‘We are drinking diseases’: Water insecurity and emotional distress in urban slums

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susan elliottSusan Elliott, Department of Geography and Environmental Management


Water security is a concern in low- to middle-income countries where increasing urbanization coupled with weak institutional capacity to expand and maintain water infrastructure affects the reliability and quality of water supply. Water insecurity poses risks to human health and well-being, from infections and diseases attributed to unsafe water and sanitation, to emotional distress and anxiety which include feelings of anger, frustration, embarrassment and depression.

In urban areas in sub-Saharan Africa, entrepreneurial water vendors have stepped up to fill supply gaps by selling water through various mediums, raising concerns about the sources of vended water, the cost to households, and the resultant environmental waste from bottles and sachets, posing serious health risks in countries with poor water, hygiene and waste management practices. The lack of control by urban households using vended water that may be inadequate or unwholesome for their own needs may negatively impact their health and well-being. In this context, this study aimed to: investigate the relationships between water insecurity and emotional distress, and document experiences of emotional distress associated with vended water use among urban slum dwellers in Accra, Ghana.


This study was conducted in five urban slums in the Accra metropolitan area of Ghana. A total of 550 household heads were randomly selected for interview, with an overall response rate of 91 per cent or a total of 499 households. We used a parallel mixed-method design that included a quantitative household survey and qualitative photo-voice interviews. A number of measures were used in the household survey to assess the following: vended water insecurity, main sources of vended water, access to sanitation, household demographics, household assets, perceived challenges associated with vended water, and willingness to participate in community interventions towards water improvement. Photo-voice interviews were used to examine the prevalence of water-related emotional distress and document the experiences of emotional distress associated with vended water use.

All statistical analyses were conducted using Stata version 15. We used Generalized Linear Latent and Mixed Models with a logit link function to build both bivariate and multivariate analyses of emotional distress. Model 1 of our analysis controlled for only water-related variables, while model 2 added socio-demographic variables. The photographs and transcripts from the photo-voice interviews were imported into NVivo 12 for analysis and coded according to four major themes: exposure to contaminants, disease burden on children, psychosocial impacts, and infrastructural challenges. The qualitative results were used to provide depth to the quantitative results.


Survey results revealed that 42 per cent of the interviewed households were water insecure, with 60 per cent relying on vended water as their main source of drinking water and only 48 per cent perceiving vended water to be wholesome. Approximately 27 per cent of the households reported to experience emotional stress related to vended water. The bivariate analysis revealed that water-insecure households were more likely to experience emotional distress compared to water-secure households. The same result was found for water-insecure households in model 1 of the multivariate results, whilst controlling for a variety of other influencing factors. The multivariate results further revealed that emotional distress decreases in households with access to sanitation or with a willingness to pay for improved water sources, but increases when vended water is perceived to be unwholesome. With the inclusion of socio-economic variables in model 2, variables such as water insecurity, perception of water quality, access to sanitation, and willingness to pay remained significant predictors of emotional distress.

The results from the photo-voice interviews pointed to concerns about: risk of exposure to contaminants through vended water, impacts of unsafe water from pipes on children’s health, health impacts associated with unsafe vended water, arbitrary price changes and other costs associated with purifying vended water, and dilapidated water and sanitation infrastructure.


This study provides evidence of emotional distress associated with vended water use. Results reveal emotional distress related to: fear of contamination, discomfort, worry and anxiety due to arbitrary changes in prices, poor water infrastructure and maintenance, poor quality of sachet water and delivery gallons, and lack of maintenance and standardization of the activities of water entrepreneurs. A holistic approach to water insecurity beyond physical health outcomes is needed to include social and emotional impacts as both inadequate water supply access and the process of negotiating water supply access led to distress.

These findings have implications for Ghana and other sub-Saharan African countries as they strive toward the Sustainable Development Goals, as better understanding of the insecurities associated with vended water will inform and promote equity in the design and supply of water interventions, particularly in urban slum areas. This includes understanding emotional distress associated with inadequate access to resources, and highlighting the need to set up and enforce vended water standards and regulate the activities of water entrepreneurs.  

Kangmennaang, J., Bisung, E., & Elliott, S.J. (2020). ‘We are drinking diseases’: Perception of water insecurity and emotional distress in urban slums in Accra, Ghana. International Journal of Environmental Research and Public Health, 17(3), 890. doi: 10.3390/ijerph17030890

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