‘When you have no water, it means you have no peace': a mixed-methods, whole-population study of water insecurity and depression in rural Uganda
Open accessAbstract
Background Lack of access to clean water has well known implications for communicable disease risks, but the broader construct of water insecurity is little studied, and its mental health impacts are even less well understood.Methods and findings We conducted a mixed-methods, whole-population study in rural Uganda to estimate the association between water insecurity and depression symptom severity, and to identify the mechanisms underlying the observed association. The whole-population sample included 1776 adults (response rate, 91.5%). Depression symptom severity was measured using a modified 15-item Hopkins Symptom Checklist for Depression. Water insecurity was measured with a locally validated 8-item Household Water Insecurity Access Scale. We fitted multivariable linear and Poisson regression models to the data to estimate the association between water insecurity and depression symptom severity, adjusting for age, marital status, self-reported overall health, household asset wealth, and educational attainment. These models showed that water insecurity was associated with depression symptom severity (b = 0.009; 95% confidence interval [CI], 0.004-0.15) and that the estimated association was larger among men (b = 0.012; 95% CI, 0.008-0.015) than among women (b = 0.008; 95% CI, 0.004-0.012. We conducted qualitative interviews with a sub-group of 30 participants, focusing on women given their traditional role in household water procurement in the Ugandan context. Qualitative analysis, following an inductive approach, showed that water insecurity led to "choice-less-ness" and undesirable social outcomes, which in turn led to emotional distress. These pathways were amplified by gender-unequal norms.Conclusions Among men and women in rural Uganda, the association between water insecurity and depression symptom severity is statistically significant, substantive in magnitude, and robust to potential confounding. Data from the qualitative interviews provide key narratives that reveal the mechanisms through which women's lived experiences with water insecurity may lead to emotional distress.
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Lack of proper maintenance of water systems and infrastructure by authorities in most places altered water availability in ways that increased bother and distress.
“Furthermore, it appeared that the lack of proper maintenance of water systems and infrastructure by authorities in most places altered water availability in ways that increased bother and distress (Khatri and Vairavamoorthy, 2007; Mushavi et al., 2020; Pearson et al., 2015; Pamla et al., 2021).”
From Psychological effects of water scarcity on community members: a case study of Lephalale municipality, Limpopo province, South Africa (2025) · cites this paper as Mushavi et al., 2020
The Results (Qualitative findings; page not available) say that maintenance failures, such as broken borehole pumps, altered water availability and increased bother. The Results (Conceptual framework; page not available) link water insecurity to emotional distress. The paper does not attribute the failures to authorities or establish that they occurred in most places. (LLM, conf=0.87)
Experimental — accuracy not yet measuredPrior studies found that community members experience increased bother and emotional distress due to altered water availability, water shortages and insecurity.
“Prior studies (Mushavi et al., 2020; Goldin, 2010; Khodarahimi et al., 2014a; Stevenson et al., 2016) found that community members experience increased bother and emotional distress due to altered water availability, water shortages and insecurity.”
From Psychological effects of water scarcity on community members: a case study of Lephalale municipality, Limpopo province, South Africa (2025) · cites this paper as Mushavi et al., 2020
Fetching water from far water resources disrupted community members' daily activities, took over people's daily schedules, and disorganized their chores.
“Fetching water from far water resources disrupted community members' daily activities, took over people's daily schedules and disorganized their chores (Mushavi et al., 2020; Hove et al., 2019; UNICEF (United Nations Children's Fund), 2021).”
From Psychological effects of water scarcity on community members: a case study of Lephalale municipality, Limpopo province, South Africa (2025) · cites this paper as Mushavi et al., 2020
Water insecurity made it difficult for some women to maintain good hygiene, which potentially jeopardized their standing with others in the community.
“Moreover, Mushavi et al. (2020) reported that water insecurity made it difficult for some women to maintain good hygiene, which potentially jeopardized their standing with others in the community.”
From Psychological effects of water scarcity on community members: a case study of Lephalale municipality, Limpopo province, South Africa (2025) · cites this paper as Mushavi et al. (2020)
Excess water demand at public water sources frequently caused verbal and physical disputes and conflicts among people in the queue.
“Mushavi et al. (2020) further indicated that excess water demand at public water sources frequently caused verbal and physical disputes and conflicts among people in the queue.”
From Psychological effects of water scarcity on community members: a case study of Lephalale municipality, Limpopo province, South Africa (2025) · cites this paper as Mushavi et al. (2020)
In Uganda, outside of refugee contexts, water insecurity has been associated with increased risk of emotional distress, sexual violence, and missed educational opportunities.
“In Uganda, outside of refugee contexts, water insecurity has been associated with increased risk of emotional distress (Mushavi et al. 2020), sexual violence (Pommells et al. 2018), and missed educational opportunities (Cooper-Vince et al. 2017).”
From Water insecurity and sexual and gender-based violence among refugee youth: qualitative insights from a humanitarian setting in Uganda (2022) · cites this paper as Mushavi et al. 2020
Water insecurity and its impacts are amplified by gender-unequal norms.
“As water insecurity and its impacts are ampli fi ed by gender-unequal norms”
From Water insecurity and sexual and gender-based violence among refugee youth: qualitative insights from a humanitarian setting in Uganda (2022) · cites this paper as Mushavi et al. 2020
Women's collective action has led to funding, demand, construction, repair, and maintenance of water services and latrines.
“Women's collective action has led to funding, demand, construction, repair, and maintenance of water services [56, 61, 73, 78, 89, 91, 125, 129, 163, 165, 168, 169, 193, 296] and latrines [129, 139, 147, 168, 170, 174, 175].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
Inadequate water provision and collection behaviors were reported to influence intimate partner violence, including violence from husbands for not providing water for bathing, not having water in the home, going to cleaner water sources considered too far, not preparing food on time, or attending water-focused community meetings.
“Inadequate water provision and collection behaviors were reported to influence intimate partner violence [26,75,101,108,111,153,165,179,198,231,260,264,266].Women reported violence from husbands if they did not provide water for bathing needs (Kenya, [198] Ethiopia, [108] Vietnam, [111] Cameroon [231]), did not have water in the home (East Africa [179]), went to cleaner water sources considered”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
Women's and girls' bodily integrity has been constrained due to water and sanitation conditions, including limiting bathing and washing, restricting food and water, suppressing defecation and urination urges, delaying changing menstrual materials, and taking anti-diarrheal medicines when lacking sufficient, safe or clean water and sanitation.
“Specifically, women limited bathing and washing hands, clothes, menstrual materials, and bathrooms; [76,86,98,100,123,144,165,197,198,200,202,229,232,281] restricted food and water to avoid defecation and urination; [135, 168, 174, 179, 184, 192, 212, 224] suppressed defecation and urination urges; [2,62,181,184,188,190,191, 214, 217, 229, 235, 236, 238, 241, 247, 248, 250, 270] delayed changing”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
Women formed and maintained social connections when collecting water and relied on social capital from family, friends, and community members for multiple water needs; they leveraged social capital to access water when queues were long or water was scarce, jump water queues, get water from private wells, haul water using carts, receive improved home water access, wait on water deliveries, or get
“Women formed and maintained social connections when collecting water [57,78,110,115,153,279] and relied on social capital from family, friends, and community members for multiple water needs.They leveraged social capital to access water when queues were long or water was scarce, [61,110,114,164,165,179,198,279] jump water queues, [168, 179] get water from private wells, [279] haul water using”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
Women reported spending money to access water sources with shorter wait times or higher quality, or to compensate male neighbors, laborers, or drivers for water collection; water was a major expense for many women.
“Women reported spending money to access water sources with shorter wait times [61,198] or higher quality, [98,198] or to compensate male neighbors, laborers, or drivers for water collection [165,201].Water was a major expense for many women [65,86,111,198,200,292].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
Men in Uganda who assisted with water collection were deemed emotionally unstable or bewitched.
“Men in Uganda who assisted with water collection were deemed emotionally unstable or bewitched, [165, 258]”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
When men or boys do collect water, it has been more acceptable when they consider it 'helping' women or use technology-like bicycles, wheelbarrows, or motorcycles.
“When men or boys do collect water, it has been more acceptable when they consider it 'helping' women [261] or use technology-like bicycles, wheelbarrows, or motorcycles-while women and girls are expected to carry water [123, 165, 229, 258, 261].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
Women and girls are expected to carry water.
“When men or boys do collect water, it has been more acceptable when they consider it 'helping' women [261] or use technology-like bicycles, wheelbarrows, or motorcycles-while women and girls are expected to carry water [123, 165, 229, 258, 261].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
In Bangladesh, India, and Uganda, women relied on social networks to access water.
“In Bangladesh, [110] India, [279] and Uganda [165] women relied on social networks to access water, but noted that relationships could be strained or unreliable when water was scarce.”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
In Bangladesh, India, and Uganda, relationships could be strained or unreliable when water was scarce.
“In Bangladesh, [110] India, [279] and Uganda [165] women relied on social networks to access water, but noted that relationships could be strained or unreliable when water was scarce.”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
Water collection sites could be places of tension and danger, including sexual exploitation, for women and girls in Zimbabwe and Uganda.
“Water collection sites could be places of tension and danger, including sexual exploitation, for women and girls in Zimbabwe [123] and Uganda [165,179].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [165]
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“Based on prior research findings, we expected that the psychological distress associated with water insecurity would disproportionately affect women due to gendered norms governing how women (and girls) in most countries throughout sub-Saharan Africa must shoulder the dominant burden of collecting water for the househ…”
BackgroundKufungisisa (thinking too much): a Shona idiom for non-psychotic mental illness.
Patel, V., Simunyu, E., & Gwanzura, F. (1995) · PubMed · Cited by 59 · see citing works
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Reflechi twòp—Thinking Too Much: Description of a Cultural Syndrome in Haiti’s Central Plateau
Kaiser, B. N., McLean, K. E., Kohrt, B. A., Hagaman, A. K., Wagenaar, B. H., Khoury, N. M., & Keys, H. M. (2014) · Culture Medicine and Psychiatry · doi:10.1007/s11013-014-9380-0 · Cited by 49 · cited 2× · see citing works
“recognized representation of depression both in Uganda and in other places around the world (42-46).”
BackgroundValidation of household water insecurity scale in urban Nepal
Aihara, Y., Shrestha, S., Kazama, F., & Nishida, K. (2015) · Water Policy · doi:10.2166/wp.2015.116 · Cited by 47 · cited 1× · see citing works
“Other studies have focused specifically on developing valid instruments for measuring water insecurity (10, 12, 18-20).”
BackgroundBulled, N. (2017) · Medical Anthropology Quarterly · doi:10.1111/maq.12270 · Cited by 41 · cited 1× · see citing works
“As one of the most fundamental forms of resource or material insecurity, water insecurity can produce profound psychological or emotional distress(9, 12-16).”
BackgroundIntimate partner violence and population mental health: why poverty and gender inequities matter
Tsai, A. C. (2013) · PLoS Medicine · doi:10.1371/journal.pmed.1001440 · Cited by 39 · cited 1× · see citing works
“These include factors like conflict, poverty, food insecurity, social isolation, violence and HIV stigma (3-8).”
BackgroundSelf-citationBeyond Distance and Time: Gender and the Burden of Water Collection in Rural Uganda
Asaba, R. B., Fagan, G. H., Kabonesa, C., & Mugumya, F. (2013) · Maynooth University ePrints and eTheses Archive (Maynooth University) · Cited by 37 · see citing works
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Self-citationSmith, M. L., Kakuhikire, B., Baguma, C., Rasmussen, J. D., Perkins, J. M., Cooper‐Vince, C. E., Venkataramani, A. S., Ashaba, S., Bangsberg, D. R., & Tsai, A. C. (2019) · SSM - Population Health · doi:10.1016/j.ssmph.2019.100448 · Cited by 35 · see citing works
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“For example, severe food insecurity and/or food insufficiency have been associated with mental distress in previous studies, with approximate relative risk nearing 2(48, 56).”
BackgroundTallman, P. (2016) · Social Science & Medicine (1967) · doi:10.1016/j.socscimed.2016.06.016 · Cited by 33 · cited 1× · see citing works
“Our study aims to take a biocultural approach (30) trying to understand how the social, environmental and biological lived experience in Mbarara produces emotional distress.”
BackgroundWhen water is scarce: the perception of water quality and effects on the vulnerable
Alhassan, H., & Kwakwa, P. A. (2013) · Journal of Water Sanitation and Hygiene for Development · doi:10.2166/washdev.2013.140 · Cited by 31 · cited 1× · see citing works
“Based on prior research findings, we expected that the psychological distress associated with water insecurity would disproportionately affect women due to gendered norms governing how women (and girls) in most countries throughout sub-Saharan Africa must shoulder the dominant burden of collecting water for the househ…”
Background“Thinking a Lot” Among the Khwe of South Africa: A Key Idiom of Personal and Interpersonal Distress
den Hertog, T. N., de Jong, M., van der Ham, A. J., Hinton, D. E., & Reis, R. (2015) · Culture Medicine and Psychiatry · doi:10.1007/s11013-015-9475-2 · Cited by 30 · cited 2× · see citing works
“recognized representation of depression both in Uganda and in other places around the world (42-46).”
Background
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Lawrance, E. L., Thompson, R., Newberry Le Vay, J., Page, L., & Jennings, N. (2022) · International Review of Psychiatry · doi:10.1080/09540261.2022.2128725 · Cited by 500 · see citing works
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“Water insecurity has since been linked with heightened worry, anger, frustration, and distress (19, 20, 33, 62, 110– 114) as well as increased depressive symptoms (101, 112, 113, 115, 116).”
Wutich, A., Brewis, A., & Tsai, A. C. (2020) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1461 · Cited by 193 · see citing works
“…Choudhary, & Wutich, 2019a, 2019b; Chindarkar, Chen, & Gurung, 2019; Cooper-Vince et al., 2017, 2018; Espinosa-Montero et al., 2016; Maxfield, 2020; Mushavi et al., 2020; Shrestha et al., 2018; Slekiene & Mosler, 2019; Snodgrass, Upadhyay, Debnath, & Lacy, 2016; Subbaraman et al., 2012, 2014;…”
InfluentialSelf-citationRosinger, A. Y., & Young, S. L. (2020) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1468 · Cited by 147 · see citing works
Water insecurity and gender‐based violence: A global review of the evidence
Tallman, P. S., Collins, S. M., Salmón-Mulanovich, G., Rusyidi, B., Kothadia, A., & Cole, S. (2022) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1619 · Cited by 112 · see citing works
“…2020; Chipeta, 2009; Choudhary et al., 2020; Collins et al., 2019; Epstein et al., 2020; Karim et al., 2012; Logie et al., 2021; Meyiwa et al., 2014; Mukuhlani & Nyamupingidza, 2014; Mushavi et al., 2020; Narang, 2014; Pommells et al., 2018; Shah, 2002; Sultana, 2011; Thompson et al., 2011).”
BackgroundInfluentialWater, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis
Caruso, B. A., Conrad, A., Patrick, M., Owens, A., Kviten, K., Zarella, O., Rogers, H., & Sinharoy, S. S. (2022) · PLOS Water · doi:10.1371/journal.pwat.0000026 · Cited by 94 · see citing works
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“Local modifications involved dropping 1 item (“feeling trapped”) and adding 1 item (“don’t care what happens to your health”) [42,60].”
BackgroundSelf-citationStoler, J. B., Miller, J. D., Brewis, A., Freeman, M. C., Harris, L. M., Jepson, W. E., Pearson, A. L., Rosinger, A. Y., Shah, S. H., Staddon, C., et al. (2021) · International Journal of Hygiene and Environmental Health · doi:10.1016/j.ijheh.2021.113715 · Cited by 78 · see citing works
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“Twenty-five studies were included, with 23,103 participants from 16 countries in three conti- nents: Africa (Kenya, Ethiopia, Ghana, Uganda, South Africa, Malawi, Mozambique, and Lesotho), Asia (Nepal, Bangladesh, India, and Iran) and the Americas (Brazil, Haiti, Bolivia and Vietnam).”
BackgroundInfluentialKangmennaang, J., Bisung, E., & Elliott, S. J. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17030890 · Cited by 63 · see citing works
Nunbogu, A. M., & Elliott, S. J. (2022) · Water Security · doi:10.1016/j.wasec.2022.100113 · Cited by 59 · see citing works
Connecting the dots between climate change, household water insecurity, and migration
Stoler, J. B., Brewis, A., Kangmennaang, J., Keough, S. B., Pearson, A. L., Rosinger, A. Y., Stauber, C., & Stevenson, E. G. J. (2021) · Current Opinion in Environmental Sustainability · doi:10.1016/j.cosust.2021.02.008 · Cited by 59 · see citing works
The embodiment of water insecurity: Injuries and chronic stress in lowland Bolivia
Rosinger, A. Y., Bethancourt, H. J., Young, S. L., & Schultz, A. F. (2021) · Social Science & Medicine · doi:10.1016/j.socscimed.2021.114490 · Cited by 55 · see citing works
Thinking Too Much": A Systematic Review of the Idiom of Distress in Sub-Saharan Africa
Backe, E. L., Bosire, E. N., Kim, A. W., & Mendenhall, E. (2021) · Culture, Medicine, and Psychiatry · doi:10.1007/s11013-020-09697-z · Cited by 52 · see citing works
Socio‐environmental confounders of safe water interventions
Smiley, S. L., & Stoler, J. B. (2020) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1438 · Cited by 50 · see citing works
“Psychosocial stress and anxiety have increasingly been appreciated as important individual-level components of water insecurity that shaped water seeking behavior (Collins et al., 2018; Hadley & Wutich, 2009; Mushavi et al., 2020; Workman & Ureksoy, 2017).”
BackgroundLocalizing resource insecurities: A biocultural perspective on water and wellbeing
Brewis, A., Piperata, B. A., Thompson, A. L., & Wutich, A. (2020) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1440 · Cited by 50 · see citing works
Brewis, A., Roba, K. T., Wutich, A., Manning, M., & Hassen, J. Y. (2021) · SSM - Mental Health · doi:10.1016/j.ssmmh.2021.100008 · Cited by 53 · see citing works
Ediz, Ç., & YANIK, D. (2023) · International Journal of Social Psychiatry · doi:10.1177/00207640231206060 · Cited by 54 · see citing works
“…climate-related threats and inadequate climate action has been associated with many psychological and emotional responses such as anxiety, stress distress, hopelessness, fear, anger, grief, helplessness, frustration and guilt (Ingle & Mikulewicz, 2020; Mushavi et al., 2020; Ojala et al., 2021).”
BackgroundAinamani, H., Alele, P. E., Rukundo, G. Z., Maling, S., Wakida, E. K., Obua, C., & Tsai, A. C. (2020) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2020.7 · Cited by 45 · see citing works
“Food and water insecurity are common (Tsai et al., 2012, 2016; Mushavi et al., 2020).”
BackgroundSelf-citationThe effects of household water insecurity on child health and well‐being
Rhue, S. J., Torrico, G., Amuzie, C., Collins, S. M., Lemaitre, A., Workman, C. L., Rosinger, A. Y., Pearson, A. L., Piperata, B. A., Wutich, A., et al. (2023) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1666 · Cited by 45 · see citing works
“Ahmed et al., 2021 Wutich et al., 2020 Rizkalla et al., 2020 Mushavi et al., 2020 (Continues) 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.”
BackgroundInfluentialNexus between Water Security Framework and Public Health: A Comprehensive Scientific Review
Paudel, S., Kumar, P., Dasgupta, R., Johnson, B. A., Avtar, R., Shaw, R., Mishra, B. K., & Kanbara, S. (2021) · Water · doi:10.3390/w13101365 · Cited by 40 · see citing works
Nunbogu, A. M., & Elliott, S. J. (2021) · Health & Place · doi:10.1016/j.healthplace.2021.102651 · Cited by 40 · see citing works
Re-examining the effects of drought on intimate-partner violence
Cooper, M., Sandler, A., Vitellozzi, S., Lee, Y., Seymour, G., Haile, B., & Azzarri, C. (2021) · PLoS ONE · doi:10.1371/journal.pone.0254346 · Cited by 38 · see citing works
“While these studies have primarily focused on women’s mental health, an analysis from Uganda showed that water insecurity is more strongly associated with depression in men than in women, with implications for IPV [29].”
Drought and social conflict in rural Zimbabwe: Does the burden fall on women and girls?
Chigusiwa, L., Kembo, G., & Kairiza, T. (2022) · Review of Development Economics · doi:10.1111/rode.12944 · Cited by 31 · see citing works
Sohns, A., Ford, J. D., Adamowski, J., & Robinson, B. E. (2020) · Environmental Management · doi:10.1007/s00267-020-01387-1 · Cited by 36 · see citing works
Simiyu, S. N., Bagayoko, M., & Gyasi, R. M. (2021) · Aging & Mental Health · doi:10.1080/13607863.2021.1910796 · Cited by 36 · see citing works
Shupler, M. S., Baame, M., Nix, E., Tawiah, T. A. S., Lorenzetti, F., Saah, J., de Cuevas, R. A., Sang, E., Puzzolo, E., Mangeni, J. N., et al. (2022) · SSM - Mental Health · doi:10.1016/j.ssmmh.2022.100103 · Cited by 35 · see citing works
Brewis, A., DuBois, L. Z., Wutich, A., Adams, E. A., Dickin, S., Elliott, S. J., Empinotti, V. L., Harris, L. M., Nébié, E. K. I., & Korzenevica, M. (2023) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1685 · Cited by 34 · see citing works
“In rural Uganda, Mushavi et al. (2020) found that an association between water insecurity and depression was especially strong for men.”
BackgroundAshaba, S., Cooper‐Vince, C. E., Maling, S., Satinsky, E. N., Baguma, C., Akena, D. H., Nansera, D., Bajunirwe, F., & Tsai, A. C. (2021) · Journal of Affective Disorders Reports · doi:10.1016/j.jadr.2021.100094 · Cited by 37 · see citing works
“earn a living through subsistence agriculture, animal husbandry, and local trading where challenges of food and water insecurity are common (Mushavi et al., 2020; Tsai et al., 2011; Tsai et al., 2016a).”
BackgroundSelf-citationHo, E. W., Strohmeier-Breuning, S., Rossanese, M., Charron, D., Pennise, D. M., & Graham, J. P. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph181910355 · Cited by 31 · see citing works
“Mushavi et al. (2020) [17] Uganda: 1642 adults Water Mixed methods ND Women experienced severe emotional distress when water is unavailable; the association between water insecurity and depression was greater for men than women Nauges & Strand (2013) [18] Ghana: 405 clusters of HH Water Descriptive…”
Barnwell, G., & Wood, N. (2022) · South African Journal of Psychology · doi:10.1177/00812463211073384 · Cited by 31 · see citing works
“Moreover, Mushavi et al. (2020) report stigma, humiliation, and social alienation owing to the social dimensions of water insecurity, in particular.”
BackgroundFreeman, M. C., Delea, M. G., Snyder, J. S., Garn, J. V., Belew, M. L., Caruso, B. A., Clasen, T., Sclar, G. D., Tesfaye, Y. A., Woreta, M., et al. (2022) · PLOS Global Public Health · doi:10.1371/journal.pgph.0000056 · Cited by 32 · see citing works
Water insecurity is associated with gender-based violence: A mixed-methods study in Indonesia
Cole, S., Tallman, P. S., Salmón-Mulanovich, G., & Rusyidi, B. (2023) · Social Science & Medicine · doi:10.1016/j.socscimed.2023.116507 · Cited by 27 · see citing works
O’Laughlin, K. N., Greenwald, K. E., Rahman, S. K., Faustin, Z. M., Ashaba, S., Tsai, A. C., Ware, N. C., Kambugu, A. D., & Bassett, I. V. (2020) · AIDS and Behavior · doi:10.1007/s10461-020-03102-x · Cited by 26 · see citing works
Self-citationLinking water (in)security and wellbeing in low-and middle-income countries
Kangmennaang, J., & Elliott, S. J. (2021) · Water Security · doi:10.1016/j.wasec.2021.100089 · Cited by 27 · see citing works
Thomson, P., Pearson, A. L., Kumpel, E., Guzman, D. B., Workman, C. L., Fuente, D. E., Wutich, A., Stoler, J. B., & Household Water Insecurity Experiences Research Coordination Network (HWISE-RCN) (2024) · Environmental Science & Technology · doi:10.1021/acs.est.3c08443 · Cited by 24 · see citing works
Kakuhikire, B., Satinsky, E. N., Baguma, C., Rasmussen, J. D., Perkins, J. M., Gumisiriza, P., Juliet, M., Ayebare, P., Mushavi, R. C., Burns, B., et al. (2021) · PLoS Medicine · doi:10.1371/journal.pmed.1003705 · Cited by 24 · see citing works
“Economic variables included food insecurity (categorical; 9-item Household Food Insecurity Access Scale [55,63]), water insecurity (categorical; 8-item Household Water Insecurity Access Scale [57,58]), and household asset wealth (categorical; [64,65]).”
BackgroundSelf-citationToivettula, A., Varis, O., Vahala, R., & Juvakoski, A. (2023) · Water Research · doi:10.1016/j.watres.2023.120335 · Cited by 25 · see citing works
Experiences of inequalities in access to safe water and psycho-emotional distress in Ghana
Achore, M., & Bisung, E. (2022) · Social Science & Medicine · doi:10.1016/j.socscimed.2022.114970 · Cited by 23 · see citing works
Health implications of coping with water insecurity at the household level
Azupogo, U. W., Achore, M., Dery, F., & Bisung, E. (2023) · Water Security · doi:10.1016/j.wasec.2023.100135 · Cited by 22 · see citing works
Hove, J., D’Ambruoso, L., Twine, R., Mabetha, D., van der Merwe, M., Mtungwa, I., Khoza, S., Kahn, K., & Witter, S. (2021) · Global Health Action · doi:10.1080/16549716.2021.1973715 · Cited by 22 · see citing works
“The local municipality in the Agincourt HDSS struggles to continuously supply safe water; a common phenomenon in rural municipalities across South Africa [41,42].”
BackgroundClimate and hydrological seasonal effects on household water insecurity: A systematic review
Broyles, L. M. T., Pakhtigian, E. L., Rosinger, A. Y., & Mejía, A. (2022) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1593 · Cited by 22 · see citing works
“…Eichelberger, 2010, 2018, 2019; Hailu et al., 2020; Hamlet et al., 2020; Hanrahan & Mercer, 2019; Kelly et al., 2018; Lasage et al., 2008; Mukasa et al., 2020; Mushavi et al., 2020; Nyong & Kanaroglou, 1999; Pearson et al., 2015; Stevenson et al., 2012; Tucker et al., 2014; Uzomah & Scholz, 2002).”
BackgroundMethodInfluentialAshaba, S., Zanoni, B. C., Baguma, C., Tushemereirwe, P., Nuwagaba, G., Kirabira, J., Nansera, D., Maling, S., & Tsai, A. C. (2022) · AIDS and Behavior · doi:10.1007/s10461-022-03856-6 · Cited by 22 · see citing works
Self-citationAshaba, S., Kakuhikire, B., Baguma, C., Satinsky, E. N., Perkins, J. M., Rasmussen, J. D., Cooper‐Vince, C. E., Ahereza, P., Gumisiriza, P., Kananura, J., et al. (2022) · SSM - Mental Health · doi:10.1016/j.ssmmh.2022.100062 · Cited by 21 · see citing works
Self-citationJoshi, N., Lopus, S. E., Hannah, C., Ernst, K. C., Kilungo, A. P., Opiyo, R. O., Ng’ayu, M. M., Davies, J. M., & Evans, T. P. (2022) · Social Science & Medicine · doi:10.1016/j.socscimed.2022.115191 · Cited by 21 · see citing works
Perkins, J. M., Kakuhikire, B., Baguma, C., Jurinsky, J., Rasmussen, J. D., Satinsky, E. N., Namara, E. B., Ahereza, P., Kyokunda, V., Perkins, H. W., et al. (2021) · Addiction · doi:10.1111/add.15615 · Cited by 18 · see citing works
Self-citationLogie, C. H., Newman, P. A., Admassu, Z., Mackenzie, F., Chakrapani, V., Tepjan, S., Shunmugam, M., & Akkakanjanasupar, P. (2024) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2024.27 · Cited by 20 · see citing works
“Water insecurity is associated with poorer mental health across diverse global regions (Cooper-Vince et al., 2018; Maxfield, 2020; Mushavi et al., 2020; Stoler et al., 2020; Wutich et al., 2020).”
BackgroundLogie, C. H., Okumu, M., Coelho, M., Loutet, M. G., Narasimhan, M., Lukone, S. O., Kisubi, N., Musoke, D. K., Kyambadde, P., Dorea, C., et al. (2022) · Journal of Water Sanitation and Hygiene for Development · doi:10.2166/washdev.2022.236 · Cited by 19 · see citing works
Tsai, A. C., Kakuhikire, B., Perkins, J. M., Downey, J., Baguma, C., Satinsky, E. N., Gumisiriza, P., Kananura, J., & Bangsberg, D. R. (2021) · Journal of Global Health · doi:10.7189/jogh.11.04056 · Cited by 17 · see citing works
Self-citationStoler, J. B., Guzman, D. B., & Adams, E. A. (2023) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1674 · Cited by 18 · see citing works
Nounkeu, C. D., & Dharod, J. M. (2021) · Health Care For Women International · doi:10.1080/07399332.2021.1931225 · Cited by 16 · see citing works
Apatinga, G. A., Schuster‐Wallace, C. J., & Dickson‐Anderson, S. E. (2022) · Wiley Interdisciplinary Reviews Water · doi:10.1002/wat2.1591 · Cited by 15 · see citing works
Impact of water insecurity amidst endemic and pandemic in Pakistan: Two tales unsolved
Ahmad, S., Zahra, J., Ali, M., Ali, S., Iqbal, S., Kamal, S., Tahir, M., & Aborode, A. T. (2022) · Annals of Medicine and Surgery · doi:10.1016/j.amsu.2022.104350 · Cited by 16 · see citing works
Rosinger, A. Y., Stoler, J. B., Ford, L. B., McGrosky, A., Sadhir, S., Ulrich, M., Todd, M., Bobbie, N., Nzunza, R., Braun, D. R., et al. (2024) · Social Science & Medicine · doi:10.1016/j.socscimed.2024.117280 · Cited by 16 · see citing works
Comfort, A. B., Asiimwe, S. B., Amanyire, G., Orrell, C., Moody, J. W., Musinguzi, N., Bwana, M., Bangsberg, D. R., Haberer, J. E., Tsai, A. C., et al. (2024) · SSM - Population Health · doi:10.1016/j.ssmph.2023.101593 · Cited by 15 · see citing works
“Food and water insecurity are prevalent in both settings (Mushavi et al., 2020; Perkins et al., 2018; Tsai et al., 2016).”
BackgroundSelf-citationUnlocking water sustainability: The role of knowledge, attitudes, and practices among women
Haddid, O. A., Ahmad, A. M. K., & AbedRabbo, M. (2024) · Journal of Cleaner Production · doi:10.1016/j.jclepro.2024.143697 · Cited by 14 · see citing works
Osinuga, A., Janssen, B., Fethke, N. B., Story, W. T., Imaledo, J. A., & Baker, K. K. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182111043 · Cited by 14 · see citing works
“Timely management and performance of daily domestic work responsibilities, such as manual laundry, cooking, and childcare, depended on women’s access to water, which is supported by prior research [70].”
BackgroundResultTallman, P. S., Salmón-Mulanovich, G., Archdeacon, N., Kothadia, A., Flórez, L. L., Castañeda, K., Collins, S. M., Rusyidi, B., & Cole, S. (2024) · Violence Against Women · doi:10.1177/10778012241230323 · Cited by 13 · see citing works
“Failure to meet prescribed gender roles around water collection, or water-related domestic tasks, is linked to physical and psychological intimate partner violence (Mushavi et al., 2020).”
Kisliuk, N., LaPointe, S., Young, S. L., Prencipe, L., Luchemba, P., Lukongo, T. M., & Palermo, T. (2024) · Global Public Health · doi:10.1080/17441692.2024.2409369 · Cited by 14 · see citing works
“…associated with psychosocial and psychological distress, especially among women (Mushavi et al., 2020; Stevenson et al., 2016; 2012; Stoler et al., 2020; Workman & Ureksoy, 2017; Wutich & Ragsdale, 2008), as WI impedes quality of life and mental health (Aihara et al., 2016; Mushavi et al., 2020).”
InfluentialLee, Y. J., Christ, R., Mbabazi, R., Dabagia, J., Prendergast, A., Wykoff, J. A., Dasari, S., Safai, D., Nakaweesi, S., Aturinde, S. R., et al. (2024) · PLOS mental health. · doi:10.1371/journal.pmen.0000069 · Cited by 14 · see citing works
Self-citationMgwele, A., Bhanye, J. I., & Mocwagae, K. (2024) · Sustainable development goals series · doi:10.1007/978-3-031-68734-1_4 · Cited by 13 · see citing works
Wallach, E. S., Lam, N. L., Nuwagira, E., Muyanja, D., Tayebwa, M., Valeri, L., Tsai, A. C., Vallarino, J., Allen, J. G., & Lai, P. S. (2022) · Indoor Air · doi:10.1111/ina.12986 · Cited by 13 · see citing works
Self-citationSeretlo-Rangata, M. L., Sodi, T., & Govender, S. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1537992 · Cited by 12 · see citing works
Water Challenges in Rural Sub-Saharan Africa
Nyika, J. M., & Dinka, M. O. (2023) · SpringerBriefs in water science and technology · doi:10.1007/978-3-031-26271-5_3 · Cited by 11 · see citing works
Bachwenkizi, J., Mohamed, H., Funsan, P., Rweyemamu, D. R., Nelson, W., Shao, M., Kaijage, H., Muyumbana, N., Salehe, S. S., Mwelange, L. P., et al. (2023) · Hygiene and Environmental Health Advances · doi:10.1016/j.heha.2023.100063 · Cited by 11 · see citing works
Dinko, D. H., & Nyantakyi‐Frimpong, H. (2023) · Annals of the American Association of Geographers · doi:10.1080/24694452.2023.2231528 · Cited by 11 · see citing works
“…constructed at the intersection of ecological and social systems (e.g., Dyck et al. 2005; Winchester and King 2018; Kangmennaang and Elliott 2019; Mushavi et al. 2020; Dinko 2022) and find that unequal gender norms intersect with geographic and topographic characteristics to frustrate women into…”
BackgroundLeahy, W., Achore, M., & Dery, F. (2024) · PLOS Water · doi:10.1371/journal.pwat.0000265 · Cited by 11 · see citing works
Interacting Water Insecurity and Food Insecurity: Recent Advances in Theory and Application
Brewis, A., Jepson, W. E., Rosinger, A. Y., Stoler, J. B., Workman, C. L., Wutich, A., & Young, S. L. (2025) · American Journal of Human Biology · doi:10.1002/ajhb.70052 · Cited by 13 · see citing works
“Examples include concerns of spousal violence from serving less-palatable meals made with too little or low-quality water in Uganda (Mushavi et al. 2020), distress of changed cooking plans in Cameroon (Nounkeu et al. 2022), and complex issues around lactation and infant feeding in Pakistan (Ahmed et al. 2021).”
Perkins, J. M., Kakuhikire, B., Baguma, C., Rasmussen, J. D., Satinsky, E. N., Kiconco, A., Kananura, J., Audet, C. M., Siedner, M. J., Haberer, J. E., et al. (2022) · AIDS and Behavior · doi:10.1007/s10461-021-03540-1 · Cited by 11 · see citing works
Self-citationInfluences on water source selection and use among women in rural Odisha, India
Patrick, M., Hennink, M. M., Dasmohapatra, M., Rout, M., Clasen, T., & Caruso, B. A. (2023) · Frontiers in Water · doi:10.3389/frwa.2023.1040981 · Cited by 13 · see citing works
Mngadi, L. C., Cuadros, D. F., Tanser, F. C., Burns, J. K., Slotow, R., & Tomita, A. M. (2023) · Psychology Health & Medicine · doi:10.1080/13548506.2023.2179643 · Cited by 10 · see citing works
“Only a few studies (Mushavi et al., 2020; Simiyu et al., 2022) have investigated their relationship with mental health, particularly depression in sub-Saharan Africa, including South Africa.”
BackgroundGüler, K. G., & Albayrak, E. (2024) · Public Health Nursing · doi:10.1111/phn.13388 · Cited by 12 · see citing works
Ashaba, S., Zanoni, B. C., Baguma, C., Tushemereirwe, P., Nuwagaba, G., Nansera, D., Maling, S., & Tsai, A. C. (2022) · Journal of the Association of Nurses in AIDS Care · doi:10.1097/jnc.0000000000000342 · Cited by 10 · see citing works
Self-citationAshaba, S., Baguma, C., Tushemereirwe, P., Nansera, D., Maling, S., Zanon, B. C., & Tsai, A. C. (2024) · PLOS Global Public Health · doi:10.1371/journal.pgph.0003600 · Cited by 9 · see citing works
“Most of the people who attend the HIV clinic reside in nearby communities and earn their livelihood through subsistence farming, animal husbandry, and small scale trading despite acknowledged challenges of water and food insecurity [36, 37].”
BackgroundSelf-citationWaSH insecurity and anxiety among people who inject drugs in the Tijuana-San Diego border region
Portillo, L. J. A., Calderón-Villarreal, A., Abramovitz, D. A., Vera, A., Cassels, S. L., Vera, C. F., Muñoz, S., Tornez, A., Rangel, G., Strathdee, S. A., et al. (2024) · BMC Public Health · doi:10.1186/s12889-023-17341-9 · Cited by 9 · see citing works
Kim, A. W., Kakuhikire, B., Baguma, C., North, C. M., Satinsky, E. N., Perkins, J. M., Ayebare, P., Kiconco, A., Namara, E. B., Bangsberg, D. R., et al. (2021) · Journal of Global Health · doi:10.7189/jogh.11.04035 · Cited by 9 · see citing works
Self-citationPerceived and misperceived norms about khat and/or cannabis use among adults in southwest Uganda
Perkins, J. M., Kakuhikire, B., Baguma, C., Meadows, M. L., Evans, C. Q., Jurinsky, J., Rasmussen, J. D., Satinsky, E. N., Ayebare, P., Kyokunda, V., et al. (2021) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2021.103527 · Cited by 9 · see citing works
Self-citationMpondo, F., Kim, A. W., Tsai, A. C., & Mendenhall, E. (2022) · Journal of Affective Disorders · doi:10.1016/j.jad.2022.02.035 · Cited by 8 · see citing works
Self-citationCaregiver preferences for physically harsh discipline of children in rural Uganda
Satinsky, E. N., Kakuhikire, B., Baguma, C., Cooper‐Vince, C. E., Rasmussen, J. D., Ashaba, S., Perkins, J. M., Ahereza, P., Ayebare, P., Kim, A. W., et al. (2023) · Journal of Family Violence · doi:10.1007/s10896-023-00536-4 · Cited by 8 · see citing works
“Additionally, since this study was conducted in a rural setting characterized by considerable food and water insecurity (Mushavi et al. 2020; Perkins et al. 2018; Tsai et al. 2011), associations between economic insecurity and harsh discipline may extend throughout the entire study setting.”
InfluentialSelf-citationRoss, A., Mack, E. A., Marcantonio, R. A., Miller‐Graff, L. E., Pearson, A. L., Smith, A. C., Bunting, E., & Zimmer, A. (2023) · Climate and Development · doi:10.1080/17565529.2023.2186746 · Cited by 9 · see citing works
“A more recent study by Mushavi et al. (2020) in rural Uganda highlights several aspects of violence linked to water.”
BackgroundKar, S., JibanbandhuGayak, Khan, K. R., Satpati, L., & Mukherjee, S. (2023) · Disaster risk reduction · doi:10.1007/978-3-031-26143-5_16 · Cited by 8 · see citing works
Yang, I. T., Hemphill, L., Kim, J., Bibangambah, P., Sentongo, R. N., Kakuhire, B., Plutzky, J., Boum, Y., Tsai, A. C., Okello, S., et al. (2020) · Journal of Global Health · doi:10.7189/jogh.10.010407 · Cited by 8 · see citing works
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Self-citationMutanda, G. W., & Nhamo, G. (2024) · Frontiers in Water · doi:10.3389/frwa.2024.1399415 · Cited by 7 · see citing works
Tufail, M., Nasir, M. J., Rahman, A., Kakakhel, S. I., Ashraf, M., & Tariq, A. (2025) · World Development Perspectives · doi:10.1016/j.wdp.2025.100679 · Cited by 7 · see citing works
Silva, B. B., & Rezende, S. C. (2022) · Environmental Science & Policy · doi:10.1016/j.envsci.2022.04.014 · Cited by 7 · see citing works
Olivieri‐Mui, B. L., Hoeppner, S. S., Tong, Y., Kohrt, E., Quach, L., Saylor, D. R., Seeley, J., Tsai, A. C., Reynolds, Z., Okello, S., et al. (2023) · Journal of Global Health · doi:10.7189/jogh.13.06003 · Cited by 7 · see citing works
Self-citationAhiabli, P., Adatara, P., & Cross, R. (2023) · Journal of Water Sanitation and Hygiene for Development · doi:10.2166/washdev.2023.142 · Cited by 7 · see citing works
Logie, C. H., Okumu, M., Admassu, Z., Mackenzie, F., Kortenaar, J., Perez‐Brumer, A., Gittings, L., Khan, N., Hakiza, R., Musoke, D. K., et al. (2024) · SSM - Mental Health · doi:10.1016/j.ssmmh.2024.100306 · Cited by 7 · see citing works
Ashaba, S., Baguma, C., Tushemereirwe, P., Nansera, D., Maling, S., Tsai, A. C., & Zanoni, B. C. (2024) · PLOS Global Public Health · doi:10.1371/journal.pgph.0003037 · Cited by 6 · see citing works
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“In particular, poor residents are less able to afford clean water than other residents (Mushavi et al., 2020; Osei et al., 2015).”
BackgroundKirabira, J., Ashaba, S., Favina, A., Maling, S., Nansera, D., & Zanoni, B. C. (2023) · Psychology Health & Medicine · doi:10.1080/13548506.2023.2198244 · Cited by 6 · see citing works
“The majority of people who seek care at MRRH HIV clinic reside in rural areas outside of the city where they are engaged in retail trading, subsistence farming and animal rearing to make a living amid challenges of water and food scarcity (Mushavi et al., 2020; Tsai et al., 2016).”
BackgroundKim, A. W., Rieder, A. D., Cooper‐Vince, C. E., Kakuhikire, B., Baguma, C., Satinsky, E. N., Perkins, J. M., Kiconco, A., Namara, E. B., Rasmussen, J. D., et al. (2023) · American Journal of Biological Anthropology · doi:10.1002/ajpa.24758 · Cited by 7 · see citing works
Self-citationSeasonal variation in household water insecurity in rural Bangladesh: A longitudinal analysis
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Money Down the Drain: Corruption and Access to Water in AfricaPreprint
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Water, economic systems, and mental health: A review of theorized relationships
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Who is more water insecure? Gendered evidence from urban Pakistan
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“Water access insecurity, concerns about quality and high costs can contribute to stress and mental health issues [46–48].”
- Authors
- Mushavi, R. C., Burns, B. F. O., Kakuhikire, B., Owembabazi, M., Vořechovská, D., McDonough, A. Q., Cooper-Vince, C. E., Baguma, C., Rasmussen, J. D., Bangsberg, D. R., & Tsai, A. C.
- Affiliations
- Brigham and Women's Hospital (US)
- Massachusetts General Hospital (US)
- Mbarara University of Science and Technology (UG)
- Duke University (US)
- Portland State University (US)
- Harvard University (US)
- Corresponding author
- Mushavi, Rumbidzai C.
- ORCID
- Venue
- Social Science & Medicine
- Publisher
- Elsevier BV
- Published
- 2020-01
- Volume
- 245
- Pages
- 112561
- ISSN
- 0277-9536 (ISSN-L)
- PMC
- PMC6936324
- OpenAlex
- W2978384331
- Cited by
- 164
- References
- 67
- Citations by year
- 2026: 21 · 2025: 22 · 2024: 28 · 2023: 31 · 2022: 24 · 2021: 29 · 2020: 9
- FWCI
- 5.61
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Social Science & Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- PDXScholar (Portland State University) (submittedVersion)
- Funders
- Doris Duke Charitable Foundation
- National Institutes of Health
- Topics
- Physical Sciences › Environmental Science › Water Science and Technology › Water Resource Management and Quality
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Keywords
- water insecurity, depression, mental health, rural Uganda, household water access, gender norms, emotional distress, social outcomes
- MeSH terms
- Water Insecurity, Adult, Depression, Female, Humans, Male, Middle Aged, Psychometrics, Surveys and Questionnaires, Rural Population, Socioeconomic Factors, Uganda
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