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‘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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“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
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“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
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“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
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“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)
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“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)
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“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
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“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
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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 the citing paper
“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 the citing paper
“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 the citing paper
“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 the citing paper
“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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“Socioeconomic instability, including poverty, unemployment, and limited access to education, exerts significant psychological strain, particularly in rural communities where mental health services are scarce (Lund et al., 2011; Mushavi et al., 2020; Tsai et al., 2016).”
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“Building on previ - ous studies, the analysis recognizes that water access is shaped not only by resource availability but also by socio-economic, socio-cultural, and governance contexts (Sultana 2011; Rodina 2016; Mushavi et al. 2020; Bukachi et al. 2021).”
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Self-citation
Metadata
- 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
- Health Sciences › Medicine › Psychiatry and Mental health › 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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