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Although the Millennium Development Goal (MDG) target for drinking water was met, in many developing countries water supplies are unreliable. This paper reviews how households in developing countries cope with unreliable water supplies, including coping costs, the distribution of coping costs across socio-economic groups, and effectiveness of coping strategies in meeting household water needs. Structured searches were conducted in peer-reviewed and grey literature in electronic databases and search engines, and 28 studies were selected for review, out of 1643 potentially relevant references. Studies were included if they reported on strategies to cope with unreliable household water supplies and were based on empirical research in developing countries. Common coping strategies include drilling wells, storing water, and collecting water from alternative sources. The choice of coping strategies is influenced by income, level of education, land tenure and extent of unreliability. The findings of this review highlight that low-income households bear a disproportionate coping burden, as they often engage in coping strategies such as collecting water from alternative sources, which is labour and time-intensive, and yields smaller quantities of water. Such alternative sources may be of lower water quality, and pose health risks. In the absence of dramatic improvements in the reliability of water supplies, a point of critical avenue of enquiry should be what coping strategies are effective and can be readily adopted by low income households.

Background Despite poor evidence of their effectiveness, colloidal silver and silver nanoparticles are increasingly being promoted for treating potentially contaminated drinking water in low income countries. Recently, however, concerns have been raised about the possible genotoxicity of particulate silver. Objectives The goal of this paper was to review the published mammalian in vivo genotoxicity studies using silver micro and nanoparticles. Methods SCOPUS and Medline were searched using the following search string: (“DNA damage” OR genotox* OR Cytotox* OR Embryotox*) AND (silver OR AgNP). Included papers were any mammalian in vivo experimental studies investigating genotoxicity of silver particles. Studies were quality assessed using the ToxRTool. Results 16 relevant papers were identified. There were substantial variations in study design including the size of silver particles, animal species, target organs, silver dose, route of administration and the method used to detect genotoxicity. Thus, it was not possible to produce a definitive pooled result. Nevertheless, most studies showed evidence of genotoxicity unless using very low doses. We also identified one human study reporting evidence of “severe DNA damage” in silver jewellery workers occupationally exposed to silver particles. Conclusions With the available evidence it is not possible to be definitive about risks to human health from oral exposure to silver particulates. However, the balance of evidence suggests that there should be concerns especially when considering the evidence from jewellery workers. There is an urgent need to determine whether people exposed to particulate silver as part of drinking water treatment have evidence of DNA damage.

The Sustainable Development Goals include commitments to end poverty, and promote education for all, gender equality, the availability of water and decent work for all. An important constraint is the fact that each day, many millions of women and children, and much less frequently men, carry their household's water home from off-plot sources. The burden of fetching water exacerbates gender inequality by keeping women out of education and paid employment. Despite speculation about the potential health impacts of fetching water, there is very little empirical evidence. We report the first large study of the health impacts of carrying water on women and children. A cross-sectional survey was conducted in South Africa, Ghana and Vietnam during 2012. It investigated water carrying methods and health status. Because areas of self-reported pain were correlated we undertook factor analysis of sites of reported pain, to interpret patterns of pain reporting. Regression analysis using Generalised Estimating Equations (GEE) investigated water carrying as a risk factor for general health and self-reported pain. People who previously carried water had increased relative risk of reporting pain in the hands (risk ratio RR 3.62, 95% confidence interval CI 1.34 to 9.75) and upper back (RR 2.27, 95% CI 1.17 to 4.40), as did people who currently carry water (RR hand pain 3.11, 95% CI 1.34 to 7.23; RR upper back pain 2.16, 95% CI 1.25 to 3.73). The factor analysis results indicate that factor 1, 'axial compression', which is correlated with pain in the head and upper back, chest/ribs, hands, feet and abdomen/stomach, is associated with currently (0.30, 95% CI 0.17 to 0.43) or previously (0.21, 95% CI 0.01 to 0.42) carrying water. Factor 2, 'soft tissue strain', which is correlated with pain in the neck, shoulders/arms, lower back and hips/pelvis or legs, is marginally negatively associated with currently (-0.18, 95% CI -0.32 to -0.04) carrying water. The factor 'axial compression' was more strongly associated with carrying water containers on the head. Participants who reported a history of current or past water carrying more frequently reported pain in locations most likely to be associated with sustained spinal axial compression in the cervical region. Given the fact that cervical spinal conditions are globally one of the more common causes of disability, our findings suggest that water carrying, especially by head loading is a major contributing factor in musculoskeletal disease burden in low income countries. Our findings support the proposed indicator for monitoring SDG6.1: \"Percentage of population using safely managed drinking water services at home.\"

The unreliability of water supplies in developing countries is a widely recognised concern. However, unreliability means different things in the variety of literature on water supplies, and no unified definition or assessment criteria exists. We review definitions of water supply reliability used in existing literature, as well as the various ways in which it is assessed. Thirty-three papers were selected for review that reported on reliability of domestic water supply and were based on empirical research in developing countries. Explicit definitions of reliability are given in four out of the 33 papers reviewed. These definitions vary, but features common are the functionality of the water supply system itself, and the extent to which it meets the needs of water users. Assessment criteria also vary greatly, with the most common criterion in urban settings being the duration/continuity of supply in hours per day, while in rural settings, the proportion of functional water systems is commonly used. The heterogeneity in the definitions and assessment criteria found in the review is perhaps indicative of a multi-attribute nature of the concept of reliability and any unifying definition and assessment criteria might do well to take this into account.

Aims: It is unclear how economic factors impact on the epidemiology of infectious disease. We evaluated the relationship between incidence of selected infectious diseases and economic factors, including economic downturn, in 13 European countries between 1970 and 2010. Methods: Data were obtained from national communicable disease surveillance centres. Negative binomial forms of the generalised additive model (GAM) and the generalised linear model were tested to see which best reflected transmission dynamics of: diphtheria, pertussis, measles, meningococcal disease, hepatitis B, gonorrhoea, syphilis, hepatitis A and salmonella. Economic indicators were gross domestic product per capita (GDPpc), unemployment rates and (economic) downturn. Results: GAM models produced the best goodness-of-fit results. The relationship between GDPpc and disease incidence was often non-linear. Strength and directions of association between population age, tertiary education levels, GDPpc and unemployment were disease dependent. Overdispersion for almost all diseases validated the assumption of a negative binomial relationship. Downturns were not independently linked to disease incidence. Conclusions: Social and economic factors can be correlated with many infections. However, the trend is not always in the same direction, and these associations are often non-linear. Economic downturn or recessions as indicators of increased disease risk may be better replaced by GDPpc or unemployment measures.

Many developing countries face severe challenges with the reliability of water supplies. These supplies are often characterised by intermittence, low pressure and poor water quality. Despite its contribution towards water-related illness and the significant coping burden it imposes on households, water supply reliability remains a difficult attribute to measure. A key challenge is the lack of a universal definition of water supply reliability. The issue of unreliability in water supply and the financial cost it imposes on households is of profound relevance in South Africa – a country whose social policies include a Free Basic Water policy which entitles all households to a free lifeline supply of 6,000 litres per month. This thesis examines household experiences of unreliable water supplies and in particular, explores the question as to what constitutes a reliable water supply, and household responses to unreliable water supplies. The analysis draws on literature reviews and a household survey conducted in peri-urban communities in the Limpopo Province of South Africa in 2012. A systematic review of definitions and assessment criteria used in studies of water supply reliability demonstrates that there is no consensus on what constitutes a reliable water supply. Assessment criteria also vary greatly, with the most common criterion in urban settings being the duration and/or continuity of supply in hours per day. In rural settings, the proportion of functional water systems is commonly assessed. A discrete choice experiment was conducted to elicit households’ preferences for a reliable water supply. Results indicate that overall, households value notification of interruptions and having water available for longer durations during the day, and would be willing to pay for these improvements. However, there is some heterogeneity in these preferences as wealthier households, who have drilled their own wells and are no longer dependant on the public supply are less willing to pay for improvements in the water supply. Findings from a systematic review of household strategies to cope with unreliability reveal that relatively wealthy households incur significant direct costs from strategies such as drilling wells and installing water storage tanks, poor households expend time and energy in collecting water from other sources. Income, level of education, land tenure and extent of unreliability are the main determinants of which strategies are adopted. Results from the survey in Limpopo highlight that Free Basic Water is not actually free; households spend significant proportions of their income on buying water, ii drilling wells and treating the water prior to consumption. Coping costs increase with wealth status and are higher in communities without alternative water sources such as springs. Notably, for many households the lifeline supply of 6,000 litres per month is unmet. The findings from this thesis highlight the need for consensus on the definition, and assessment approach for water supply reliability. Further, the analysis of households’ responses to unreliable water supplies in South Africa draws attention to how poor reliability negates the Free Basic Water policy. Without reliable water supply services, the objectives of improving public health and promoting equity cannot be met.