of a range of poor nutrition and health outcomes. Household water insecurity (HHWI), the inability to reliably access water in sufficient quantity and quality, may be similarly predictive of adverse health outcomes. Yet the role of HHWI in health outcomes of women and young children has received little attention. The absence of appropriate and validated scales for assessing HHWI is one important reason for this gap. Therefore, the objectives of this study were to develop and validate a novel tool to measure HHWI in such a population. Data were drawn from a longitudinal cohort study of postpartum women of mixed HIV status in western Kenya (n=243). In the first phase, Photovoice (a participatory photo elicitation method), Go‐Along interviews (accompanied in‐depth interviews), and the Delphi Method (online and in‐person iterative process of consensus building) were used to develop a list of 29 potential HHWI scale items ( Table 1). The questions were administered at 15 and 18 months postpartum. Analyses were performed in Stata and Mplus. Item retention was determined using inter‐item correlation, item‐total correlation, and estimated residual variances. To determine the number of factors to retain, we employed exploratory factor analysis (EFA), parallel analysis, and scree plots. Next, we performed confirmatory factor analysis (CFA) and created unidimensional and bifactor models to establish the number of dimensions. Reliability was assessed using a test of internal consistency (Cronbach's α) and test‐retest reliability at 15 and 18 months. Scale validity was assessed through convergent, discriminant and predictive tests of associations with scale items, e.g. amount of money spent on water, amount of water used by household, maternal stress (Perceived Stress Scale) and food insecurity (Individual Food Insecurity Access Scale). Twenty of the 29 items were retained ( Table 1). EFA and parallel analysis extracted two factors consisting of 17 and 3 items respectively. CFA models suggested a unidimensional model was more robust than considering two factors separately. The test of internal consistency produced a Cronbach's alpha of 0.97. Our test‐retest reliability produced a significant correlation coefficient ( r =0.46, p≤0.001; 95% CI: 0.33–0.57). Convergent validity was indicated by a positive correlation between HHWI and amount of money spent on water ( r =0.18, p≤0.01; 95% CI: 0.06–0.30). Discriminant validity was indicated by a negative correlation between HHWI and amount of water used by household ( r =−0.24. p>0.05; 95% CI, −0.54–0.11). Predictive validity was revealed with statistically significant associations between HHWI and perceived stress (β=0.085; 95% CI: 0.05–0.12) as well as between HHWI and food insecurity (β=0.13; 95% CI: 0.09–0.18). In sum, this 20‐item scale is valid and reliable in this population. Future research should explore (1) the sequelae of HHWI (e.g. the physical, mental, economic, social and nutritional consequences) and (2) develop a cross‐culturally valid HHWI scale Support or Funding Information Supported by NIH‐NIMH K01 MH098902; R2|MH|108444 1 Initial and Final Household Water Insecurity Scale Items for use among postpartum women of mixed HIV status in western KenyaInitial Items Final items * HHWI Scale ItemsX F1 1) In the last 4 weeks, how frequently did you WORRY you would not have enough water for all of your household needs? X 2) In the last 4 weeks, how frequently have you lacked money needed to buy water? X F1 3) In the last 4 weeks, how frequently did you feel angry or frustrated that you would not have enough water for all of your household needs? X 4) In the last 4 weeks, how frequently have you thought of leaving (name of town) because there was no water there? X F1 5) In the last 4 weeks, how frequently have you worried about the safety of the person getting water for your household? By getting, I mean: traveling to, drawing the water, and returning with the water. X 6) In the last 4 weeks, how frequently has the household not had enough water for your garden/shamba or crops?X 7) In the last 4 weeks, how frequently has there not been enough water to give to your animals and poultry ? X F1 8) In the last 4 weeks, how frequently has the time spent fetching water prevented anyone in your household from earning money ? X F1 9) In the last 4 weeks, how frequently has the time spent fetching water prevented you or anyone in your household from caring for your children ? X 10) In the last 4 weeks, how frequently has the time spent fetching water prevented anyone in your household from doing household chores (such as cooking, preparing food, washing clothes, etc.)? X 11) In the last 4 weeks, how frequently did the children in your household miss school because they were collecting water ? X F1 12) In the last 4 weeks, how frequently has anyone in your household asked to borrow water from other people? X 13) In the last 4 weeks, how frequently have you loaned water to anyone? X F1 14) In the last 4 weeks, how frequently has there not been enough water in the household to wash clothes ? X F1 15) In the last 4 weeks, how frequently have you missed meetings in your community (church, funerals, community meetings, etc.) because there wasn't enough water? X F1 16) In the last 4 weeks, how frequently have you missed meetings in your community (church, funerals, community meetings, etc.) because you lacked water to take a bath and you felt too dirty to go ? X F1 17) In the last 4 weeks, how frequently have you or anyone in your household had to change what was being cooked because there wasn't enough water? X F2 18) In the last 4 weeks, how frequently have you or anyone in your household had to go without washing hands after defecating, changing diapers or other dirty activities because you didn't have enough water? X F1 19) In the last 4 weeks, how frequently have you not had enough water to wash your children's face and hands ? X F1 20) In the last 4 weeks, how frequently have you or anyone in your household had to go without washing their body because there wasn't enough water? X F2 21) In the last 4 weeks, how frequently did you want to treat your water , but couldn't? By treat, I mean boiling, using chemicals to treat, or other ways you make your water safe to use or drink. X F2 22) In the last 4 weeks, how frequently have you or anyone in your household actually had to drink water that you thought was unsafe? X F1 23) In the last 4 weeks, how frequently did you have problems with water that caused arguments/trouble with neighbors or others in the community? X 24) In the last 4 weeks, how frequently did you have problems with water that caused arguments/trouble with people within your household ? X F1 25) In the last 4 weeks, how frequently has there not been as much water lo drink as you would like for you or members of your household? X F1 26) In the last 4 weeks, how frequently have you or anyone in your household not had enough water to take medications ? X 27) In the last 4 weeks, how frequently have you not collected water where you wanted to because you were too sick or weak to collect water? X F1 28) In the last 4 weeks, how frequently have you or anyone in your household gone to sleep thirsty ? X F1 29) In the last 4 weeks, how frequently have you had no water whatsoever in your household?Notes: F1=Scale factor 1; F2=Scale factor 2