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Safe and secure water is a cornerstone of modern life in the global North. This article critically examines a set of prevalent myths about household water in high-income countries, with a focus on Canada and the United States. Taking a relational approach, we argue that household water insecurity is a product of institutionalized structures and power, manifests unevenly through space and time, and is reproduced in places we tend to assume are the most water-secure in the world. We first briefly introduce "modern water" and the modern infrastructural ideal, a highly influential set of ideas that have shaped household water provision and infrastructure development over the past two centuries. Against this backdrop, we consolidate evidence to disrupt a set of narratives about water in high-income countries: the notion that water access is universal, clean, affordable, trustworthy, and uniformly or equitably governed. We identify five thematic areas of future research to delineate an agenda for advancing scholarship and action-including challenges of legal and regulatory regimes, the housing-water nexus, water affordability, and water quality and contamination. Data gaps underpin the experiences of household water insecurity. Taken together, our review of water security for households in high-income countries provides a conceptual map to direct critical research in this area for the coming years. This article is categorized under: Human Water > Human Water Peter Wall Institute for Advanced Study, University of British Columbia; PLUS Alliance; Texas AM University; U.S. National Science FoundationNational Science Foundation (NSF) [BCS-17759972] Peter Wall Institute for Advanced Study, University of British Columbia; PLUS Alliance; Texas A&M University; U.S. National Science Foundation, Grant/Award Number: BCS-17759972

Water sharing between households could crucially mitigate short‐term household water shortages, yet it is a vastly understudied phenomenon. Here we use comparative survey data from eight sites in seven sub‐Saharan African countries (Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Malawi, Nigeria, and Uganda) to answer three questions: With whom do households share water? What is expected in return? And what roles do need and affordability play in shaping those transfers? We find that water is shared predominantly between neighbors, that transfers are more frequent when water is less available and less affordable, and that most sharing occurs with no expectation of direct payback. These findings identify water sharing, as a form of generalized reciprocity, to be a basic and consistent household coping strategy against shortages and unaffordability of water in sub‐Saharan Africa.

OBJECTIVES Geophagy, the intentional consumption of earth, is widely practiced among humans and other mammals, but its causes are not well understood. Given the growing number of reports of geophagy among nonhuman primates (NHP), we sought to (1) advance and codify our understanding of the patterns and functional and evolutionary significance of geophagy among NHP and (2) provide a research agenda for a more unified approach to its study. METHODS We systematically reviewed all available literature on NHP geophagy, extracted available data on taxa, geography, climate, diet, sex, age-class, reproductive status, and the characteristics of the earth. We used these data to evaluate three major hypotheses about geophagy, that it is protective, provides mineral supplementation, and is nonadaptive. RESULTS We identified 287 accounts of geophagy among 136 species, adding 79 new primate species to the list of those considered in prior reviews. Nineteen percent of species were in the suborder Strepsirrhini, while 81% were in the suborder Haplorrhini. There were reports of geophagy from 9 of the 17 families and 39 of the 76 genera currently recognized by the International Union for Conservation of Nature. DISCUSSION The limited evidence suggests that geophagy is adaptive, and provides protection and mineral supplementation. We specify the behavioral, dietary, and soil data required to more rigorously investigate these hypotheses across representative species of all taxonomic groups, geographical regions, and dietary classification. Given the plausibility of geophagy for maintaining the health of both wild and captive populations, we urge further study and conservation of geophagy sites.

Objectives Schistosome infections can damage organs important for water homeostasis, especially the kidneys. Urogenital schistosomiasis (caused by Schistosoma haematobium) increases protein and blood in urine and intestinal schistosomiasis (caused by S. mansoni) affects total body water. However, no data exist on how different schistosome species affect urine specific gravity (USG), a hydration biomarker. Therefore, we assessed the relationship between S. haematobium- and S. mansoni-infected and uninfected women and USG in rural Tanzania. Materials and methods Surveys were conducted and stool and urine samples were collected among 211 nonpregnant women aged 18-50. S. haematobium eggs were detected using the urine filtration method. S. mansoni eggs were detected using the Kato Katz method. USG was measured using a refractometer and analyzed as both a continuous and dichotomous variable. Regression (linear/logistic) models were estimated to test the relationship between infection and hydration status. Results The prevalence of S. haematobium was 5.9% and S. mansoni was 5.4% with no coinfections. In regression models, S. haematobium-infected women had significantly higher USG (Beta = 0.007 g mL-1 ; standard error = 0.002; p = 0.001) and odds (Odds ratio: 7.76, 95% CI: 1.21-49.5) of elevated USG (>1.020 g mL-1 ) than uninfected women, whereas S. mansoni-infected women did not. Discussion Schistosoma haematobium, but not S. mansoni, infection is associated with higher USG and risk of inadequate hydration. Future work should determine whether findings are attributable to parasite-induced debris in urine or urinary tract pathologies and signs of renal damage. Human and non-human primate studies using USG in schistosome-endemic areas should account for schistosomiasis.

The World Health Organization recommends exclusive breastfeeding (EBF) for 6 months and continued breastfeeding for at least 2 years. Social support has been widely recognized to influence breastfeeding practices. However, existing scales do not measure exclusive breastfeeding social support (EBFSS), rather, they assess social support for any breastfeeding. Further, they are tailored towards high-income settings. Therefore, our objectives were to develop and validate a tool to measure EBFSS in low-income settings. To develop the scale, local and international breastfeeding experts were consulted on modifications to the Hughes’ Breastfeeding Social Support Scale. It was then implemented in an observational cohort in Gulu, Uganda at 1 (n=238) and 3 (n=237) months postpartum (NCT02925429). We performed polychoric and polyserial correlations to remove redundant items, and exploratory factor analysis at 1 month postpartum to determine the latent factor structure of EBFSS. We further applied confirmatory factor analysis to assess dimensionality of the scale at 3 months postpartum. We then conducted tests of predictive, convergent, and discriminant validity against exclusive breastfeeding, self-efficacy, general social support, and depression. The modification of the Hughes’ scale resulted in 18 items, which were reduced to 16 after examining variances and factor loadings. Three dimensions of support emerged: Instrumental, Emotional and Informational, with alpha coefficients of 0.79, 0.85 and 0.83, respectively. Predictive, convergent, and discriminant validity of the resultant EBFSS scale was confirmed. The EBFSS Scale is valid and reliable for measuring EBFSS in northern Uganda, and may be of use in other low-income settings to assess determinants of EBF.

Despite the central importance of water for human wellbeing and development, researchers and practitioners have few tools to quantitatively measure, assess, and compare the scope and scale of household and individual water insecurity across cultural and climatic variations. There are multiple definitions of water insecurity, and the analytical tools for measuring household-level water insecurity are in their infancy. This paper provides an overview and systematic evaluation of current household and individual water in security metrics for human development. We seek to advance micro-level metrics—attending to the considerations of dimensionality, temporality, unit of analysis, and comparability—because they will provide the research community with necessary tools to untangle the complex determinants and outcomes of water insecurity. Moreover, such metrics will support the translation of research outcomes into meaningful and useful products and results for stakeholders, communities, and decision-makers. WIREs Water 2017, 4:e1214. doi: 10.1002/wat2.1214 For further resources related to this article, please visit the WIREs website.

Objectives Pica is the craving for and consumption of nonfood items, including the ingestion of earth (geophagy), raw starch (amylophagy), and ice (pagophagy). Pica has long been associated with micronutrient deficiencies, but the strength of this relationship is unclear. We aimed to evaluate the association between pica behavior and the risk of being anemic or having low hemoglobin (Hb), hematocrit (Hct), or plasma zinc (Zn) concentrations. Methods We systematically reviewed studies in which micronutrient levels were reported by pica status. We calculated the pooled odds ratio for anemia or weighted mean difference in Hb, Hct, or Zn concentrations between groups practicing or not practicing pica behaviors. Results Forty-three studies including 6,407 individuals with pica behaviors and 10,277 controls were identified. Pica was associated with 2.35 times greater odds of anemia (95% CI: 1.94–2.85, P < 0.001), lower Hb concentration (−0.65 g/dl, 95% CI: −0.83 to −0.48 g/dl, P < 0.001), lower Hct concentration (−1.15%, 95% CI: −1.61 to −0.70%, P < 0.001), and lower Zn concentration (−34.3 μg/dl, 95% CI: −59.58 to −9.02 μg/dl, P = 0.008). Statistical significance persisted after excluding outliers and in subgroup analyses by pica type and life stage. Conclusion Pica is significantly associated with increased risk for anemia and low Hb, Hct, and plasma Zn. Although the direction of the causal relationship between pica and micronutrient deficiency is unknown, the magnitude of these relationships is comparable to other well-recognized causes of micronutrient deficiencies. Pica warrants greater public health attention; specifically the potential physiological mechanisms underpinning the relationship between pica and micronutrient deficiencies merit further study. Am. J. Hum. Biol. 27:84–93, 2015. © 2014 Wiley Periodicals, Inc.

Although pica, the craving and purposive consumption of non-food substances, is common among many populations, especially during pregnancy, the health consequences are not well understood. Further, very little is known about pica among Mexican populations in the United States and Mexico. Therefore, we conducted formative research to understand pica in this understudied population. Our objectives were to identify the frequency and types of pica behaviours, to understand perceived aetiologies and consequences of pica and to ascertain if the behaviour was common enough to warrant a larger study. We held nine focus group discussions (three in the Salinas Valley, California; six in Xoxocotla, Morelos, Mexico) with 76 Mexican-born women who were currently pregnant or had delivered within the past 2 years. Earth, adobe, bean stones and ice were the most commonly reported pica substances. Twenty-eight of the 76 participants (37%) reported ever engaging in pica; 22 participants (29%) reported doing so during pregnancy. The proportion of women reporting pica in the United States and Mexico was 43% and 34%, respectively. Women attributed pica to the overwhelming organoleptic appeal of pica substances (especially smell and texture) and to micronutrient deficiencies. Perceived consequences of unfulfilled pica cravings were birthmarks or fetal loss; fulfilled pica cravings were also thought to be generally harmful to the mother or child, with several women specifying toxic lead, pesticides or ‘worms’. In sum, pica among Mexican women is common enough to warrant a larger epidemiologic study of its sociodemographic correlates and physiological consequences.

Pregnancy and food insecurity may impact antiretroviral (ART) pharmacokinetics (PK) adherence and response. We sought to quantify and characterize the PK of lopinavir/ritonavir (LPV/r) and efavirenz (EFV) by pregnancy and nutritional status among HIV-infected women in Tororo Uganda. In 2011 62/225 ante-partum/post-partum single dried blood spot samples DBS and 43 post-partum hair samples for LPV/r were derived from 116 women 51/194 ante-/post-partum DBS and 53 post-partum hair samples for EFV from 105 women. Eighty percent of Ugandan participants were severely food insecure 26% lost weight ante-partum and median BMI post-partum was only 20.2 kg/m(2) . Rich PK-data of normally nourished (pregnant) women and healthy Ugandans established prior information. Overall drug exposure was reduced (LPV -33% EFV -15% ritonavir -17%) compared to well-nourished controls (P < 0.001) attributable to decreased bioavailability. Pregnancy increased LPV/r clearance 68% (P < 0.001) whereas EFV clearance remained unchanged. Hair concentrations correlated with plasma-exposure (P < 0.001) explaining 29% PK-variability. In conclusion pregnancy and food insecurity were associated with lower ART exposures in this cohort of predominantly underweight women compared to well-nourished women. Much variability in plasma-exposure was quantified using hair concentrations. Addressing malnutrition as well as ART-PK in this setting should be a priority. (c) 2013 The American College of Clinical Pharmacology.

BackgroundAntepartum depression (AD) is a risk factor for adverse pregnancy outcomes and may be worsened by food insecurity (FI) and lack of social support (SS). We studied the progression of AD fr...

Food insecurity (FI) during pregnancy may lead to adverse health outcomes for affected women. However, little is known on whether such effects are due to short-term within person changes (longitudi...

Objectives Geophagy is commonly reported by pregnant women and children, yet its causes and consequences remain poorly understood. Therefore, we sought to determine if geophagy could contribute micronutrients and/or be a source of heavy metal exposure by examining the elemental composition of earths consumed in Kakamega, Kenya. Methods Ten samples of earths commonly consumed during pregnancy were collected by study enumerators and analyzed using inductively coupled plasma-atomic emission spectroscopy. Samples were either collected at markets or from walls of participants' homes, based on where participants reported most commonly sourcing their consumed earths. Results Based on estimated intakes (40 g/day), all samples had lead levels that exceeded the provisional maximum tolerable daily intake, and one sample exceeded the threshold for arsenic. Further, estimated intakes of iron for all samples were at least 8.9 times higher than the established threshold. Elemental concentrations were also compared by the site of sample collection (market vs. household wall); market samples had significantly higher iron concentrations and lower calcium concentrations than wall samples. Conclusions Geophagic earths in Kakamega may be harmful because of dangerously high levels of lead, arsenic, and iron. The prevalence of geophagy among vulnerable populations underscores the importance of understanding its causes and consequences for accurate public health messaging.

The World Health Organization now recommends integrating calcium supplements into antenatal micronutrient supplementation programmes to prevent pre‐eclampsia, a leading cause of maternal mortality. As countries consider integrating calcium supplementation into antenatal care (ANC), it is important to identify context‐specific barriers and facilitators to delivery and adherence. Such insights can be gained from women's and health workers' experiences with iron and folic acid (IFA) supplements. We conducted in‐depth interviews with 22 pregnant and post‐partum women and 20 community‐based and facility‐based health workers in Kenya to inform a calcium and IFA supplementation programme. Interviews assessed awareness of anaemia, pre‐eclampsia and eclampsia; ANC attendance; and barriers and facilitators to IFA supplement delivery and adherence. We analyzed interviews inductively using the constant comparative method. Women and health workers identified poor diet quality in pregnancy as a major health concern. Neither women nor health workers identified pre‐eclampsia, eclampsia, anaemia or related symptoms as serious health threats. Women and community‐based health workers were unfamiliar with pre‐eclampsia and eclampsia and considered anaemia symptoms normal. Most women had not received IFA supplements, and those who had received insufficient amounts and little information about supplement benefits. We then developed a multi‐level (health facility, community, household and individual) behaviour change strategy to promote antenatal calcium and IFA supplementation. Formative research is an essential first step in guiding implementation of antenatal calcium supplementation programmes to reduce pre‐eclampsia. Because evidence on how to implement successful calcium supplementation programmes is limited, experiences with antenatal IFA supplementation can be used to guide programme development.

To inform perinatal nutrition and mental health interventions, we used a cohort study to: 1) examine the directionality of relationships between maternal food insecurity (MFI) and prenatal depressive symptoms (PDS); and 2) see if social support (SS) or domestic violence (DV) modify this relationship. We enrolled 403 Ugandan pregnant women (33% HIV+ on antiretrovirals)) in mid-gestation and assessed them monthly through delivery for MFI (IFIAS) and the PDS (CES-D) using validated scales. Each woman contributed ~ 4.3 study visits including enrollment visits. At baseline, 58.3% of the women had probable prenatal depression (CES-D蠅17), 27.1% had experienced DV, and 74.4% reported moderate or severe MFI. Longitudinal mixed effects models indicate that MFI and PDS predicted each other. Multivariate lagged response and covariate models confirmed bidirectional relationships for MFI and PDS. SS modified the relationship in both directions ((βMFI*SS=-0.050, p

Although anecdotal evidence suggests that pica occurs among Mexican-born women, especially during pregnancy, the prevalence and covariates of pica in this population are unknown. Given the potentia...

Food insecurity (FI) has been associated with poor maternal and infant health in high-income countries. However, little is known about the determinants or consequences of FI during pregnancy and la...

In Sub-Saharan Africa, the differential impact of maternal HIV infection and/or food insecurity on the pattern of weight gain among pregnant women is unknown. To fill this gap, data on 402 pregnant...

Antenatal alcohol use (AAU) is associated with poor health outcomes in maternal-infant dyads. However, AAU prevalence and risk factors are poorly understood, particularly in low-income settings. Therefore we studied correlates of any AAU among pregnant women receiving antenatal care in Gulu, Uganda. Characteristics of pregnant women enrolled in a cohort study (n=403, 33% HIV+) were assessed at multiple levels of the social-ecological model (SEM). AAU was reported by 20.1% of participants. Beer (10.1%) and kweete (sorgum-millet brew) (9.2%) were the most frequently consumed alcohols (Figure 1). Excessive drinking was rare; mean alcohol units consumed/month was 4.4 in those who drank. In multivariate logistic models, social environment, (partner drinking 蠅30 days/month, [Odds Ratio (OR) 2.17, p=0.03] or friends drinking 1-29 days/month [OR 3.59, p

Iron deficiency anaemia is the most common form of malnutrition in the world. Pregnant women are particularly at risk for anaemia. Insufficient attention has been paid to the reasons underlying the only moderate success of iron supplementation. In this article an additional factor that can affect the use of iron supplements is proposed: their relevance to 'traditional' or nonbiomedical treatments of anaemia. This paper represents what is to our knowledge the first ethnographic description of nonbiomedical treatments for maternal anaemia. The research was conducted over several months on Pemba, one of the islands of the Zanzibar archipelago. Data were collected using a variety of qualitative methods, including in-depth interviews, focus group discussions and participant observation. Informants included 25 mothers and 27 tradi- tional and biomedical health care workers. The resulting ethnography elucidates Pembans' beliefs about the relationship of food, traditional medicine, spirits and biomedical medicine in relation to anaemia. In the analysis of the ethnography, both anthropology and public health perspectives are incorporated to suggest how the understanding of these beliefs is useful for increasing iron supplement use.

Prenatal calcium supplementation is now recommended by the WHO to prevent preeclampsia and eclampsia (PE/E), a leading cause of maternal mortality globally. To guide calcium supplementation program...

Complex biological, behavioral, socioeconomic and psychological factors influence appetite and subsequent dietary intake; as such, focusing only on a single factor can lead to inappropriate dietary recommendations. This is especially true when poverty-associated malnutrition and infectious diseases coexist; although both negatively impact dietary intake, very different solutions are needed. Therefore, our objective was to evaluate an adapted scale of appetite sensations and compare these scores to dietary intake among 20 pregnant and 18 lactating women in Nyanza province. A research dietitian implemented the adapted appetite and dietary intake questionnaires. The appetite questionnaire consisted of a 5-point visual analog scale for each of 4 questions to assess degree of hunger, desire to eat, satiety or food aversions. Dietary intake was assessed by a 24-hour dietary recall with macronutrient intake, dietary quality and diversity estimated. The majority (60%) consumed a sufficiently diverse diet (蠅6 food...

Common mental disorders, such as depression and anxiety, affect approximately 16% of pregnant women in low- and middle-income countries. Food insecurity (FI) has been shown to be associated with depressive symptoms. It has also been suggested that the association between FI and depressive symptoms is moderated by social support (SS); however, there is limited evidence of these associations among pregnant women living in low-income and middle-income countries. We studied the association between FI and depressive symptoms severity and assessed whether such an association varied among Ugandan pregnant women with low vs. high SS. Cross-sectional data were collected among 403 pregnant women in northern Uganda. SS was assessed using an eight-item version of the Duke-UNC functional SS scale. FI and depressive symptoms were assessed by, respectively, the individually focused FI scale and the Center for Epidemiologic Studies-Depression scale. Women were categorized into two SS groups, based on scoring < or ≥ to the median SS value. Multivariate linear regression models indicated an independent association between FI and depressive symptoms severity. The association between FI and depressive symptoms severity was moderated by SS i.e. was stronger among women in the low SS category (adjusted beta (95%CI): 0.91 (0.55; 1.27)) than for women belonging to the high SS group (0.53 (0.28; 0.78)) (adjusted p value for interaction = 0.026). There is need for longitudinal or interventional studies among pregnant women living in northern Uganda or similar contexts to examine the temporal sequence of the associations among food insecurity, depressive symptoms severity and social support. © 2016 John Wiley & Sons Ltd