Water journeys: Household water insecurity, health risks, and embodiment in slums and informal settlements

Abstract

Water insecurity is a critical public-health challenge in Africa's urban informal settlements, where most of the population often lacks access to household taps. In these settings, water fetching is disproportionately performed by women. While water fetching is physically laborious and exposes women to multiple risks, the water-insecurity literature has predominantly focused on household experiences, ignoring women's water-collection journeys. This paper uses the water journey as a window into embodied dimensions of water insecurity. Combining theoretical insights from embodiment, embodied political ecology of health, and time geographies, we use video-recorded walking interviews to analyze women's everyday water journeys in Ntopwa, an urban informal settlement in Blantyre, Malawi, from initial decision making through exposure to water-fetching risks and household practices regarding use and storage. We identify three principal sources of environmental risk— terrain, built environment, and human behavior—that present challenges for water collectors. Using the walking interview as a heuristic, we show how the seemingly simple practice of water fetching is compounded by complex decision making, constant spatiotemporal trade-offs, and exposure to diverse risks, all of which have embodied health consequences. Based on our findings, we conclude that interventions seeking to improve household water insecurity must consider the embodied effects of water-fetching journeys. This study also provides methodological insights into using walking interviews and videos for water and health research.

Full text

Social Science & Medicine 313 (2022) 115394
Available online 30 September 2022
0277-9536/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-
nc/4.0/).
Water journeys: Household water insecurity, health risks, and embodiment
in slums and informal settlements
Ellis Adjei Adams
a
,
*
, Sydney Byrns
b
, Save Kumwenda
c
, Richard Quilliam
b
,
Theresa Mkandawire
d
, Heather Price
b
a
Keough School of Global Affairs, Eck Institute for Global Health, University of Notre Dame, 1010 Jenkins Nanovic Halls, Notre Dame, IN, 46556, USA
b
Department of Biological and Environmental Sciences, Faculty of Natural Sciences, University of Stirling, Stirling, FK9 4LA, UK
c
Malawi University of Business and Applied Sciences (MUBAS), Department of Environmental Health, Private Bag 303, Chichiri, Blantyre 3, Malawi
d
Malawi University of Business and Applied Sciences (MUBAS), Department of Civil Engineering, Private Bag 303, Chichiri, Blantyre 3, Malawi
ARTICLE INFO
Keywords:
Walking interviews
Malawi
Videos
Embodied political ecology of health
Water insecurity
Water fetching journeys
Time geographies
ABSTRACT
Water insecurity is a critical public-health challenge in Africa’s urban informal settlements, where most of the
population often lacks access to household taps. In these settings, water fetching is disproportionately performed
by women. While water fetching is physically laborious and exposes women to multiple risks, the water-
insecurity literature has predominantly focused on household experiences, ignoring women’s water-collection
journeys. This paper uses the water journey as a window into the embodied dimensions of water insecurity.
Combining theoretical insights from embodiment, embodied political ecology of health, and time geographies,
we use video-recorded walking interviews to analyze women’s everyday water journeys in Ntopwa, an urban
informal settlement in Blantyre, Malawi, from initial decision making through exposure to water-fetching risks
and household practices regarding use and storage. We identify three principal sources of environmental risk—
terrain, built environment, and human behavior—that present challenges for water collectors. Using the walking
interview as a heuristic, we show how the seemingly simple practice of water fetching is compounded by
complex decision making, constant spatiotemporal trade-offs, and exposure to diverse risks, all of which have
embodied health consequences. Based on our ndings, we conclude that interventions seeking to improve
household water insecurity must consider the embodied effects of water-fetching journeys. This study also
provides methodological insights into using walking interviews and videos for water and health research.
1. Introduction
Unsafe water remains a major contributor to the global burden of
disease and mortality (Prüss-Ustün et al., 2019; Anthonj, 2021). Glob-
ally, nearly 2 billion people do not have access to safe water. Of these,
1.2 billion are without basic water services, dened as drinking water
from an improved source with total collection and queuing time of no
more than 30 min (WHO and UNICEF, 2021). These numbers likely
underestimate the challenge, because water access indicators often do
not adequately consider the multiple layers of water insecurity. For
example, not all improved sources yield water of acceptable quality, and
water that may be clean at the source can get contaminated through
transportation, storage, and handling at the household (Boateng et al.,
2013; Smiley, 2017; Cassivi et al., 2021). Global statistics on water
supply often focus on international, national, and regional patterns of
water insecurity, obscuring the impact of water insecurity and associ-
ated health effects on a ner scale (Price et al., 2019; Price et al., 2021).
In rapidly expanding informal settlements in sub-Saharan Africa, unsafe
water is compounded by population growth, poverty, poor housing, and
myriad physical and environmental risks, which can compromise health
and well-being (Adams et al., 2020). Poor sanitation and overcrowding
can cause fecal contamination (Adams et al., 2019; Price et al., 2021).
Intermittent supply in informal settlements leads to long waiting times
(Adams, 2018), whereas privately sold water, a common option in many
cities, can be costly and unsafe (Sarkar, 2020).
The most recent Joint Monitoring Programme data reports that up-
wards of 46% of urban households in sub-Saharan Africa depend on
water sources outside of the home, and this gure reaches a staggering
* Corresponding author.
E-mail addresses: eadams7@nd.edu (E.A. Adams), s.c.byrns@stir.ac.uk (S. Byrns), skumwenda@mubas.ac.mw (S. Kumwenda), richard.quilliam@stir.ac.uk
(R. Quilliam), tmkandawire@mubas.ac.mw (T. Mkandawire), heather.price@stir.ac.uk (H. Price).
Contents lists available at ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
https://doi.org/10.1016/j.socscimed.2022.115394
Received 11 April 2022; Received in revised form 30 July 2022; Accepted 22 September 2022

Social Science & Medicine 313 (2022) 115394
2
89.5% when expanded to consider rural contexts (WHO and UNICEF,
2021). The burden of water fetching falls disproportionately on women
and girls and usually entails multiple steps: walking to a source, joining
long queues, lling containers, and carrying them home (Sorenson et al.,
2011; Sarkar, 2020). Water fetching predisposes women and girls to
musculoskeletal injuries, fatigue, and physical pain (Asaba et al., 2013;
Venkataramanan et al., 2020). Recurrent injuries from water collection
can also lead to disability (Geere et al., 2018). Water fetching after dark
increases the risks of rape, sexual harassment, gender-based violence,
and other physical attacks (Caruso et al., 2015; Choudhary et al., 2020).
Water collection is also linked with higher emotional distress and
reduced daily functioning (Tomberge et al., 2021). Cumulatively, water
insecurity affects women’s mental and psychosocial health by increasing
levels of stress, anger, anxiety, shame, and stigma (Bisung and Elliott,
2016; Wutich et al., 2020).
Though a large body of literature underscores the strong relationship
between place and health (Cutchin, 2007; King, 2010; Adams and
Nyantakyi-Frimpong, 2021), studies on water insecurity have not paid
sufcient attention to place-based environmental risks of the water
fetching journey. Specically, they have largely overlooked how expo-
sure to risks during water fetching contributes to embodied experiences
of water insecurity. The meager literature that addresses the
water-fetching journey usually limits the burdens of water collection to
number of trips, waiting time, and the weight of water-collection con-
tainers (Bapat and Agarwal, 2003; Crow and Odaba, 2010; Adams,
2018). In one of the few exceptions, a study in Dar es Salaam, Tanzania,
employed spatial video and mapping to uncover the many challenges in
the water-fetching environment, including trash, open drains, uneven
terrains, and people (Smiley et al., 2017).
To address this research gap, we used walking (go-along) interviews,
videos, and risk coding to examine how women’s everyday struggles for
water in informal settlements expose them to environmental risks and
compromise their health and well-being. Our specic objectives are to 1)
examine women’s everyday struggles for water, 2) identify the envi-
ronmental risks on women’s water-fetching paths and their potential
health impacts, and 3) examine the embodied dimensions of these ex-
periences. We dene risks as physical, social, or environmental factors
that might cause harm. We use the term informal settlements to indicate
unplanned residential areas where the lack of many public services is
pervasive - including access to safe water - which others may refer to as
urban unplanned settlements or slums. Through a combined focus on
observed (via video) and perceived risks (via interview), this study
draws from and contributes to the anthropological and geographic
concepts of embodiment, the embodied political ecology of health, and
time geographies. We argue that water journeys, beginning with the
seemingly simple practice of water fetching, is compounded by complex
decision making, constant spatiotemporal trade-offs, and exposure to
diverse risks, all of which have embodied health consequences.
2. Theoretical framework
While the construct of embodiment has origins in epidemiology and
medical/biological anthropology, it has increasingly become a useful
framework in human geography for theorizing the impact of resource
insecurity on bodies. Embodiment acknowledges that humans are
simultaneously social and biological (Csordas, 1999; Robinovich et al.,
2018). It asserts that bodies reect real livelihood challenges closely
intertwined with power and inequality (Petteway et al., 2019). Krieger
(2005), for instance, highlights that 1) bodies tell stories about—and
cannot be divorced from—the conditions of our existence; 2) bodies tell
stories that often—but not always—match people’s stated accounts; and
3) bodies tell stories that people cannot or will not tell. These stories
provide insights into how historical processes deepen social inequalities
and create uneven exposure to health risks (Krieger, 2005). It invites
careful analysis of how social and environmental experiences “get under
our skin” to affect health (Petteway et al., 2019, p. 1). Analysis of
embodiment requires keen attention to how ecological conditions and
social processes such as power relations, institutions, culture, inequality,
and behavior are entangled in the stories that bodies tell (Krieger and
Davey Smith, 2004).
Critical scholars of political ecology of health (PEH) acknowledge
that the subeld has not focused sufciently on embodiment (Jackson
and Neely, 2015). This critique has prompted renewed interest in
embodiment among PEH researchers. For instance, one emerging body
of work, broadly classied as political ecology of the body (see Kinkaid,
2019), takes seriously the body as an analytical site for understanding
society-environment relations (Doshi, 2017; Mountz, 2018; Petteway
et al., 2019). Embodied political ecology of health (EPEH) allows for
more rigorous analyses of often-invisible dimensions of
socio-environmental struggles tied to the body. For example, Nyanta-
kyi-Frimpong (2021) uses an EPEH approach to examine how climate
change increases women’s workloads and causes undernutrition by
altering child-feeding practices, while Kinkaid (2019) uses the frame-
work to interrogate the embodied health impacts of chemical farming in
north India.
Recent work on gender in urban spaces has, similarly, examined the
body as infrastructure (Andueza et al., 2021; Desai et al., 2015; Ram-
akrishnan, O’Reilly and Budds, 2021; Truelove and Ruszczyk, 2022).
Such scholarship illustrates how bodies express uneven experiences and
politics of resource ow in cities. For example, Truelove and Ruszczyk
(2022) demonstrate how the body as infrastructure underpins not just
social and material workings of the city but the everyday politics that
enable and constrain resource ows. Attention to “embodied infra-
structural congurations,” they argue, reveals important social and
political dimensions of everyday urban life (Truelove and Ruszczyk,
2022, p. 2). Similarly, in examining the politics of open defecation by
looking at the entanglements of the body with urban sanitation in-
frastructures, Desai et al. (2015) reveal the urban micro-politics that
shape how infrastructures are made, unmade, and experienced unevenly
by different bodies.
Despite many studies theorizing that water insecurity can become
embodied, empirical analysis in this area remains underdeveloped
(Rosinger and Brewis, 2019; Brewis et al., 2020). Recently, Rosinger
et al. (2021) established how water insecurity becomes embodied
through injuries and chronic stress. Elsewhere in Dhaka, Bangladesh,
Sultana (2020) found connections between water, embodiment, and
urban citizenship. We build on these emerging streams of inquiry by
extending the EPEH framework to an urban context and focusing on the
water-fetching journey as an embodied but largely overlooked dimen-
sion of water insecurity. By looking at both observed and perceived
risks, we contribute to EPEH by uncovering less visible aspects of
socio-environmental struggles and their embodied impacts. Importantly,
our paper moves the water insecurity literature forward by conceptu-
alizing embodiment as simultaneously physical and emotional.
We also borrow insights from time-geographical approaches that
emphasize that spatial and temporal interdependencies between in-
dividuals and their environment inuence health (Rainham et al.,
2010). Examining how humans allocate scarce time resources among
different, competing activities in geographic space (Miller, 2005), is
particularly useful in understanding the role of space-time constraints in
women’s everyday water journeys and decision making. Further, it is
useful for understanding how women survive different environmental
conditions and cope with spatiotemporal constraints by reshufing
everyday livelihoods (Fajarwati et al., 2022). Thus, engaging with time
geography is important for at least two reasons: 1) water journeys are
about how individuals’ everyday water collection activities are arranged
and coordinated in time and place; and 2) time-varying exposures
through water collection have health consequences.
Water journeys are far from straightforward and are often embedded
in temporal, emotional, and structural calculations and trade-offs
(Panchang, 2021). In the present conceptualization of the water
journey, we situate urban water-insecurity experiences in the body
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
3
while combining insights from time geographies to further illuminate
spatial and temporal dimensions. This combined approach opens new
possibilities for understanding how different experiences of water
insecurity produce diverse physical, emotional, and health effects,
particularly among women, and how everyday practices, social re-
lations, politics, gender, and emotions inuence water insecurity expe-
riences in urban environments (Doshi, 2017; Truelove, 2019).
3. Methods
3.1. Setting
We undertook this study in Ntopwa, a crowded informal settlement
in Blantyre, the second-largest city and commercial center in Malawi
(Fig. 1). Data were collected in the rainy season (January 2018). While
Malawi has made signicant progress toward improving access to safe
water, it is far from achieving the universal coverage of safe drinking
water specied in the United Nations’ Sustainable Development Goal Six
(United Nations, 2018). Over the last few decades, growth in the urban
supply of potable water has not kept pace with growth in demand from
population increase and rapid urbanization. Further, widespread in-
equalities in access to potable water persist between afuent neigh-
borhoods and informal settlements (Adams, 2018). The major
water-access challenges in Malawi’s urban areas include intermittent
water supply, frequent breakdowns of communal water kiosks, and long
waiting times at water points (Adams, 2018). In Ntopwa, most residents
are unable to pay the high cost of publicly available water from
improved sources (Coulson et al., 2021). These factors force people to
seek alternative, often unimproved, sources of water, such as streams,
rivers, and shallow open wells. One study found that use of river water
for cooking and cleaning was associated with increased risk of typhoid
fever in Blantyre (Gauld et al., 2020). Other studies have established
that even water sources generally considered safe by Ntopwa residents
have signicant concentrations of E. coli (Price et al., 2021), a nding
that is consistent with recent work showing that allegedly safe sources in
Malawi may be contaminated (Holm et al., 2016; Boakye-Ansah et al.,
2016).
3.2. Participants
As women are primarily responsible for household water collection
in Malawi, we focused on female water collectors. Using convenience
sampling, we recruited 25 women at 5 different types of water points in
Ntopwa: boreholes, water kiosks, public taps, small ponds, and shallow
wells. Participating women were aged 18 years or older and provided
written or verbal consent. The University of Stirling’s General University
Ethics Panel approved this study (reference GUEP169). We submitted
the study proposal and ethical clearance to the Blantyre City Council,
which reviewed it, provided an acceptance letter, and put us in touch
with community leaders.
3.3. Data collection
We used video-recorded walking (go-along) interviews to gather
data on perceived (by the participant) and observed (by the researcher)
risks during water fetching. This approach built on previous work using
spatial video to explore risks at the water point during water collection
(Smiley et al., 2017). A trained local female research assistant (RA)
undertook the interviews in Chichewa, a common local language of
Malawi. Questions explored water access, water use, experiences of
water collection, and perceived risks during water journeys. Interviews
were semi-structured, allowing exibility to explore topics that arose
during the interview and to enable place-based questioning dependent
on dynamic observations and experiences of the RA and interviewee
during the walk. The RA wore a GoPro HERO5 on a chest strap to video
record the route and audio record the interview. This method supported
more natural conversation since the interviewee wore no recording
devices and the RA had her hands free. The method was piloted locally
before data collection began.
3.4. Audio data analysis
All audio les were translated into English, transcribed, and saved as
a Word document. Following established procedures in qualitative data
analysis, we analyzed the transcripts using ve steps: data familiariza-
tion, independent coding, code consolidation, thematic sorting, and
content extraction and analysis (Miles et al., 2014). First, two coauthors
(EAA and SB) hand-coded the transcripts independently using a the-
matic analysis approach to identify common and recurrent themes
related to the research objectives. Coding was done both deductively to
identify predetermined themes related to water-fetching risks and
inductively to explore additional dimensions of risks and water-fetching
challenges. The coders generated about 40 codes, falling under topics
including water insecurity, risk types, contamination, perceptions of
Fig. 1. Map of Malawi showing the location of Ntopwa relative to the twin centers of Blantyre and Limbe. Background map for the right-hand panel from ©
OpenStreetMap contributors.
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
4
water quality, and water use. Through a series of iterations and dis-
cussions regarding their independent sets of codes, the two coders
agreed on the nal codes. The selected codes were then combined under
three overarching themes: 1) water insecurity experiences and coping
strategies; 2) everyday planning and decision making; and 3) percep-
tions of risks, contamination, and hygiene.
3.5. Video data analysis
We used an approach similar to Smiley et al.’s (2017) to code the
walking routes for risks and challenges. First, two researchers watched
30% of videos together to develop a consistent approach to code gen-
eration. Both researchers were familiar with Ntopwa, having been pre-
sent during data collection (HP) or worked there previously (EAA).
Using observation and discussion, researchers identied risks and
challenges the water collectors experienced under each of three cate-
gories: terrain, built environment, and people and behavior. We
considered built environment to be any aspect of the environment with
less human footprint or one that is more structural and less likely to
change with time. People and behavior, on the contrary, denote risks
that change more rapidly and can more easily be linked to everyday
decisions by people, such as vehicles, washing lines, and waste. Re-
searchers then coded the remaining videos independently. Once inde-
pendent coding was complete, the researchers discussed their
experiences of coding and areas of divergence before reaching a
consensus on codes. Risks and challenges were then grouped into
themes. GPS data from the water-collection journeys were combined
with the video data to explore the spatial distribution of observed risks
and challenges using QGIS (version 3.20.2). Route data were available
for 92% of walking interviews (n =23).
4. Results
4.1. Water insecurity experiences and coping strategies
Based on observations and qualitative analysis of audio interviews,
we found that participants collected water from public taps, kiosks,
boreholes, wells, and rivers/ponds (Fig. 2). Depending on level of de-
mand, water from small ponds and shallow wells could be fetched for
free, while water from kiosks and public taps cost between 35 and 80
Malawi Kwacha per 25-L bucket. Most participants used public tap and
water kiosk water for drinking and the water from the other sources for
household cleaning, bathing, laundry, and cooking. However, families
who could not afford tap water relied entirely on wells and rivers. Daily
expenditure on water varied widely; households spent 100 MK (0.12
USD) to 400 MK (0.48USD) daily depending on factors including cost
per bucket, family size, daily need, and number of water-related chores.
Most women did not know their exact monthly water expenditure
because of daily variation in water purchase and use. Some of those who
could not afford to buy water every day leveraged friendships with
water vendors to fetch water and pay later.
Many women shared frustrations about unpredictable water supply
and long waiting times at the water kiosk. For example, some women
reported arriving at the water point as early as 2 a.m. to mitigate for
intermittent supply, especially during the dry season. While the walking
times to primary sources, which we dened as the main source for most
household needs, were short—with one-way trips ranging from 25 s to 7
min and an average of 3 min across all participants—waiting times were
long, often extending beyond an hour. Coupled with the need for mul-
tiple trips, often to supplementary sources, water fetching was a sig-
nicant time burden, especially for those with fewer buckets. Some
women lamented that wait times were unpredictable and therefore
derailed daily plans to complete household chores such as cooking.
Conicts often occurred between women at the water point because of
disagreements over arrival time, position in queue, bucket theft, and
number of buckets one person could fetch. On rare occasions these
conicts escalated into st ghting.
Women used diverse strategies to cope with different aspects of
water insecurity. When taps stopped owing, the most popular alter-
natives were water kiosks in other communities, private taps owned by
individuals, boreholes, and rivers and wells, which many described as
unsafe for drinking. To carry water over longer distances, most women
used small buckets, which reduced how much water they could access
per trip. Finally, communal practices of water sharing at the water point
were critical to how women dealt with intermittent supply. These
practices included, for example, allowing only one bucket at a time per
person until everyone in line had water. These norms were started either
by individual water fetchers, water sellers to prevent conicts, or
traditional leaders to ensure fair water access.
4.2. Navigating water insecurity through everyday planning and decision
making
Everyday decisions, planning, and budgeting were critical to how
women navigated the uncertainties of water insecurity. To minimize
water use, reduce water expenditure, and cope with intermittent water
supply, women triaged water-related tasks at home, used water from
different sources for different needs, and planned when and how to
complete household tasks. To reduce water expenditure and reduce
water carrying, some washed dirty clothes in the river. Most women
would rst secure safe drinking water from the taps before fetching
water from wells and rivers for other uses.
Interviewees reported a range of decisions that underpinned their
water-fetching journeys (compiled in Fig. 3), beginning with a thorough
assessment of needs and capabilities. This assessment included, at
minimum, how much water was needed on a given day, income versus
cost of water, choice of route, and household storage capacity. Planning
for the journey also involved budgeting money and time while being
Fig. 2. Examples of key local water sources used by Ntopwa women: a) public tap, b) water kiosk, c) borehole, d) well, e) pond, and f) river.
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
5
Fig. 3. Domains of decision making for women collecting water in Ntopwa.
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
6
cognizant of uncertain water supply. These domains of decision making
are neither chronological nor idealistic. Rather, the order in which they
are considered, and the weight given to each on a given day may be
inuenced by different factors, including day, season, cost, competing
household chores, and other space-time considerations.
Women also described the multiple measures they took once home
with the water to prevent cross contamination, including separating
used and unused drinking cups, allocating specic cups for water
fetching from buckets, and keeping used cups far from buckets. Mothers
reported monitoring young children regularly to ensure that used and
unused cups were not mixed, and ngers were not dipped in stored
water. In some households, if water originally earmarked for drinking
displayed visible signs of contamination, they discontinued using it for
drinking and instead used it for cleaning and washing dishes. Some
households separated buckets for everyday use from storage buckets to
prevent mixing of clean and unclean water.
The decision-making process for water fetching is rife with trade-
offs, many of which have consequences either on the quality of water
obtained or on the physical, nancial, or time burden placed on the
water bearer. Fig. 4 shows the difference between four participants that
described one aspect of decision making – where to fetch water – and the
resulting trade-offs. Those participants who were able to avoid a trade-
off on water quality, whether through proximity to a reliable safe water
source and/or greater nancial security or otherwise, experienced less
water insecurity. However, all participants in this study experienced a
high base level of water insecurity, as water journeys can be unpre-
dictable and costly. Women can leave their homes not knowing where
they will nd water, how much they will need to pay, or how long they
will have to wait for it.
4.3. Perceptions and experiences of risks described in interviews
The most common risks reported by women on their water-fetching
routes were slippery terrains, sharp objects, muddy paths, rocks and
stones, mosquitoes, and conicts. Table 1 illustrates some of the com-
mon complaints about environmental risks. Many women indicated that
water fetching was more difcult during the rainy season because of
muddy and slippery terrain. Slippery paths littered with rubbish were
even more difcult to pass. Some women said falling was quite common,
but they accepted it as part of their water journey. To avoid slipping,
some women chose to go without shoes, but this strategy also exposed
their feet to sharp objects that could similarly cause harm to their bodies.
Some removed their footwear to avoid slipping while fetching water,
especially from rivers and streams. Some women tried walking slowly
Fig. 4. Examples of factors that led four participants to make different trade-offs when fetching water. Participants listed from left to right as least to most
water insecure.
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
7
and watching every step to guard against potential falls. Others com-
plained of thorns and other sharp objects that cause stumbling, falling,
and injuries. Many used expressions of acceptance, such as ‘We are used
to it’ (#11), ‘We just keep walking’ (#10), ‘We pick ourselves [up] and
continue walking; what else can we do?’ (#6), ‘We have no other option’
(#5),‘You just have to be strong. What else can I do?’ (#5), and ‘What else
can we do since water is life?‘ (#2). In one instance, a woman said the
following about her experience on slippery terrain: ‘It gets slippery of
course, but what can you do? As a woman, you must just use your feet and
knees until you get home.’ (#24).
Most women recognized potential sources of water contamination
and took steps to minimize exposure to fecal pathogens. During their
water journey, some avoided sticking their ngers into the water bucket.
Others took preventative steps at home to avoid compromising the
quality of their water. For example, those who fetched water with
buckets or containers with no covers would improvise covers at home to
try to keep the water safe. Some avoided using water from boreholes
constructed near toilets because of fear of contamination through
groundwater leakage. Those women who failed to take preventative
measures stated that they knew about the risks of using contaminated
water but were constrained by other factors such as nances, time, or
mobility.
4.4. Risks and challenges observed from videos
We identied 442 risks or challenges during 25 walks from the water
source to the house (one-way trip) through observations of the routes
taken (Table 2). On average, there were 6.3 risks or challenges per
minute (range 1.9–15.2). The most common of these were rocks and
stones (n =82; terrain), uneven/sloping ground (n =74; terrain),
muddy or slippery ground (n =52; terrain), water-lled drainage
channels (n =46; terrain) and waste (n =39; people & behavior).
Narrow paths (n =26; built environment), steps (n =24; built envi-
ronment) and dry drainage channels (n =22; terrain) were also com-
mon. Most of the risks and challenges related to terrain (68.8%; n =
304), followed by people & behavior (17.6%; n =78), and built envi-
ronment (13.6%; n =60). It is worth noting that because dense urban
areas such as Ntopwa often have shorter walk times to off-premise
supply compared to the national average, which is driven more sub-
stantially by rural contexts and statistics, the volume and variance of
risks observed on an average water journey in Malawi would likely be
greater. Examples of the challenges and risks encountered are shown in
Fig. 5.
We plotted observed risks and challenges on a map to explore spatial
patterns (Fig. 6). Women experienced risks and challenges relating to
terrain across the community, including along the major routes through
the settlement, as highlighted by the concentration of terrain-related
challenges observed along the main horizontal path/road through
Ntopwa (Fig. 6a; black arrow). Risks and challenges relating to the built
environment were observed predominantly in the most densely popu-
lated parts of the settlement and around water points (e.g., steps down
from the kiosk to the path). Risks and challenges relating to people and
behavior were observed where people were using and sharing spaces, for
example along main routes through Ntopwa and in more densely
populated parts of the settlement which were used for multiple purposes
at once, for example, walking through to fetch water, drying, washing,
or cooking. In Fig. 6b, we combine the spatial patterns of risks and
challenges with frames from video footage to illustrate in more detail
what a typical walk to fetch water looked like for one woman.
Use of the video during the walking interviews enabled researchers
to observe the women’s footwear, facial expressions, and carrying
techniques. For example, while crossing a wide, deep ditch with a full
bucket of water, one woman removed the bucket from her head
(Fig. 7a–c), carried it in her hands in front of her (Fig. 7d–h) while
stepping across the ditch (Fig. 7i), rested it on a rock shelf once across
the ditch (Fig. 7j), and put the bucket back on her head before
continuing her walk (Fig. 7k–l). This example highlights the varied
physical strains water collection places on bodies and the high number
of body movements involved in navigating a single hazard.
5. Discussion
Many of our ndings align with the literature on urban water inse-
curity, showing high household expenditures on water, intermittent
water supply, and a heavy time burden of multiple trips and long waiting
times (e.g., Adams, 2018; Sarkar, 2020; Cassivi et al., 2021; Stoler et al.,
2020). Our nding that some areas coped with water insecurity by
instituting one-bucket-at-a-time rules at the water point is consistent
with the emerging literature on water sharing (Wutich et al., 2018;
Bukachi et al., 2021). Some coping mechanisms illustrated inequalities
in water-insecurity experiences – for example, households with more
buckets could store more water and therefore limit the number of trips,
and households who could afford additional tap water did not have to do
their laundry in the river.
Our approach of using video-recorded walking interviews during
everyday water journeys allows us to go beyond examining these ex-
periences of water insecurity, to map the different pathways through
which an activity like water fetching predisposes people in a community
to different environmental risks. Direct observation of water fetching
encouraged us to broaden our initial conception of risks from primarily
physical to important social dimensions such as conicts on private
routes. It has also enabled us to consider urban water insecurity as an
embodied experience from decision making through trips to water
points and household practices for use and storage. The following ana-
lyses advance both the embodiment and the EPEH literatures by
bringing to light how social and environmental struggles ‘get under the
skin’ and affect health through visible and invisible pathways (Krieger,
2005; Petteway et al., 2019).
5.1. Bodies as infrastructure: physical embodiment
Water-insecurity experiences become physically embodied through
impacts on women’s bodies and livelihoods (Rosinger et al., 2021), in
part due to a reliance on bodies as infrastructure (Truelove and Ruszc-
zyk, 2022). In the present study, there are at least two salient ways in
which women’s bodies act as infrastructure. The rst is obviously
through the transportation of water from the source to the home which
would, in other contexts, be performed by pipes. As in previous work, we
found that women are exposed to many risks of injury during water
fetching including not only the carrying of heavy containers but also
navigating difcult physical environmental factors such as slippery
terrains, narrow paths, ditches, puddles, sharp objects, stones, and tree
Table 1
Perceived water-fetching risks and illustrative quotes from transcripts.
Risk Illustrative Quote
Slippery
terrain
“You can lose your footing and fall of course when it gets slippery at
times. I have fallen before” (#13)
Falls “It’s possible that I can fall, and if it happens that the water has
spilled, then I return to the tap, wash the bucket out, rell it, and
return home with it.” (#14)
Drowning “A child can drown, but an adult cannot. The well is waist deep. A
child can drown. If I were to stand in the well, the water will only be
level with my waist.” (#21)
Sharp objects “… the problem is thorns and sharp objects that we regularly step
on as we are walking.” (#4)
Mosquitoes “Obviously there are mosquitos breeding here for sure.“. (#1)
Muddy path “It’s muddy here. When it rains, this place is very muddy, making
walking difcult.” (#7)
Rocks/stones “We walk through the stony path, what else can we do?” (#12)
Route conict “We get shouted at. We get told that ‘this is not a public road.’”
(#16)
Road crossing “We must cross the tarmac road to get there when water is scarce.
We wait for the cars to pass before we cross the road.” (#14)
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
8
branches (Geere et al., 2018; Venkataramanan et al., 2020; Patil and
Sangle, 2022). Another way in which women’s bodies act as infra-
structure is by sacricing sleep to join early morning queues, or trav-
eling even longer distances to access alternate sources, to compensate
for intermittent supply – a challenge often addressed through infra-
structure such as municipal storage tanks.
A large portion of the risks women encountered during water jour-
neys stemmed from the built environment as well as from people and
their behavior (Fig. 5). As established elsewhere, social and behavioral
factors in densely populated areas elevate the risk of falls and injuries
because women have to carefully move around people who are using the
same route and navigate wet terrains and puddles created by roadside
laundry and cooking (Smiley et al., 2017). Women in our study had to
cross constructed ditches, move sideways through narrow spaces be-
tween buildings, and bend under clotheslines while carrying water, all of
which could result in musculoskeletal and spinal injuries (Venkatar-
amanan et al., 2020). While crossing ditches, women oriented their
bodies in ways that could lead to pain and lumbar injury (Fig. 6). These
ndings support calls for more systematic biomechanical analyses on
how different postures and movements during water carrying affect the
spine (Patil and Sangle, 2022). Further impacts on women’s bodies
occurred at the water point, through conicts over arrival time, bucket
thefts, and contested positions in the queue that were commonplace and
sometimes escalated into brawls. Some suffered verbal assaults while
looking for water from private sources in other neighborhoods.
Analysis of the videos revealed signicantly more risks in both
number and type (442 risks in 23 categories across 25 journeys; Table 2)
than women self-identied during the interviews, suggesting that many
risks are so embedded within the everyday water-fetching experience
that they are invisible to those experiencing them. We found that on
average, women tended to identify risks related to terrain or social
conicts more readily than risks stemming from the built environment.
That many observed risks were not perceived by participants has im-
plications for practitioners designing urban policies and programs, in
that relevant risks may not be identied through community consulta-
tion alone.
5.2. Mental burdens of water insecurity: emotional embodiment
Previous work has illustrated how fear of injuries from water
fetching can induce psychosocial stress (Bisung and Elliott, 2016). Our
study found that another pathway that water insecurity becomes
embodied is through the emotional burden of planning and decision
making, which shapes several aspects of women’s daily lives. These
decisions are neither simple nor casual and comprise a complex web of
considerations involving difcult trade-offs (Panchang, 2021). Partici-
pants in the present study reported making complex choices as they
planned their daily water-fetching journey: assessing household water
needs, deciding where to fetch water and the route they would take, and
deciding how water would be stored and whether it would be treated.
Within the framework of time geographies, this contingent
decision-making process considering multiple factors such as availabil-
ity, cost, and time, highlights not only the spatial and temporal limita-
tions of a single trip but also daily uctuations in water insecurity and
related decision making (Magnus, 2018; Price et al., 2019; Pers et al.,
2022). These decisions are also embedded in social inuences, which
Table 2
Risks and challenges encountered during journeys from water source to home identied from videos.
Terrain
# Source One-way trip
time (mm:ss)
Lid Ditch Drainage
channel – dry
Drainage
channel – wet
Muddy/slippery
ground
Narrow
path
Puddles Rocks and
stones
Step Uneven/sloping
ground
Tree branches
and roots
1 Tap 03:31 N 0 1 2* 1 0 1 1 0 3 0
2 Tap 02:21 N 1 1 2* 0 0 0 3 0 1 0
4 BH 01:43 N 1 0 0 1 0 0 2 0 2 0
5 Kiosk 03:42 N 0 1 0 0 0 0 2 0 3 0
6 Well 05:07 N 1 5 5 3 0 0 7 0 7* 0
7 Kiosk 01:31 Y 0 1 1 0 0 0 3 0 2 0
8 Pond 02:22 N 1 0 2 2 0 0 2 0 1 0
9 Kiosk 02:29 N 0 0 1 1 0 0 2 0 0 0
10 Tap 04:57 N 1 4 3* 1 0 0 6 4 2 0
11 River 01:39 N 0 2 0 1 0 0 6 0 6 0
12 Tap 02:00 N 0 1 0 0 0 0 2 0 3 0
13 Tap 01:33 N 0 1 1 0 0 0 1 0 1 0
14 Tap 00:25 N 0 1 0 0 0 0 1 0 1 0
15 Kiosk 00:50 N 0 0 0 1 0 0 2 0 2 1
16 Kiosk 06:00 N 0 0 7* 7 1 1 8* 0 4* 0
17 Pond 03:10 N 0 0 3 4 0 0 7 1 5 0
18 Pond 05:44 N 0 0 5 9 0 1 9 0 8 0
19 Well 07:36 N 2 1 3 4 0 2 1 0 4 0
20 BH 04:11 N 0 0 0 5 0 1 3 0 1 1
21 Pond 01:59 N 0 0 3 1 0 0 1 0 1 0
22 Kiosk 02:55 Y 1 0 2 3 0 0 1 2 3 1
23 Tap 04:02 Y 0 2 1 2 0 0 6 0 5 0
24 Tap 04:18 Y 0 1 3 4 0 0 4 0 6 0
25 Kiosk 01:26 N 0 0 1 1 1 0 1 0 2 0
26 BH 02:37 N 0 0 1 1 0 0 1 0 1 0
TOTAL: 8 22 46 52 2 6 82 7 74 3
For each specic risk or challenge, the number shows how many times it was encountered on the water fetching route and n* indicates that one or more instances of
the risk or challenge were sustained for part of the journey. For the water sources outlined, all taps refer to public taps and BH =borehole. The ‘Lid’ column relates
to whether the water fetcher put a lid on the bucket (Y) or not (N).
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
9
Krieger and Davey Smith (2004) show can then become embodied into
health. Furthermore, the sheer number of decisions and the trade-offs
involved implicitly add to the mental energy as well as the time
required for water fetching.
Each decision or incident along the way can also compound the
number of worries a woman might experience on a water journey. For
example, our study uncovered a cascade of consequences from a fall that
participants worried about. A woman falling while carrying water loses
both the cost of the water and the time they took to walk and queue for
it. A broken bucket from a fall necessitates a trip back home for another
bucket and reduces overall household storage capacity. One less bucket
at home could also mean cross-contamination of water for drinking and
domestic purposes. In this way, the psychosocial stress caused by fear of
falling extends well beyond the fear of physical injury. These dimensions
of psychosocial stress underscore the increasing importance of analyzing
the embodied impacts of water insecurity, which are not just physical,
but also emotional.
5.3. Water fetching: an survival and acceptance as embodiment
Perhaps the most striking sign of embodiment of urban water inse-
curity we observed was women’s acceptance and normalization of the
many risks, uncertainties, and challenges associated with the water
journey—illustrated by expressions such as ‘We are used to it’. Other
statements, like ‘As a woman, you just have to use your feet and knees until
you get home,’ illustrate how women sacrice their bodies daily as
infrastructural labor to make up for uneven ows of water in cities
(Lancione and McFarlane, 2016; Truelove and Ruszczyk, 2022). Women
normalized their everyday experiences of water insecurity for different
reasons. First, because water is indispensable for household functioning,
many women viewed water fetching as an act of survival, normalizing
risk in the interest of self-preservation and avoidance of debilitating
stress. As one participant said, “Human life depends on water, so if we get
discouraged after a fall then there won’t be anything good” (#24). This view
suggested that the daily need for water is normal, so all aspects of
fetching water must also be normal. Second, there was a general sense of
recurrence among women, most of them well accustomed to
water-insecurity experiences. Obtaining water required them to
repeatedly optimize labor, time, and cost. It also required them to
internalize risk because the trade-off involved water, a necessity for
their family’s well-being. Third, women communicated an undercurrent
of helplessness associated with institutional and sociopolitical failures to
address water challenges. Statements such as ‘We have no choice’ show
that women recognized how little they could change about deep-seated
institutional failures that produce water insecurity.
Such acknowledgements of state failure, no matter how subtle, are
manifestations of how water insecurity is tied to historical processes of
social inequality and embodied through social and material struggles
(Brewis et al., 2020). It is also a notable critique of the often all-or-none
thinking behind water strategies that priotize technical drinking water
standards over ease of access. For example, in Malawi there has his-
torically been controversy over self-supply approaches, with proponents
arguing for incremental improvements while opponents say it compro-
mises on water quality and other technical standards. Those opposed to
self-supply for reasons of water quality, though likely considering health
and wellbeing, may be overlooking the negative health impact on
women’s bodies when fetching water for domestic use from a distant
source. Our study shows that most women were already well-aware of
the dangers of drinking unsafe water and drawing from different water
sources accordingly. Private sources for domestic use could therefore
Terrain Built environment People & behavior
Other Low door Low roof Narrow path Step Other Fingers in water Household items on path People and animals Vehicles Washing lines Waste Other TOTAL
0 0 0 0 1 0 1 0 2 0 0 2 0 15
0 0 1 0 0 0 1 0 1 0 1 1 0 13
0 0 0 2 0 0 0 0 0 0 0 0 0 8
0 0 0 0 1 0 0 0 0 0 0 1 0 8
0 0 0 3 1 0 0 0 0 0 0 5 0 37
0 0 0 2 1 0 0 0 0 0 1 0 0 11
0 0 0 0 0 0 0 0 1 0 0 1 0 10
0 0 0 0 1 0 1 3 0 0 1 1 0 11
0 0 1 6 0 0 0 1 0 0 2 2 0 33
0 0 0 3 0 1 0 3 0 0 1 2 0 25
0 1 0 1 2 1 0 0 0 0 2 0 0 13
0 1 0 0 0 1 0 0 2 0 0 0 0 8
0 0 0 0 0 0 0 0 2 0 0 0 0 5
0 0 0 2 1 0 0 0 1 0 0 0 0 10
1 0 0 1 0 1 0 0 0 0 0 7 0 38
0 0 0 2 1 0 0 0 0 0 0 0 2 25
0 0 0 1 1 0 0 0 0 0 0 4 0 38
1 1 0 0 2 0 1 0 1 1 0 2 0 26
0 0 0 0 0 0 0 1 0 0 0 3 0 15
0 0 0 3 2 0 0 0 0 0 0 1 0 12
0 1 0 0 2 0 0 1 0 0 1 3 0 21
0 0 0 0 2 0 0 0 0 1 0 1 0 20
0 0 0 0 3 0 0 1 2 0 0 1 0 25
0 0 0 0 2 0 0 0 0 0 0 2 0 10
0 0 0 0 1 0 0 0 0 0 0 0 0 5
2 4 2 26 24 4 4 10 12 2 9 39 2 442
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
10
help to reduce the number of long-distance water journeys required
without increasing consumption of contaminated drinking water.
5.4. Lessons and limitations
Recent geographical scholarship has called for consideration of
walking interviews as a valuable data-collection method, especially for
understanding urban phenomena (Pierce and Lawhon, 2015). Despite
having a long history in ethnographic research (Kusenbach, 2003),
walking interviews have only become central to geographic research in
the last decade. Our study afrms walking interviews as a powerful
method for eliciting everyday lived experiences in informal settlements
in support of embodiment research. This method is useful for under-
standing human interactions with the natural environment and people’s
lived experiences in different social and physical contexts (Carpiano,
2009; Evans and Jones, 2011). It also enables the researcher to build
rapport with research subjects and develop useful networks in study
communities (Carpiano, 2009). In urban environments, this method can
uncover otherwise-invisible experiences of inequality.
Walking interviews enabled us to achieve more in-depth ndings
than traditional household interviews or surveys would have yielded.
They enabled the RA to use dynamic questioning in response to place-
based observations regarding relevant social and physical phenomena
(Carpiano, 2009), reduced the power imbalance between the inter-
viewer and the interviewee by situating the interview on a route familiar
to the interviewee and avoiding the pressure of face-to-face interviews,
and decreased the time burden placed on participants since the inter-
view took place during an activity they were already undertaking. Oc-
currences during the water-fetching journey triggered emotions about
water insecurity and water-fetching risks that women might not other-
wise have communicated. The present study provides a useful example
of combining interviews and spatial video that could be used in future
studies to achieve a fuller understanding of the water journey. By
combining interviews with video data, we can better understand ‘the
stories bodies tell in conjunction with those recounted—or hidden or
denied—by individuals’ (Krieger, 2005, pg 351).
Despite these advantages, we encountered a number of challenges
inherent to these methods that researchers wishing to use them in future
studies should consider. Because interviews happen along an uncharted
path, the interviewer must be sufciently skilled to adapt questioning to
the surrounding environment and, potentially, to operate multiple
pieces of equipment simultaneously (e.g., video recorder, GPS). This
complexity necessitates that interviewers undergo enhanced training on
methods and that the methods are piloted locally. Informal settlements
often have signicant background noise, including, as in our case, the
noise of wind and the in-built microphone scratching against clothing.
Adding a clip-on audio recorder to the interviewer, and even the inter-
viewee if possible, can ensure that the audio is audible throughout the
interview recording, which is vital for transcription and translation.
Additional straps to reduce the swinging of the video recorder while
walking would also be benecial to ensure a more stable image is
captured and reduce noise interference if relying on the in-built micro-
phone. Finally, it is important that at least two people code the videos
independently and then compare results to validate coding and ensure
consistency across codes.
6. Conclusion
By tracing water journeys using video-recorded walking interviews,
we have shown how the seemingly simple practice of water fetching is
compounded by the need for complex planning and decision making,
omnipresent trade-offs, and exposure to diverse risks, all of which have
both physical and emotional embodied consequences. Findings
contribute empirical evidence to the study of water insecurity and
embodiment (Rosinger et al., 2021) and strengthen the theoretical
framework centering bodies as analytical sites (Doshi, 2017; Mountz,
2018) and as infrastructure (Andueza et al., 2021; Truelove and
Ruszczyk, 2022).
By demonstrating that environmental risks and embodiment are
important dimensions of water insecurity in informal settlements, our
study provides important lessons for the global monitoring of safe water
and the design of water-insecurity interventions. The world is currently
not on track to achieve the United Nations’ Sustainable Development
Goal number six (SDG 6), which seeks to ensure availability and sus-
tainable management of water and sanitation for all by 2030 (UN Water,
2021). While piped water on premises is a proven path to household
water security (Bisung and Elliott, 2018), it remains a distant goal for the
nearly 1 billion people living in urban informal settlements. Therefore,
although communal taps and basic water-service infrastructure remain
important for achieving global targets on safe water, the burdens of
water insecurity in dense urban settlements extend beyond the physical
availability of public water points.
In order to achieve desired health outcomes, interventions must also
address the myriad risks associated with water fetching journeys by
incorporating improvements in the water-fetching environment. These
may include, but are not limited to: extending water point installation
and maintenance guidelines to include a suitable throughfare for water
fetchers; upgrades or arrangements at existing communal water points
for water storage – through simple tank systems and either a pumping
system or a rota for night workers to ll them; and incentivising and/or
regulating water supplied from private individuals when accessed dur-
ing public water shortages. Important changes to policies regarding
private sources, water point allocation criteria, and built environment
regulations may also be required where relevant.
Finally, our ndings suggest areas for further research. While a
rapidly growing body of scholarship has established a strong relation-
ship between the physical burden of water carriage and emotional
distress (Tomberge et al., 2021), it is unclear whether normalization of
the burden of water fetching—as observed in the present study-
—attenuates or elevates this distress. Further, the question of whether
different natural or built environmental and behavioral risks, as well as
total number of risks, are associated with different psychosocial out-
comes requires systematic inquiry.
Credit author statement
Ellis Adjei Adams: Conceptualization, Writing – original draft,
Writing – review & editing; Sydney Byrns: Writing – review & editing;
Save Kumwenda: Review & Editing; Richard S. Quilliam: Review &
Editing; Theresa Mkandawire: Review & Editing; Heather Price:
Conceptualization, Writing – review & editing.
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
11
Fig. 5. Examples of the risks and challenges
commonly experienced by Ntopwa women during
water collection as captured on video during the
walking interviews included 1) terrain: a) rocky,
uneven/sloping ground made slippery from rain, b)
muddy ground, c) rocky steps, d) muddy ground with
large puddles, e) muddy/slippery ground with a wet
drainage channel on the left; 2) the built environ-
ment: f) low door, g) stepping over a dry drainage
channel, h) narrow path, i) large pile of bricks (coded
as ‘other’), j) steps into the house; and 3) people &
behavior: k) sharing the path with a motorcyclist, l)
sharing the path with someone washing dishes, m)
clotheslines across the path, n) large waste pile, o)
children playing with taps at a kiosk.
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
12
Fig. 6. a) Spatial distribution of risks and challenges
observed from video-recorded walking interviews
undertaken during 23 water-fetching journeys with
women in Ntopwa. The categories of risks/challenges
(people and behavior, built environment, and terrain)
align with data in Table 2. The black arrow highlights
one of the main routes through Ntopwa. b) Zoomed-
in map from (a) highlighting the risks/challenges of
one woman’s journey to collect water (participant 5).
Still images from the video illustrate some of the
risks/challenges experienced on the route.
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
13
Funding statement
This work was supported by the Royal Geographical Society, UK
[grant number ESRG02/17].
Data availability
The authors do not have permission to share data.
Acknowledgement
We are grateful to Elizabeth Nkwanda for providing eld research
assistance and to Enock Bamusi for transcribing the videos. We are also
thankful to Peter Nkwanda for facilitating the eldwork. We appreciate
the anonymous reviewers for their insightful feedback and comments
that helped to improve the manuscript. Finally, we thank all community
members of Ntopwa, Blantyre who participated in the study.
References
Adams, E.A., Nyantakyi-Frimpong, H., 2021. Stressed, anxious, and sick from the oods:
a photovoice study of climate extremes, differentiated vulnerabilities, and health in
Old Fadama, Accra, Ghana. Health Place 67, 102500.
Adams, E.A., Stoler, J., Adams, Y., 2020. Water insecurity and urban poverty in the
Global South: implications for health and human biology. Am. J. Hum. Biol. 32 (1),
e23368.
Adams, E.A., 2018. Thirsty slums in African cities: household water insecurity in urban
informal settlements of Lilongwe, Malawi. Int. J. Water Resour. Dev. 34, 869–887.
Adams, E.A., Price, H., Stoler, J., 2019. Urban slums, drinking water, and health: trends
and lessons from sub-Saharan Africa. In: Handbook of Global Urban Health.
Routledge, pp. 533–552.
Andueza, L., Davies, A., Loftus, A., Schling, H., 2021. The body as infrastructure.
Environ. Plann.: Nat. Space 4, 799–817.
Anthonj, C., 2021. Contextualizing linkages between water security and global health in
Africa, Asia and Europe. Geography matters in research, policy and practice. Water
Secur. 13, 100093.
Asaba, R.B., Fagan, H., Kabonesa, C., Mugumya, F., 2013. Beyond distance and time:
gender and the burden of water collection in rural Uganda. WH2O: J. Gend. Water 2
(1), 31–38.
Bapat, M., Agarwal, I., 2003. Our needs, our priorities; women and men from the slums
in Mumbai and Pune talk about their needs for water and sanitation. Environ.
Urbanization 15 (2), 71–86.
Bisung, E., Elliott, S.J., 2018. Improvement in access to safe water, household water
insecurity, and time savings: a cross-sectional retrospective study in Kenya. Soc. Sci.
Med. 200, 1–8.
Bisung, E., Elliott, S.J., 2016. ‘Everyone is exhausted and frustrated’: exploring
psychosocial impacts of the lack of access to safe water and adequate sanitation in
Usoma, Kenya. J. Water, Sanit. Hyg. Dev. 6, 205–214.
Boakye-Ansah, A.S., Ferrero, G., Rusca, M., Van Der Zaag, P., 2016. Inequalities in
microbial contamination of drinking water supplies in urban areas: the case of
Lilongwe, Malawi. J. Water Health 14 (5), 851–863.
Boateng, D., Tia-Adjei, M., Adams, E.A., 2013. Determinants of household water quality
in the Tamale Metropolis, Ghana. J. Environ. Earth Sci. 3 (7), 70–77.
Brewis, A.A., Piperata, B., Thompson, A.L., Wutich, A., 2020. Localizing resource
insecurities: a biocultural perspective on water and wellbeing. Wiley Interdiscipl.
Rev.: Water 7, e1440.
Bukachi, S.A., Omia, D.O., Musyoka, M.M., Wambua, F.M., Peter, M.N., Korzenevica, M.,
2021. Exploring water access in rural Kenya: narratives of social capital, gender
inequalities and household water security in Kitui county. Water Int. 46, 677–696.
Carpiano, R.M., 2009. Come take a walk with me: the “Go-Along” interview as a novel
method for studying the implications of place for health and well-being. Health Place
15 (1), 263–272.
Caruso, B.A., Sevilimedu, V., Fung, I.C.H., Patkar, A., Baker, K.K., 2015. Gender
disparities in water, sanitation, and global health. Lancet 386 (9994), 650–651.
Cassivi, A., Tilley, E., Waygood, E.O.D., Dorea, C., 2021. Household practices in
accessing Drinking water and post collection contamination: a seasonal cohort study
in Malawi. Water Res. 189, 116607.
Csordas, T.J., 1999. Embodiment and cultural phenomenology. Perspect. Embodiment:
Intersections Nat. Cult. 143, 162.
Choudhary, N., Brewis, A., Wutich, A., Udas, P.B., 2020. Sub-optimal household water
access is associated with greater risk of intimate partner violence against women:
evidence from Nepal. J. Water Health 18 (4), 579–594.
Coulson, A.B., Rivett, M.O., Kalin, R.M., Fern´
andez, S.M.P., Truslove, J.P., Nhlema, M.,
Maygoya, J., 2021. The cost of a sustainable water supply at network kiosks in peri-
urban Blantyre, Malawi. Sustainability 13, 4685. https://doi.org/10.3390/
su13094685.
Crow, B., Odaba, E., 2010. Access to water in a Nairobi slum: women’s work and
institutional learning. Water Int. 35 (6), 733–747.
Cutchin, M.P., 2007. The need for the “new health geography” in epidemiologic studies
of environment and health. Health Place 13 (3), 725–742.
Desai, R., McFarlane, C., Graham, S., 2015. The politics of open defecation: informality,
body, and infrastructure in Mumbai. Antipode 47, 98–120.
Doshi, S., 2017. Embodied urban political ecology: ve propositions. Area 49, 125–128.
Evans, J., Jones, P., 2011. The walking interview: methodology, mobility and place.
Appl. Geogr. 31 (2), 849–858.
Fajarwati, A., Sukamdi, S., Hizbaron, D.R., Listyaningsih, U., Hadijah, Z.,
Rachmadani, P., 2022. Exercising time geography in gender and disaster. Discourse
through women headed household experience during drought. Hum. Geogr. 16,
53–70.
Fig. 7. Still images taken from a video recording of a woman crossing a ditch while holding a bucket of water. a–b) approaching the ditch, c) removing the bucket
from her head in preparation for crossing, d–h) crossing the ditch with the bucket held in front of her body, i–l) putting the bucket back on her head and continuing
her journey.
E.A. Adams et al.

Social Science & Medicine 313 (2022) 115394
14
Geere, J.A., Bartram, J., Bates, L., Danquah, B., Evans, M.B., Fisher, N., Groce, B.,
Majuru, M.M., Mokoena, Mukhola, M.S., 2018. Carrying water may be a major
contributor to disability from musculoskeletal disorders in low income countries: a
cross-sectional survey in South Africa, Ghana and Vietnam. J. Glob. Health 8.
Gauld, J.S., Olgemoeller, F., Nkhata, R., Li, C., Chirambo, A., Morse, T., Gordon, M.A.,
Read, J.M., Heyderman, R.S., Kennedy, N., Diggle, P.J., Feasey, N.A., 2020.
Domestic river water use and risk of typhoid fever: results from a case-control study
in Blantyre, Malawi. Clin. Infect. Dis. 70, 1278–1284. https://doi.org/10.1093/cid/
ciz405.
Holm, R., Wandschneider, P., Felsot, A., Msilimba, G., 2016. Achieving the sustainable
development goals: a case study of the complexity of water quality health risks in
Malawi. J. Health Popul. Nutr. 35 (1), 1–9.
Jackson, P., Neely, A.H., 2015. Triangulating health: toward a practice of a political
ecology of health. Prog. Hum. Geogr. 39 (1), 47–64.
King, B., 2010. Political ecologies of health. Prog. Hum. Geogr. 34 (1), 38–55.
Kinkaid, E., 2019. Embodied political ecology: sensing agrarian change in north India.
Geoforum 107, 45–53.
Krieger, N., 2005. Embodiment: a conceptual glossary for epidemiology. J. Epidemiol.
Community Health 59 (5), 350–355.
Krieger, N., Davey Smith, G., 2004. Bodies count,” and body counts: social epidemiology
and embodying inequality. Epidemiol. Rev. 26, 92–103.
Kusenbach, M., 2003. Street phenomenology: the go-along as ethnographic research tool.
Ethnography 4 (3), 455–485.
Lancione, M., McFarlane, C., 2016. Life at the urban margins: sanitation infra-making
and the potential of experimental comparison. Environ. Plann.: Econ. Space 48,
2402–2421.
Magnus, E., 2018. The time-geographic diary method in studies of everyday life. In: Time
Geography in the Global Context. Routledge, pp. 135–154.
Miles, M.B., Huberman, A.M., Saldana, J., 2014. Qualitative Data Analysis: A Methods
Sourcebook. SAGE.
Miller, H.J., 2005. A measurement theory for time geography. Geogr. Anal. 37, 17–45.
Mountz, A., 2018. Political geography III: bodies. Prog. Hum. Geogr. 42, 759–769.
Nyantakyi-Frimpong, H., 2021. Climate change, women’s workload in smallholder
agriculture, and embodied political ecologies of undernutrition in northern Ghana.
Health Place 68, 102536.
Panchang, S.V., 2021. Beyond toilet decisions: tracing sanitation journeys among women
in informal housing in India. Geoforum 124, 10–19.
Petteway, R., Mujahid, M., Allen, A., 2019. Understanding embodiment in place-health
research: approaches, limitations, and opportunities. J. Urban Health 96 (2),
289–299.
Patil, S.P., Sangle, K.K., 2022. Water fetcher’s lumbar load analysis while carrying heavy
loads. Mater. Today Proc. 56, 3506–3511.
Pers, A.S., Lagerqvist, M., Bj¨
orklund, A., 2022. Walk a mile in someone else’s shoes: the
difcult school route and how it was managed during the emergence of the Swedish
folkskolan, 1840–1930. Nor. Geogrask Tidsskr.-Norweg. J. Geogr. 76, 1–13.
Pierce, J., Lawhon, M., 2015. Walking as method: toward methodological forthrightness
and comparability in urban geographical research. Prof. Geogr. 67 (4), 655–662.
Price, H.D., Adams, E.A., Nkwanda, P.D., Mkandawire, T.W., Quilliam, R.S., 2021. Daily
changes in household water access and quality in urban slums undermine global safe
water monitoring programmes. Int. J. Hyg Environ. Health 231, 113632.
Price, H., Adams, E., Quilliam, R.S., 2019. The difference a day can make: the temporal
dynamics of drinking water access and quality in urban slums. Sci. Total Environ.
671, 818–826.
Prüss-Ustün, A., Wolf, J., Bartram, J., Clasen, T., Cumming, O., Freeman, M.C.,
Johnston, R., 2019. Burden of disease from inadequate water, sanitation and hygiene
for selected adverse health outcomes: an updated analysis with a focus on low-and
middle-income countries. Int. J. Hyg Environ. Health 222 (5), 765–777.
Rainham, D., McDowell, I., Krewski, D., Sawada, M., 2010. Conceptualizing the
healthscape: contributions of time geography, location technologies and spatial
ecology to place and health research. Soc. Sci. Med. 70, 668–676.
Ramakrishnan, K., O’Reilly, K., Budds, J., 2021. Between Decay and Repair: Embodied
Experiences of Infrastructure’s Materiality. SAGE Publications Sage UK, London,
England, pp. 669–673.
Robinovich, J., Ossa, X., Baeza, B., Krumeich, A., van der Borne, B., 2018. Embodiment
of social roles and thinness as a form of capital: a qualitative approach towards
understanding female obesity disparities in Chile. Soc. Sci. Med. 201, 80–86.
Rosinger, A.Y., Bethancourt, H.J., Young, S.L., Schultz, A.F., 2021. The embodiment of
water insecurity: injuries and chronic stress in lowland Bolivia. Soc. Sci. Med. 291,
114490.
Rosinger, A.Y., Brewis, A., 2019. Life and death: toward a human biology of water. Am.
J. Hum. Biol. 32.
Sarkar, A., 2020. Everyday practices of poor urban women to access water: lived realities
from a Nairobi slum. Afr. Stud. 79, 212–231.
Smiley, S.L., 2017. Dening and measuring water access: lessons from Tanzania for
moving forward in the post-Millennium development goal era. Afr. Geogr. Rev. 36
(2), 168–182.
Smiley, S.L., Curtis, A., Kiwango, J.P., 2017. Using spatial video to analyze and map the
water-fetching path in challenging environments: a case study of Dar es Salaam,
Tanzania. Trop. Med. Infect. Dis. 2, 8.
Sorenson, S.B., Morssink, C., Campos, P.A., 2011. Safe access to safe water in low income
countries: water fetching in current times. Soc. Sci. Med. 72 (9), 1522–1526.
Stoler, J., Pearson, A.L., Staddon, C., Wutich, A., Mack, E., Brewis, A., Zinab, H., 2020.
Cash water expenditures are associated with household water insecurity, food
insecurity, and perceived stress in study sites across 20 low-and middle-income
countries. Sci. Total Environ. 716, 135881.
Sultana, F., 2020. Embodied intersectionalities of urban citizenship: water,
infrastructure, and gender in the global south. Ann. Assoc. Am. Geogr. 110 (5),
1407–1424.
Tomberge, V.M.J., Bischof, J.S., Meierhofer, R., Shrestha, A., Inauen, J., 2021. The
physical burden of water carrying and women’s psychosocial well-being: evidence
from rural Nepal. Int. J. Environ. Res. Publ. Health 18, 7908.
Truelove, Y., Ruszczyk, H.A., 2022. Bodies as urban infrastructure: gender, intimate
infrastructures and slow infrastructural violence. Polit. Geogr. 92, 102492.
Truelove, Y., 2019. Rethinking water insecurity, inequality, and infrastructure through
an embodied urban political ecology. Wiley Interdiscipl. Rev.: Water 6 (3), e1342.
United Nations, 2018. Sustain. Dev. Goals United Nation. Sustain. Dev. URL https
://www.un.org/sustainabledevelopment/sustainable-development-goals/ accessed
2.10.22.
UN-Water, 2021. Summary Progress Update 2021 – SDG 6 – Water and Sanitation for All.
Version: July 2021 (Geneva, Switzerland).
Venkataramanan, V., Geere, J.-A.L., Thomae, B., Stoler, J., Hunter, P.R., Young, S.L.,
2020. In pursuit of ‘safe’water: the burden of personal injury from water fetching in
21 low-income and middle-income countries. BMJ Glob. Health 5, e003328.
WHO and UNICEF, 2021. Progress on household drinking water, sanitation, and hygiene.
2000-2020. Five Years Into SDGs. Accessed Feb 20, 2022. Available at: https://wash
data.org/.
Wutich, A., Brewis, A., Tsai, A., 2020. Water and mental health. Wiley Interdiscipl. Rev.:
Water 7 (5), e1461.
Wutich, A., Budds, J., Jepson, W., Harris, L.M., Adams, E., Brewis, A., Cronk, L.,
DeMyers, C., Maes, K., Marley, T., 2018. Household water sharing: a review of water
gifts, exchanges, and transfers across cultures. Wiley Interdiscipl. Rev.: Water 5,
e1309.
E.A. Adams et al.