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E023558.Full.Pdf Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2018-023558 on 17 January 2019. Downloaded from Development and validation protocol for an instrument to measure household water insecurity across cultures and ecologies: the Household Water InSecurity Experiences (HWISE) Scale Sera L Young,1 Shalean M Collins,2 Godfred O Boateng,2 Torsten B Neilands,3 Zeina Jamaluddine,4 Joshua D Miller,2 Alexandra A Brewis,5 Edward A Frongillo,6 Wendy E Jepson,7 Hugo Melgar-Quiñonez,8 Roseanne C Schuster,5 Justin B Stoler,9 Amber Wutich,5 on behalf of the HWISE Research Coordination Network To cite: Young SL, ABSTRACT Strengths and limitations of this study Collins SM, Boateng GO, et al. Introduction A wide range of water-related problems Development and validation contribute to the global burden of disease. Despite protocol for an instrument to ► This study is based on rigorous, multidisciplinary the many plausible consequences for health and measure household water formative research on water insecurity by anthro- insecurity across cultures well-being, there is no validated tool to measure pologists, geographers, nutritionists, statisticians and ecologies: the Household individual- or household-level water insecurity and epidemiologists, among others. equivalently across varying cultural and ecological Water InSecurity Experiences ► Data on household water insecurity experiences are (HWISE) Scale. BMJ Open settings. Accordingly, we are developing the being collected in 28 sites across four continents by 2019;9:e023558. doi:10.1136/ Household Water Insecurity Experiences (HWISE) local partners in widely varying ecological and cul- bmjopen-2018-023558 Scale to measure household-level water insecurity in tural settings. ► Prepublication history and multiple contexts. ► Analytic methods from both classical test and item additional material for this Methods and analysis After domain specification response theories will be used to develop and eval- paper are available online. To and item development, items were assessed for both uate the eventual scale. http://bmjopen.bmj.com/ view these files, please visit content and face validity. Retained items are being ► The Household Water Insecurity Experiences Scale the journal online (http:// dx. doi. asked in surveys in 28 sites globally in which water- will be validated for assessing water insecuri- org/ 10. 1136/ bmjopen- 2018- related problems have been reported (eg, shortages, ty in low-income and middle-income countries. 023558). excess water and issues with quality), with a target Additional scale assessments necessary for valida- Received 11 April 2018 of at least 250 participants from each site. Scale tion in high-income countries are planned. Revised 19 October 2018 development will draw on analytic methods from both Accepted 9 November 2018 classical test and item response theories and include item reduction and factor structure identification. INTRODUCTIon on September 26, 2021 by guest. Protected copyright. Scale evaluation will entail assessments of reliability, Water insecurity, the inability to ‘access and and predictive, convergent, and discriminant validity, as well as the assessment of differentiation between benefit from affordable, adequate, reliable and safe water for well being and a healthy known groups. 1 Ethics and dissemination Study activities received life’, has manifold adverse effects on phys- 2 3 4 5 necessary ethical approvals from institutional review ical and psychosocial health ; under- 6 bodies relevant to each site. We anticipate that the mines productivity ; triggers and perpetuates final HWISE Scale will be completed by late 2018 domestic, social and political tensions and and made available through open-access publication. conflicts7 8; and reinforces environmental Associated findings will be disseminated to public and social inequities.9 Water insecurity has © Author(s) (or their employer(s)) 2019. Re-use health professionals, scientists, practitioners and been shown to co-occur with food insecurity, permitted under CC BY. policymakers through peer-reviewed journals, malnutrition and communicable diseases and Published by BMJ. scientific presentations and meetings with various to produce syndemics, or systemically exacer- For numbered affiliations see stakeholders. Measures to quantify household food bating epidemics,10 11 much like food insecu- end of article. insecurity have transformed policy, research and rity and HIV.12 Furthermore, water insecurity humanitarian aid efforts globally, and we expect that is projected to worsen in many regions due to Correspondence to an analogous measure for household water insecurity climate change and increased inequalities in Dr Sera L Young; will be similarly impactful. sera. young@ northwestern. edu resource distribution.9 Young SL, et al. BMJ Open 2019;9:e023558. doi:10.1136/bmjopen-2018-023558 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-023558 on 17 January 2019. Downloaded from However, we do not know how many households or scale development across a wide array of settings (http:// individuals globally are affected by water insecurity. Esti- www. hwise. org). mates of available surface water derived from satellite imagery suggest that 4 billion people worldwide experi- ence severe water scarcity for at least 1 month of every METHODS AND ANALYSIS year,13 and this is likely an underestimation given issues Phase 1: item development with infrastructure and access. Additionally, chronic Domain specification 14 15 flooding and poor water quality mean that many more Specifying the domains for a scale is the first step in individuals are experiencing water insecurity. Currently, item development (table 1, 1.1).33 34 The boundary of measures of water at the national, regional and commu- the domain of water insecurity, that is, the underlying nity levels are used and are referred to as indicators of construct that the scale will attempt to measure, was 16–19 water scarcity, water poverty or water security. These based on extensive literature review1 and draws on the measures do not capture the range and granularity of team’s expertise in water insecurity, for example.4 8 23 35 how households experience water insecurity, including We define water insecurity as the condition where ‘afford- 20 factors such as perceptions of quality, instances of water ability, reliability, adequacy, and safety [of water] is 21 4 5 excess or perceived consequences for psychosocial significantly reduced or unattainable so as to threaten or 22 and physical health and well-being. Furthermore, while jeopardize well-being’.1 household-level scales to measure water insecurity have A best practice is to clearly articulate subdomains of been developed for several sites, for example, in the the eventual scale, if they are known.34 36 Although some 23 4 24 5 10 USA, Bolivia, Uganda, Ethiopia and Kenya, their subdomains of water insecurity have been proposed,1 5 11 37 comparability, comprehensiveness and applicability to there is currently no consensus in the literature. There- other sites have not been systematically investigated or fore, we will assess subdomains during the analytic phase. validated. As such, a comprehensive, validated scale to measure Item generation the experiences of household or individual water inse- Candidate scale items were identified deductively, based curity would enable researchers, practitioners and on an extensive literature review of items used in prior policymakers to: improve estimates of water insecurity site-specific household water insecurity scales1 (table 1, prevalence, identify factors that shape this phenomenon, 1.2). This includes team members’ prior work in colonias recognise direct consequences of water insecurity, under- in the USA-Mexico boderlands23; a squatter settlement stand how to more effectively distribute resources, eval- in Cochabamba, Bolivia4; in rural, periurban and urban uate the impacts and cost-effectiveness of interventions households in Kenya10; and elsewhere, including rural and monitor progress towards the Sustainable Develop- areas in Ethiopia5 and Uganda.24 Initial items include ment Goals.25 Indeed, in March 2018, the UN’s High- experiences of water insecurity that have consequences http://bmjopen.bmj.com/ Level Panel on Water cited lack of data on water in many for psychosocial and physical health, nutrition, impacts parts of the world as a major challenge, and the need on livelihoods and household economy, and agriculture for better data on water as one of nine priority actions.26 (online supplementary file 1). Given that measures of household food insecurity (eg, Each question is phrased to elicit experiences within Latin American and Caribbean Food Security Scale,27 the prior 4 weeks or month (ie, ‘In the last four weeks, Household Food Insecurity Access Scale,28 Food Insecu- how frequently have…’). This recall period was systemat- rity Experience Scale29) have proven vital to implemen- ically determined using the Delphi method of consensus tation and evaluation of policy and programmes,30–32 building with international and local experts in water on September 26, 2021 by guest. Protected copyright. development of an analogous household water insecurity insecurity, food insecurity and scale development and scale is overdue and urgently needed, particularly for by comparing the responses in this recall period to assessing water insecurity in low-income and middle-in- a prospective daily recall of water insecurity experi- come settings where household
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