WIREs Water - 2023 - Stoler - Measuring Transformative WASH A New Paradigm For Evaluating Water Sanitation and Hygiene

Received: 15 December 2022 Revised: 11 April 2023 Accepted: 16 May 2023
DOI: 10.1002/wat2.1674
PERSPECTIVE
Measuring transformative WASH: A new paradigm for

evaluating water, sanitation, and hygiene interventions
Justin Stoler 1,2 | n 3,4

Danice B. Guzma | Ellis A. Adams 3,4,5
1
Department of Geography and
Sustainable Development, University of Abstract
Miami, Coral Gables, Florida, USA Progress toward achieving Sustainable Development Goal 6, clean water and
2
Department of Public Health Sciences, sanitation for all, is behind schedule and faces substantial financial challenges.
Miller School of Medicine, Miami,
Rigorous water, sanitation, and hygiene (WASH) interventions have
Florida, USA
3
Pulte Institute for Global Development,
underperformed, casting doubt on their efficacy and potentially undermining
University of Notre Dame, South Bend, confidence in WASH funding and investments. But these interventions have
Indiana, USA leaned on a narrow set of WASH indicators—linear growth and diarrhea—that
4
Keough School of Global Affairs,
reflect a 20th-century prioritization of microbiological water quality as the most
University of Notre Dame, South Bend,
Indiana, USA important measurement of WASH intervention success. Even when water is
5
Eck Institute for Global Health, microbiologically safe, hundreds of millions of people face harassment, assault,
University of Notre Dame, South Bend, injury, poisoning, anxiety, exhaustion, depression, social exclusion, discrimina-
Indiana, USA
tion, subjugation, hunger, debt, or work, school, or family care absenteeism
Correspondence when retrieving or consuming household water. Measures of WASH interven-
Justin Stoler, Department of Geography tion success should incorporate these impacts to reinforce the WASH value
and Sustainable Development, University
of Miami, Coral Gables, FL, USA. proposition. We present a way forward for implementing a monitoring and eval-
Email: stoler@miami.edu uation paradigm shift that can help achieve transformative WASH.
Funding information This article is categorized under:

National Science Foundation, Engineering Water > Water, Health, and Sanitation
Grant/Award Number: BCS-1759972
Human Water > Value of Water
Human Water > Methods
Edited by: Wendy Jepson, Co-Editor-in-
Chief and Jan Seibert, Editor-in-Chief KEYWORDS
gender, mental health, metrics, monitoring and evaluation, participatory research
1 | INTRODUCTION
Water, sanitation, and hygiene (WASH) insecurity affects billions globally (WHO/UNICEF, 2021) and has been
increasingly acknowledged as a cause and consequence of low socioeconomic development (Chenoweth, 2008;
Flörke et al., 2013). The WASH-attributable disease burden is estimated to be 3.3% of global deaths and 4.6% of
global disability-adjusted life-years (DALYs)—over half of which is in sub-Saharan Africa alone—and 13% of
deaths and 12% of DALYs among children under 5 (WHO, 2019). Even before the coronavirus pandemic, we
were not on track to meet Sustainable Development Goal (SDG) 6, which aspires to provide universal access to
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes.
© 2023 The Authors. WIREs Water published by Wiley Periodicals LLC.
WIREs Water. 2023;10:e1674. wires.wiley.com/water 1 of 16

https://doi.org/10.1002/wat2.1674
20491948, 2023, 5, Downloaded from https://wires.onlinelibrary.wiley.com/doi/10.1002/wat2.1674 by CAPES, Wiley Online Library on [12/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 of 16 STOLER ET AL.
safely managed water and sanitation services by 2030 (Sadoff et al., 2020). One estimate priced the investments
needed to achieve SDG 6 at $114 billion per year through 2030, or $28.4 billion annually for universal basic
WASH services, both of which offer compelling cost–benefit ratios (Hutton & Varughese, 2016). But the corona-
virus pandemic created a global debt boom that will present ongoing challenges to WASH infrastructure financ-
ing (Kose et al., 2021).
Amid these challenges, WASH continues to have an existential crisis—billions of dollars are spent annually
implementing, monitoring, and evaluating WASH projects, yet SDG 6 seems out of reach. There were already questions
about whether foreign aid for WASH interventions was effective (Wayland, 2017). Then, in 2018–2019, a series of stud-
ies from the WASH Benefits and SHINE trials in Bangladesh, Kenya, and Zimbabwe reported no effect on child linear
growth and only mixed effects on diarrhea (Humphrey et al., 2019; Luby et al., 2018; Null et al., 2018). These primary
outcomes of diarrhea and stunting are traditional measures of WASH effectiveness. But in retrospect, they were
remarkably narrow evaluation criteria for such ambitious projects. Even when water is microbiologically safe, hundreds
of millions of people—disproportionately women and girls—face harassment, assault, injury, poisoning, anxiety,
exhaustion, depression, social exclusion, discrimination, subjugation, hunger, debt, or work, school, or family care
absenteeism when retrieving or consuming household water (e.g., Mushavi et al., 2020; Peloso & Morinville, 2014;
Ranganathan, 2014; Smiley & Stoler, 2020). By neglecting to regularly measure how WASH interventions address these
wider challenges, the development community has tacitly endorsed a limited understanding of WASH program
effectiveness.
2 | TRANSFORMATIVE WASH
WASH interventions have increasingly relied on randomized controlled trials (RCTs), despite their limitations
in external validity and in capturing respondent heterogeneity (Levy & Eisenberg, 2019). In 2019, a group of
WASH insiders convened to reconcile the WASH Benefits and SHINE RCT results. This team ultimately rea-
ffirmed RCTs as the preferred tool for evaluating WASH interventions and called for more detailed studies to
control for additional pathways that were presumed to attenuate WASH intervention effects on linear growth
and diarrhea, but the authors did not offer much of a roadmap (Cumming et al., 2019). One of the legacies of
that discourse was the call for transformative WASH (Cumming et al., 2019; Pickering, Null, et al., 2019), which
has subsequently been referred to by others as WASH++ (Husseini et al., 2018) or transformational WASH
(Kearns, 2019; Levy & Eisenberg, 2019). Years later, it is still not clear what transformative WASH is, or how
to achieve it.
The initial call for transformative WASH centered around fecal contamination and stronger governance (Pickering,
Null, et al., 2019). The authors partially attributed the perceived ineffectiveness of the original trials to targeting particu-
larly deep-seated public health challenges (Cumming et al., 2019). This call generated two correspondences in The Lan-
cet Global Health titled “Moving toward transformational WASH.” In one, Levy and Eisenberg (2019) highlighted
caveats of the study design and the nonrepresentativeness of these trials' rural sites in an increasingly urbanized world,
but ended by affirming the need for new interventions “to reduce fecal contamination in the domestic environment,”
again keeping the focus on microbial contamination. In the second correspondence, Kearns (2019) explained how these
trials could have been confounded by chemical pollution, as synthetic chemicals can dysregulate immune function and
increase susceptibility to waterborne pathogens.
Pickering, Arnold, et al. (2019) responded to these letters but still seemed stuck in the same paradigm. They are not
alone: recent reflections about the future of WASH continue to reinforce the pathogen-oriented paradigm
(Howard, 2021; Mraz et al., 2021). The Lancet recently rewarded a group of WASH establishment leaders—many of
whom were involved in the WASH Benefits and SHINE trials—with a new Commission on water, sanitation and
hygiene, and health, ostensibly to reconcile many of these issues. The Commission's stated priorities include “provid
[ing] a comprehensive assessment of the potential benefits [of achieving universal access to at least safely managed
WASH services], encompassing public health gains, financial returns through improvements in human capital and pro-
ductivity, and other benefits relating to social and environmental justice and gender equality” (Amebelu et al., 2021).
Yet the Commission's first product doubled-down on microbiological water quality and diarrhea as WASH's most press-
ing problem, with a mere two sentences about “other benefits” (Wolf et al., 2022). How did we get to this point? Two
things stand out: inconsistent application of the WASH Theory of Change, and the WASH establishment's preoccupa-
tion with a 20th-century water quality paradigm.
STOLER ET AL. 3 of 16
3 | THEORY OF CHANGE
Many WASH programs are guided by some version of the Theory of Change, which explicitly maps out how an initia-
tive's impacts will be achieved. The Theory of Change is often visualized and communicated using a logic model that
starts with the desired impacts and works backward through the causal logic that will lead to the desired outcomes and
impacts. If we examine how leading global WASH programs operationalize the Theory of Change, it becomes clear that
outcomes and impacts are often poorly articulated.
For example, UNICEF's WASH-oriented Goal Area 4 in its 2022–2025 Strategic Plan is that “Every child, including
adolescents, has access to safe and equitable WASH services and supplies, and lives in a safe and sustainable climate
and environment” (UNICEF, 2021). Each Goal Area has multiple nested Results Areas, which in turn contain indica-
tors. These indicators measure successful implementation activities, such as “4.1.3. Number of people reached with at
least basic hygiene services through UNICEF-supported programmes,” or engagement, such as “4.2.5. Number of coun-
tries integrating a humanitarian-development-peace nexus approach on WASH programming through the participation
of affected populations.” These kinds of indicators do not measure how the services, or engagement in service provision,
improved people's lives. WASH indicators should measure what WASH interventions are accomplishing through
improvements in quality, quantity, temporal availability, service predictability, and so forth, not these characteristics
themselves.
Other major WASH project implementers are organized similarly. WASH Alliance International (WAI), a consor-
tium of nine organizations, uses a Theory of Change built upon three pillars: affordable WASH markets, sustainable
governance, and empowered citizens (WASH Alliance International, 2016). Very few of the activities described in these
pillars were explicitly linked to a measurable improvement in people's lives. IRC International Water and Sanitation
Centre (a WAI member) is guided by their Sustainable Services at Scale (Triple-S) Theory of Change with expressed
outcomes that comprise the adoption of a service delivery approach by donors, NGOs, and government stakeholders
with adaptive, sustainable management (Schouten & Moriarty, 2013). Their 2020 annual report highlighted expenditure
totals and staff, project, and donor counts in each partner country, rather than community- or household-level improve-
ments (IRC, 2020). A few organizations do emphasize impact. Water for People's Theory of Change explicitly culmi-
nates with Impacts including “improved health, education, economic options, and quality of life for generations”
(Water For People, 2019). Splash International's Theory of Change also differentiates between Outcomes, for example,
improved infrastructure or behavior change, and Impact such as better health and development (Splash, 2018).
None of this is intended as a critique of these organizations' structures and missions, all of which aim to improve
WASH security around the world. But the “wicked” problem of global safe water and sanitation requires complicated
integration of global health efforts with supply chain management, finance, governance, and many other sectors to
implement the causal chain of activities that leads to desired impacts. Given this multi-sectoral complexity (Rhodes-
Dicker et al., 2022), some practitioners have suggested the use of the human-centered design of WASH interventions
based on Behavior Centred Design Theory (Burton et al., 2021). Outcomes and impacts need to reflect the full range of
FIGURE 1 Hypothetical logic model of a WASH intervention with examples of human-centered impacts beyond microbiological
indicators.
what WASH interventions can accomplish, as depicted in the sample logic model in Figure 1, and be measured system-
atically. But instead, WASH program evaluations continue to focus narrowly on water quality and waterborne diseases.
4 | T H E WA T E R Q U A L I T Y P A R A D I G M
WASH evaluation strategy continues to focus on water quality, stuck in a 20th-century paradigm of clean water that
hearkens back to John Snow, germ theory, and traditional sources of infant mortality. If you look at broad WASH liter-
ature over the past decade or two, one might reasonably conclude that if we could just provide everyone with “access”
to water that is free of E. coli, water security would be ensured. But anyone working in this sector knows it is not that
simple, and that even when safe water is provided, there are often substantial structural, behavioral, and institutional
barriers to access.
This is not to say water quality does not matter—of course, it does. But there is a disproportionate outpouring
of funding—from governments and NGOs—to drill wells, install pumps, and perfect all kinds of point-of-use and
point-of-acquisition water safety technologies, which can be cynically viewed as the “WASH industrial complex.”
Few (if any) of these solutions have been sustainably scaled beyond local communities, and they often lack clear
evaluation criteria. Researchers at UCL have piloted concept mapping in rural India to embrace and gain a more
holistic view of the socio-environmental, cultural, and political-economic context around infant health, but again
focused on enteric infections (Vila-Guilera et al., 2021). There are many confounders of the pathways and behavior
changes associated with indicators like diarrhea and stunting (Smiley & Stoler, 2020). More importantly, those
enduring water insecurity face so many challenges to health and well-being that studies just focused on water
quality-related outcomes seem to be missing the bigger picture.
Despite all we have learned, the development community is still doing many of the same old things. Perhaps
the most high-profile ongoing WASH program is the RISE trials (“revitalizing informal settlements and their envi-
ronments”) headquartered at Monash University in Melbourne (Leder et al., 2021). The project integrates transfor-
mative WASH and planetary health with hopes of generating a new, empirically grounded conceptual model of
health and environment in urban informal settlements. The work is based on the traditional WASH Theory of
Change: if we reduce child exposure to fecal-oral contamination, it will improve gastro-intestinal health and thus
physical development outcomes. Part of the innovation is the use of TaqMan Array Cards to screen 30+ pathogens
simultaneously, but they are still focused on microbiological water quality and enteric pathogens. The project has a
strong gender empowerment component, intent on creating resources for practitioners to improve gender-inclusive
co-design of WASH infrastructure. Perhaps the most significant advance in this RCT might be the use of psychoso-
cial impacts, such as validated measures of subjective wellbeing, depression, quality of life, and social cohesion. It
pushes boundaries, but not nearly to the extent possible given all that we know about the impacts of WASH
insecurity.
In fact, there is wide-ranging literature demonstrating how WASH insecurity disrupts people's lives in many more
ways than waterborne diseases. Many of these pathways demonstrate intricate links between resource insecurities, such
as food, water, and sanitation securities, and likely exacerbate diarrheal diseases and child stunting (Workman, Stoler,
et al., 2021). To many interdisciplinary WASH scholars, the burden of diarrheal diseases is a drop in the proverbial
bucket. But in the WASH establishment—which is dominated by civil and environmental engineers whose background
and training has, for a century, focused on health impacts related to water quality—few are measuring a diverse set of
socio-medical burdens, even though all of these projects probably improve community well-being in unmeasured—
perhaps even transformative—ways. What we need is a paradigm shift in the monitoring and evaluation of WASH pro-
jects. We have the tools to demonstrate to governments and funders just how overwhelmingly transformative WASH
may be, end the narrative about ineffective WASH, and attract financing for transformative change. To do that, we have
to measure transformative WASH.
5 | M EAS URING TRANSFORMATIVE WAS H
The WASH literature offers a growing set of tools for measuring different physical and biosocial outcomes related to
WASH insecurity in diverse international contexts. These examples—summarized in Table 1—are far from comprehen-
sive, but generally present opportunities for survey-based monitoring and evaluation programs to quantify how WASH
TABLE 1 Summary of select survey tools for measuring physical and biosocial outcomes of WASH interventions.
Domain Measure
Water and sanitation Household Water Insecurity Experiences (HWISE) Scale (Young et al., 2019)—measures
insecurity experiences frequency of 12 water-related disruptions
Sanitation Quality of Life (SanQoL; Ross et al., 2022)—measures frequency of five sanitation
attributes
Mental health Perceived Stress Scale (PSS-4; Cohen et al., 1983)—measures perceptions of psychological stress
General Anxiety Disorder (GAD-7; Spitzer et al., 2006)—measures severity of anxiety
Depression Anxiety Stress Scale (DASS-21; Henry & Crawford, 2005)—measures depression,
anxiety, and tension/stress
Patient Health Questionnaire depression scale (PHQ-9; Kroenke et al., 2001)—measures degree of
depression severity
Gender roles Empowerment in Water, Sanitation and Hygiene Index (Dickin et al., 2021)—measures women's
empowerment and other gendered outcomes
Reproductive health Menstrual Practice Needs Scale (MPNS-36; Hennegan et al., 2020) or other menstrual insecurity
tools (Caruso et al., 2020)—measures the extent to which respondents' menstrual practices and
environments meet women's needs
Violence DHS module on domestic violence (Choudhary et al., 2020)—collects self-reported data on
women's experiences of physical and emotional violence from family members
Individual survey items about conflict (Pearson et al., 2021)—measure WASH-related conflict
within the household, community, and potentially other scales
Injuries Water-fetching injuries and symptoms module (Venkataramanan et al., 2020)—assigns multiple
ICD-11 codes to injury or symptom, body location, mechanism/activity, and environmental
context
Noncommunicable diseases Assessments of maternal health, nutrition, and other leading noncommunicable diseases are
regularly captured by population health household surveys and can be incorporated into WASH
evaluations.
Climate resilience and Standard questions on international migration (United Nations, 2018)—reasons for migration
migration should be expanded to capture dimensions of environmental change
projects transform lives. Most of these tools can, and should, be adapted to local contexts through community-based
participation in intervention design and program evaluation, a theme we will return to below.
5.1 | Water and sanitation insecurity experiences
A variety of household-level survey modules have been developed for assessing household water insecurity
(Octavianti & Staddon, 2021). Among the most commonly-used is the Household Water Insecurity Experiences
(HWISE) scale which asks how frequently, over the prior 4 weeks, a respondent encountered 12 disruptions to
daily activities or to emotional well-being (Young et al., 2019). The 12 items are related to access, use, and reli-
ability of household water, and span topics such as hygiene, water worry, and quantity. These items represent
universal, though not comprehensive, household experiences associated with water insecurity. The first-
generation HWISE scale appears to be a significant improvement over traditional water security metrics used
by the WHO Joint Monitoring Programme which focused on the type of water source as a proxy for quality.
The HWISE scale is a plug-and-play tool with short-form (Young, Miller, et al., 2021) and individual-level
(Young, Bethancourt, et al., 2021) versions that can be used to assess intra-household disparities. Others have
proposed similar experiential scales to measure sanitation and hygiene insecurity (Caruso et al., 2017; Ross
et al., 2022), but these tools have not yet been validated in cross-cultural contexts. Next-generation versions of
these scales should ideally also capture the relative severity of WASH disruptions, and how people are adapting
to them to help guide integration of resilience-building into WASH interventions (Sidote et al., 2022; Stoler
et al., 2023). For example, Ross (2022) proposed an important starting point for quantifying the economic value
of water insecurity experiences into water-adjusted person-years using the respondent's perceived importance or
severity of each measured experience. At the very least, experience-based scales remind WASH practitioners of
the breadth of impacts of resource insecurity.
5.2 | Mental health
Research on WASH insecurity's effects on mental health and well-being has flourished over the past 5 years, even if
scholars are still scratching the surface of these pathways (Kangmennaang & Elliott, 2021). It is clear that water worry,
and related forms of stress, anxiety, and depression, are incredibly disruptive to households and individuals, whether
directly through inadequate WASH (Wutich, Brewis, & Tsai, 2020), or indirectly through adaptations to inadequate
WASH such as the distress often generated by water sharing arrangements (Wutich et al., 2022). Mental ill health can
also be shaped by the loss of dignity and autonomy over one's water situation, effects that demonstrate the far-reaching
implications of the human right to water (Robina-Ramírez et al., 2020; Shreyaskar, 2016). Researchers have adapted a
variety of Western psychometric tools to measure WASH-related stress in international settings (e.g., Stoler et al., 2020;
Workman & Ureksoy, 2017), while also implementing biometric assessments such as blood pressure (Brewis
et al., 2019) or oxidative stress (Lin, Mertens, Rahman, et al., 2021) during household surveys.
5.3 | Gender roles
Scholars have also long observed gendered WASH disparities (Caruso et al., 2015), particularly imbalances in household
responsibilities for water fetching (Geere & Cortobius, 2017) and participation in economic activities (Indarti
et al., 2019). Generally speaking, transformative gender studies engage with agency, relations, and power dynamics to
critically examine gender dynamics inherent in WASH service delivery (MacArthur et al., 2020). For example, gender-
and disability-inclusive designs have strengthened WASH programs in Cambodia and Timor-Leste by shifting aware-
ness, roles, relationships, and attitudes (Huggett et al., 2022). Yet WASH data have traditionally not been sex-
disaggregated, and this obscures intra-household dynamics, particularly related to gender roles (Caruso &
Sinharoy, 2019). Dickin et al. (2021) recently filled an important gap in our ability to measure women's empowerment
and gender outcomes in WASH, echoing earlier calls (Caruso & Sinharoy, 2019; Kayser et al., 2019). The Empowerment
in WASH Index uses gendered indicators of agency, participation, and empowerment at multiple scales and can be used
in tandem with other intra-household parity and autonomy measures (Bisung & Dickin, 2021). Another measure in
development is the WASH gender equality measure (WASH-GEM) which is conceptualized across five domains:
resources, agency, critical consciousness, structures, and wellbeing (Carrard, MacArthur, et al., 2022).
5.4 | Reproductive health
Inadequate WASH services are well-known to limit menstrual hygiene and cause other reproductive health problems
(Campbell et al., 2015; Mahon & Fernandes, 2010). Constraints on menstrual hygiene can, in turn, lead to a wide range
of physical, mental, social, and economic consequences (Hennegan et al., 2019; Sommer et al., 2013). Efforts to measure
menstrual hygiene experiences, such as the Menstrual Practice Needs Scale (MPNS-36; Hennegan et al., 2020), or other
menstrual insecurity measures (Caruso et al., 2020), aim to measure the extent to which menstrual practices and envi-
ronments meet women's needs. The MPNS-36, for example, is composed of 28 items answered by all respondents, and
eight additional items related to washing and drying experiences during the reusing of menstrual materials.
5.5 | Violence
A growing body of work has documented the links between WASH access and gender-based violence (Abu
Sharekh, 2021; Pommells et al., 2018) and intimate partner violence (Choudhary et al., 2020; Mushavi et al., 2020).
Recent work has connected water insecurity with community-level and intra-household conflict, and how these rela-
tionships may be shaped by regional conflict (Pearson et al., 2021) and exacerbated by climate change (Caridade
et al., 2022; Mack et al., 2021). While traditional water conflict metrics have tended to be implemented at regional
scales, we can learn a lot about community and household conflict through short survey modules, with additional
precautions for assessing physical and sexual violence.
5.6 | Injuries
Water carriage and management associated with WASH insecurity are widely known to lead to pain, fatigue, perinatal
effects, violence, stress, and disability from musculoskeletal disorders (Geere et al., 2010; Geere, Bartram, et al., 2018;
Geere, Cortobius, et al., 2018; Rosinger et al., 2021). In one study, 13% of 6291 households across 24 LMIC sites reported
at least one-lifetime water-fetching injury (Venkataramanan et al., 2020). The study also proposed a survey module for
assessing water-fetching injuries and symptoms. This tool allows for assigning multiple ICD-11 codes for injury or
symptom, body location, mechanism/activity, and environmental context, while potentially capturing intersecting
themes of safety and violence. Beyond SDG 6, injury prevention is also strongly aligned with several SDG priorities such
as health and well-being, sustainable cities, gender equity, responsible consumption and production, and decent work
and economic growth (Ma et al., 2020).
5.7 | Life course noncommunicable diseases
Inadequate WASH also leads to a wide range of health issues by interacting with poverty (Adams et al., 2020). For
example, water fetching by women was found to be associated with lower likelihood of giving birth in a healthcare
facility, increased risk of childhood death, reduced utilization of antenatal care, and increased risk of leaving a
young child unsupervised for an hour or more (Geere & Hunter, 2020). Recent studies have assessed how water
insecurity is related to children's gut health (Piperata et al., 2020), and how WASH interventions may improve
immune function (Lin, Mertens, Tan, et al., 2021). Across the life course, studies have measured the WASH bar-
riers faced by people living with disabilities (Banks et al., 2019; Groce et al., 2011) or invisible health issues such as
incontinence (Adjorlolo et al., 2023; Rosato-Scott et al., 2020). These issues have been assessed in the context of
workforce participation (Wrisdale et al., 2017), intra-household WASH access (Mactaggart et al., 2021),
schoolchildren (Redman-MacLaren et al., 2018), and old age (Richard & Kiani, 2019). Others have noted additional
human biological relationships between water insecurity and noncommunicable health issues such as nutrition,
cognitive performance, hypertension, and kidney disease (Rosinger & Young, 2020). Although long-term chronic
health issues are difficult to link to WASH interventions, changes in how they are experienced can be inexpen-
sively surveyed. Measuring rates of maternal health complications and behaviors associated with child care are
also opportunities for evaluating WASH project impact. Many of these health outcomes are regularly assessed by
household surveys such as USAID's Demographic and Health Surveys (DHS), UNICEF's Multiple Indicator Cluster
Survey (MICS), and WHO's Stepwise Approach to Surveillance (STEPS), and context-appropriate modules can be
incorporated into WASH evaluations.
5.8 | Climate resilience and migration
Climate change is regarded as an increasingly important driver of migration (Kaczan & Orgill-Meyer, 2020). In commu-
nities vulnerable to climate change, WASH improvements can build resilience by stimulating economic activity, social
capital, education and training, and community health (Omasete et al., 2021). Emerging studies have begun to explicitly
connect climate migration, traditional migration drivers, and WASH services (Khan, 2022; Stoler et al., 2022). A 2021
World Bank report estimated that water scarcity is now believed to be associated with 10% of the increase in global
migration, with much of this due to rainfall shocks (Zaveri et al., 2021). But chronic water insecurity is theorized to
spur migration through everyday disruptions to social and economic well-being (Stoler, Brewis, et al., 2021). One study
found that 21.8% of 8098 households from 29 LMIC sites around the world said they had considered moving at least
once in the prior 4 weeks due to water problems (Stoler, Miller, et al., 2021). We know almost nothing about the thresh-
olds of WASH inadequacy that shape migration decision-making, especially amid climate change. It is plausible that
WASH security could yield some degree of migration security, or at least mitigate climate-induced displacement, but
migration is rarely integrated into WASH interventions. Standard modules, such as the United Nations' standard
questions on international migration (United Nations, 2018), could be adapted to capture migration push and pull fac-
tors related to environmental change, with focus on WASH insecurity.
5.9 | Emerging contaminants
There are many classes of emerging chemical toxicants in water include “halogenated organics, plasticizers such as
phthalates and bisphenol-A, numerous pesticides including atrazine and chlordane, flame retardants, and PFAS”
(Kearns, 2019), and usually without published health criteria (Wutich, Rosinger, et al., 2020). All these compounds have
demonstrated immunotoxicity; Kearns (2020) summarized over a decade of literature about chemical exposures in
Bangladesh, Kenya, and Zimbabwe that could confound projects such as the WASH Benefits and SHINE trials. We are
unable to test most emerging contaminants in low-cost, rapid field conditions because testing procedures are expensive
and limited to specialized laboratories. Innovations such as biosensors may one day enable low-cost diagnostic methods
for many natural and synthetic contaminants (Thavarajah et al., 2020). It is incumbent upon the WASH community to
actively monitor advances in detection technologies and, when the opportunity arises, be ready to expand our toolkit
beyond basic physicochemical and microbiological monitoring (Wutich, Rosinger, et al., 2020).
6 | TRANSFORMATION THROUGH DECOLONIZATION
Theories of change demonstrate that WASH interventions could improve people's lives in many measurable ways. The
breadth of WASH's potential influence on so many domains of well-being warrants reconsideration of SDG 6 as a key-
stone goal (Boltz et al., 2019; Marcos-Garcia et al., 2021). Without WASH, it is hard to imagine ending poverty and hun-
ger; improving health, education, and gender equity; providing ample work opportunities and infrastructure for
industrial development; and reducing global inequalities. We might also rethink deeper integration with SDGs
10 (reduce inequality within and among countries) and 16 (promote peaceful and inclusive societies for sustainable
development) to expedite the decolonization of WASH (Dietvorst, 2020).
The movement to decolonize global health—and WASH in particular—continues to decry the influence of insider
elite circles who fail to adequately include minoritized voices (Gautier et al., 2022; Irfan & St Jean, 2021; Kapur, 2020;
Worsham et al., 2021). For example, while Global North researchers retreated to online webinars, conferences, and
trainings during the COVID-19 pandemic, Africans innovated and managed to greatly increase access to water for han-
dwashing in some of the most difficult-to-reach places (Luseka, 2020). Recent panels with high-level donors continue to
share the same stories of WASH intervention failures, such as the typical tale of equipment installation by an interna-
tional NGO with unsustainable maintenance structures (Dietvorst, 2020). These failures demonstrate the flaws of an
approach which focuses only on immediate access to water—and its quality—rather than system sustainability through
equitable partnership and co-production of knowledge (Carrard, Willetts, & Mitchell, 2022). Fortunately, a growing dia-
logue around WASH failures recognizes how the lack of community engagement, limited diversity among senior WASH
insiders, and inadequate measurement—among other aspects—can undermine WASH interventions (Barrington
et al., 2021, 2022). Influential global WASH entities might reconsider how their funding of, and commitment to,
traditional WASH paradigms inhibit their broader goals. The WASH community might be better served to focus on
inclusivity and accelerate the integration of participatory research designs into future interventions (Roque et al., 2022).
The 2022 US Global Water Strategy, for example, updated its strategy to “prioritize local leadership” of WASH systems
(USAID, 2022).
These issues underscore why there is contradictory evidence from the past two decades over whether WASH foreign
aid actually expands access to WASH services and improves human health (Wayland, 2017). Any messages that under-
mine the value proposition for WASH projects risk sowing seeds of doubt in the development community, particularly
with donors, investors, and policy makers. To be clear: we certainly do not support suppressing null findings for fear of
worrying donors and bureaucrats. Rather, we urgently call for the expansion of WASH evaluation criteria—
incrementally if needed, given local context—to encompass a broader range of potential impacts. This wider lens can
help implementers, donors, and researchers understand how vital WASH services are for human well-being and devel-
opment, and ultimately enhance the deployment ecosystem, or “enabling environment,” for improving WASH services
(Shields et al., 2022). This is crucial in light of new challenges for achieving SDG 6 related to the COVID-19 pandemic
(Ekwebelem et al., 2020; The Lancet Public Health, 2020), and with the feasibility of universal safe water again being
called into question (Taing, 2022).
7 | C ON C L U S I ON
There are many valid criticisms of the SDG 6 indicators (Cassivi et al., 2021; Guest, 2019; Guppy et al., 2019;
Herrera, 2019), and by chasing these indicators, we have perhaps been lured into counting project implementations
(i.e., households “with access”) rather than explicitly assessing if and how WASH projects transform lives. Focusing dis-
proportionately on the microbial impact of WASH projects risks missing a big part of the picture if such interventions
can transform communities and individuals in the ways described here. Broadening our set of indicators can help donor
communities more fully understand the impact of their investments. Let us make use of all feasible measurement tools
at our disposal—even if some seem unfamiliar.
WASH program implementors can start by reviewing each tool's appropriateness and cost in a given setting with
the receiving community, and ultimately phasing useful modules into baseline evaluations with protocols for incorpo-
rating new indicators into long-term evaluation plans as they become available (e.g., rapid tests for emerging contami-
nants). This means that WASH interventions may need to adapt to reduce psychosocial stress through greater
reliability, predictability, and personal safety of services; avoid inadvertently reinforcing socio-political dynamics that
lead to gender (or ethnic, etc.) inequities; or increase resilience to other resource stressors. Some policy makers may be
slow to accept or fund an expansion of WASH indicators, particularly in regions that are making satisfactory progress
toward the SDG 6 targets using traditional metrics. Because the evidence presented here suggests that using broader
WASH evaluation criteria will result in an improved measurement of return on investment, we recommend deploying
these new measurement tools in regions that are struggling to meet their SDG 6 targets or to attract WASH financing.
Transformative WASH may be at our fingertips, but we must promote multiple-indicator, dashboard-type approaches
to the monitoring and evaluation of WASH interventions to know for sure. This implies a commitment to transdisciplin-
ary WASH research, particularly between the engineering and social sciences, which fortunately has substantial precedent
(Workman, Cairns, et al., 2021). Through participatory research that evaluates a fuller set of WASH impacts, we can gain
much deeper insights into how WASH interventions change lives, that is, “what works,” and improve our ability to con-
vey the WASH value proposition. In doing so, we can bolster community trust, convene more equitable partnerships,
strengthen ties with funders, improve project sustainability, incentivize supporting governance structures, and otherwise
reinforce the deployment ecosystems that can help us regain momentum toward achieving SDG 6.
A U T H O R C ON T R I B U T I O NS
Justin Stoler: Conceptualization (lead); resources (equal); writing – original draft (lead); writing – review and editing
(equal). Danice B. Guzm an: Resources (equal); writing – review and editing (equal). Ellis Adams: Resources (equal);
writing – review and editing (equal).
FUNDING INFORMATION
Justin Stoler was supported by the Household Water Insecurity Experiences Research Coordination Network
(HWISE-RCN) through the National Science Foundation (grant BCS-1759972). This project was supported by the Pulte
Institute for Global Development at the University of Notre Dame. Our funding sources had no involvement in this
study, and the authors' expressed opinions do not necessarily represent those of the funders.
CONFLICT OF INTEREST STATEMENT

The authors have nothing to declare.
DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.
ORCID
Justin Stoler https://orcid.org/0000-0001-8435-7012
Danice B. Guzman https://orcid.org/0000-0002-8564-9145
Ellis A. Adams https://orcid.org/0000-0003-3783-9005
R EL ATE D WIR Es AR TI CL ES
Socio-environmental confounders of safe water interventions
The role of chemical exposures in reducing the effectiveness of water-sanitation-hygiene interventions in Bangladesh,
Kenya, and Zimbabwe
A review of 80 assessment tools measuring water security
Participatory approaches in water research: A review
FURTHER READING
Commissioners of the Lancet Commission on Water, Sanitation and Hygiene, and Health. (2021). The Lancet commission on water, sanita-
tion and hygiene, and health. The Lancet, 398(10310), 1469–1470. https://doi.org/10.1016/S0140-6736(21)02005-5
Ross, I. (2020, November 30). What is transformative WASH? Retrieved from https://washeconomics.com/2020/11/30/what-is-
transformative-wash/.
Water for Women. (2022, August 19). Toward transformation: Shifting social norms for transformative WASH. Retrieved from https://www.
waterforwomenfund.org/en/news/towards-transformation-shifting-social-norms-for-transformative-wash.aspx.
R EF E RE N C E S
Abu Sharekh, Y. (2021). Relationship between gender-based violence and poor access to water, sanitation, and hygiene services (Vol. 131).
English Language Institute. Retrieved from https://surface.syr.edu/eli/131.
Adams, E. A., Stoler, J., & Adams, Y. (2020). Water insecurity and urban poverty in the global south: Implications for health and human biol-
ogy. American Journal of Human Biology, 32, e23368. https://doi.org/10.1002/ajhb.23368
Adjorlolo, S., Ani-Amponsah, M., Hammond, E., & Nyame, M. E. P. (2023). Obstetric fistula-induced incontinence and WASH programming
in humanitarian settings: Agenda for research, innovation, and practice. Journal of International Humanitarian Action, 8(1), 1. https://
doi.org/10.1186/s41018-022-00133-y
Amebelu, A., Ban, R., Bhagwan, J., Brown, J., Chilengi, R., Chandler, C., Colford, J. M., Jr., Cumming, O., Curtis, V., Evans, B. E.,
Freeman, M. C., Guiteras, R., Howard, G., Humphrey, J., Kang, G., Kulabako, R., Lanata, C. F., Montgomery, M. A., Pickering, A. J., …
Wolf, J. (2021). The lancet commission on water, sanitation and hygiene, and health. The Lancet, 398(10310), 1469–1470. https://doi.org/
10.1016/S0140-6736(21)02005-5
Banks, L. M., White, S., Biran, A., Wilbur, J., Neupane, S., Neupane, S., Sharma, A., & Kuper, H. (2019). Are current approaches for measur-
ing access to clean water and sanitation inclusive of people with disabilities? Comparison of individual- and household-level access
between people with and without disabilities in the Tanahun district of Nepal. PLoS One, 14(10), e0223557. https://doi.org/10.1371/
journal.pone.0223557
Barrington, D. J., Sindall, R. C., Chinyama, A., Morse, T., Sule, M., Beale, J., Luwe, K., Malolo, R., Mcharo, O., Odili, A., Ravnda, K. T.,
Rose, J., Shaylor, E., & Wozei, E. (2021). Research brief: Amplifying local voices to reduce failure in the water, sanitation and hygiene
sector. Retrieved from https://pureportal.strath.ac.uk/en/publications/research-brief-amplifying-local-voices-to-reduce-failure-in-the-w.
Barrington, D. J., Sindall, R. C., & Shaylor, E. L. (2022). Learning from failure in environmental and public health research. Environmental
Health Insights, 16, 117863022211040. https://doi.org/10.1177/11786302221104067
Bisung, E., & Dickin, S. (2021). Who does what and why? Examining intra-household water and sanitation decision-making and autonomy
in Asutifi north, Ghana. Journal of Water, Sanitation and Hygiene for Development, 11(5), 794–804. https://doi.org/10.2166/washdev.
2021.039
Boltz, F., LeRoy Poff, N., Folke, C., Kete, N., Brown, C. M., St. George Freeman, S., Matthews, J. H., Martinez, A., & Rockström, J. (2019).
Water is a master variable: Solving for resilience in the modern era. Water Security, 8, 100048. https://doi.org/10.1016/j.wasec.2019.
100048
Brewis, A., Choudhary, N., & Wutich, A. (2019). Low water access as a gendered physiological stressor: Blood pressure evidence from Nepal.
American Journal of Human Biology, 31(3), e23234. https://doi.org/10.1002/ajhb.23234
Burton, J., Patel, D., Landry, G., Anderson, S. M., & Rary, E. (2021). Failure of the “gold standard”: The role of a mixed methods research
toolkit and human-centered design in transformative WASH. Environmental Health Insights, 15, 11786302211018391. https://doi.org/10.
1177/11786302211018391
Campbell, O. M. R., Benova, L., Gon, G., Afsana, K., & Cumming, O. (2015). Getting the basic rights—The role of water, sanitation and
hygiene in maternal and reproductive health: A conceptual framework. Tropical Medicine & International Health, 20(3), 252–267.
https://doi.org/10.1111/tmi.12439
Caridade, S. M. M., Vidal, D. G., & Dinis, M. A. P. (2022). Climate change and gender-based violence: Outcomes, challenges and future per-
spectives. In W. Leal Filho, D. G. Vidal, M. A. P. Dinis, & R. C. Dias (Eds.), Sustainable policies and practices in energy, environment and
Health Research: Addressing cross-cutting issues (pp. 167–176). Springer International Publishing. https://doi.org/10.1007/978-3-030-
86304-3_10
Carrard, N., MacArthur, J., Leahy, C., Soeters, S., & Willetts, J. (2022). The water, sanitation and hygiene gender equality measure
(WASH-GEM): Conceptual foundations and domains of change. Women's Studies International Forum, 91, 102563. https://doi.org/10.
1016/j.wsif.2022.102563
Carrard, N., Willetts, J., & Mitchell, C. (2022). Placing sustainability at the Centre of water, sanitation and hygiene: Knowledge
co-production for sectoral transformation. Current Research in Environmental Sustainability, 4, 100154. https://doi.org/10.1016/j.crsust.
2022.100154
Caruso, B. A., Clasen, T., Yount, K. M., Cooper, H. L. F., Hadley, C., & Haardörfer, R. (2017). Assessing women's negative sanitation experi-
ences and concerns: The development of a novel sanitation insecurity measure. International Journal of Environmental Research and
Public Health, 14(7), 755. https://doi.org/10.3390/ijerph14070755
Caruso, B. A., Portela, G., McManus, S., & Clasen, T. (2020). Assessing women's menstruation concerns and experiences in rural India:
Development and validation of a menstrual insecurity measure. International Journal of Environmental Research and Public Health,
17(10), 3468. https://doi.org/10.3390/ijerph17103468
Caruso, B. A., Sevilimedu, V., Fung, I. C.-H., Patkar, A., & Baker, K. K. (2015). Gender disparities in water, sanitation, and global health. The
Lancet, 386(9994), 650–651. https://doi.org/10.1016/S0140-6736(15)61497-0
Caruso, B. A., & Sinharoy, S. S. (2019). Gender data gaps represent missed opportunities in WASH. The Lancet Global Health, 7(12), e1617.
https://doi.org/10.1016/S2214-109X(19)30449-8
Cassivi, A., Tilley, E., Waygood, E. O. D., & Dorea, C. (2021). Evaluating self-reported measures and alternatives to monitor access to drink-
ing water: A case study in Malawi. Science of the Total Environment, 750, 141516. https://doi.org/10.1016/j.scitotenv.2020.141516
Chenoweth, J. (2008). Minimum water requirement for social and economic development. Desalination, 229(1), 245–256. https://doi.org/10.
1016/j.desal.2007.09.011
Choudhary, N., Brewis, A., Wutich, A., & Bhushan, P. (2020). Sub-optimal household water access is associated with greater risk of intimate
partner violence against women: Evidence from Nepal. Journal of Water and Health, 18(4), 579–597. https://doi.org/10.2166/wh.
2020.024
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396.
https://doi.org/10.2307/2136404
Cumming, O., Arnold, B. F., Ban, R., Clasen, T., Esteves Mills, J., Freeman, M. C., Gordon, B., Guiteras, R., Howard, G., Hunter, P. R.,
Johnston, R. B., Pickering, A. J., Prendergast, A. J., Prüss-Ustün, A., Rosenboom, J. W., Spears, D., Sundberg, S., Wolf, J., Null, C., …
Colford, J. M. (2019). The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea
and stunting: A consensus statement. BMC Medicine, 17(1), 173. https://doi.org/10.1186/s12916-019-1410-x
Dickin, S., Bisung, E., Nansi, J., & Charles, K. (2021). Empowerment in water, sanitation and hygiene index. World Development, 137,
105158. https://doi.org/10.1016/j.worlddev.2020.105158
Dietvorst, C. (2020). Decolonising the WASH sector. Retrieved from https://www.ircwash.org/blog/decolonising-wash-sector.
Ekwebelem, O. C., Ofielu, E. S., Nnorom-Dike, O. V., Iweha, C., Ekwebelem, N. C., Obi, B. C., & Ugbede-Ojo, S. E. (2020). Threats of
COVID-19 to achieving United Nations sustainable development goals in Africa. The American Journal of Tropical Medicine and
Hygiene, 104(2), 457–460. https://doi.org/10.4269/ajtmh.20-1489
Flörke, M., Kynast, E., Bärlund, I., Eisner, S., Wimmer, F., & Alcamo, J. (2013). Domestic and industrial water uses of the past 60 years as a
mirror of socio-economic development: A global simulation study. Global Environmental Change, 23(1), 144–156. https://doi.org/10.
1016/j.gloenvcha.2012.10.018
Gautier, L., Karambé, Y., Dossou, J.-P., & Samb, O. M. (2022). Rethinking development interventions through the lens of decoloniality in
sub-Saharan Africa: The case of global health. Global Public Health, 17(2), 180–193. https://doi.org/10.1080/17441692.2020.1858134
Geere, J.-A. L., Bartram, J., Bates, L., Danquah, L., Evans, B., Fisher, M. B., Groce, N., Majuru, B., Mokoena, M. M., Mukhola, M. S.,
Nguyen-Viet, H., Duc, P. P., Williams, A. R., Schmidt, W.-P., & Hunter, P. R. (2018). Carrying water may be a major contributor to dis-
ability from musculoskeletal disorders in low income countries: A cross-sectional survey in South Africa, Ghana and Vietnam. Journal of
Globalization and Health, 8(1), 010406. https://doi.org/10.7189/jogh.08.010406
Geere, J.-A. L., & Cortobius, M. (2017). Who carries the weight of water? Fetching water in rural and urban areas and the implications for
water security. Water Alternatives, 10(2), 513–540.
Geere, J.-A. L., Cortobius, M., Geere, J. H., Hammer, C. C., & Hunter, P. R. (2018). Is water carriage associated with the water carrier's
health? A systematic review of quantitative and qualitative evidence. BMJ Global Health, 3(3), e000764. https://doi.org/10.1136/bmjgh-
2018-000764
Geere, J.-A. L., & Hunter, P. R. (2020). The association of water carriage, water supply and sanitation usage with maternal and child health.
A combined analysis of 49 multiple indicator cluster surveys from 41 countries. International Journal of Hygiene and Environmental
Health, 223(1), 238–247. https://doi.org/10.1016/j.ijheh.2019.08.007
Geere, J.-A. L., Hunter, P. R., & Jagals, P. (2010). Domestic water carrying and its implications for health: A review and mixed methods pilot
study in Limpopo Province, South Africa. Environmental Health, 9, 52. https://doi.org/10.1186/1476-069X-9-52
Groce, N., Bailey, N., Lang, R., Trani, J. F., & Kett, M. (2011). Water and sanitation issues for persons with disabilities in low- and middle-
income countries: A literature review and discussion of implications for global health and international development. Journal of Water
and Health, 9(4), 617–627. https://doi.org/10.2166/wh.2011.198
Guest, J. S. (2019). Editorial perspectives: We need innovation for water, sanitation, and hygiene (WASH) in developing communities. Envi-
ronmental Science: Water Research & Technology, 5(5), 819–820. https://doi.org/10.1039/C9EW90014D
Guppy, L., Mehta, P., & Qadir, M. (2019). Sustainable development goal 6: Two gaps in the race for indicators. Sustainability Science, 14,
501–513. https://doi.org/10.1007/s11625-018-0649-z
Hennegan, J., Nansubuga, A., Smith, C., Redshaw, M., Akullo, A., & Schwab, K. J. (2020). Measuring menstrual hygiene experience: Devel-
opment and validation of the menstrual practice needs scale (MPNS-36) in Soroti, Uganda. BMJ Open, 10(2), e034461. https://doi.org/10.
1136/bmjopen-2019-034461
Hennegan, J., Shannon, A. K., Rubli, J., Schwab, K. J., & Melendez-Torres, G. J. (2019). Women's and girls' experiences of menstruation in
low- and middle-income countries: A systematic review and qualitative metasynthesis. PLoS Medicine, 16(5), e1002803. https://doi.org/
10.1371/journal.pmed.1002803
Henry, J. D., & Crawford, J. R. (2005). The short-form version of the depression anxiety stress scales (DASS-21): Construct validity and nor-
mative data in a large non-clinical sample. British Journal of Clinical Psychology, 44(2), 227–239. https://doi.org/10.1348/
014466505X29657
Herrera, V. (2019). Reconciling global aspirations and local realities: Challenges facing the sustainable development goals for water and sani-
tation. World Development, 118, 106–117. https://doi.org/10.1016/j.worlddev.2019.02.009
Howard, G. (2021). The future of water and sanitation: Global challenges and the need for greater ambition. Journal of Water Supply:
Research and Technology-Aqua., 70, 438–448. https://doi.org/10.2166/aqua.2021.127
Huggett, C., Da Costa Cruz, L., Goff, F., Pheng, P., & Ton, D. (2022). Beyond inclusion: Practical lessons on striving for gender and disability
transformational changes in WASH systems in Cambodia and Timor-Leste. H2Open Journal, 5(1), 26–42. https://doi.org/10.2166/h2oj.
2022.039
Humphrey, J. H., Mbuya, M. N. N., Ntozini, R., Moulton, L. H., Stoltzfus, R. J., Tavengwa, N. V., Mutasa, K., Majo, F., Mutasa, B.,
Mangwadu, G., Chasokela, C. M., Chigumira, A., Chasekwa, B., Smith, L. E., Tielsch, J. M., Jones, A. D., Manges, A. R., Maluccio, J. A.,
Prendergast, A. J., … Makoni, T. (2019). Independent and combined effects of improved water, sanitation, and hygiene, and improved
complementary feeding, on child stunting and anaemia in rural Zimbabwe: A cluster-randomised trial. The Lancet Global Health, 7(1),
e132–e147. https://doi.org/10.1016/S2214-109X(18)30374-7
Husseini, M., Darboe, M. K., Moore, S. E., Nabwera, H. M., & Prentice, A. M. (2018). Thresholds of socio-economic and environmental condi-
tions necessary to escape from childhood malnutrition: A natural experiment in rural Gambia. BMC Medicine, 16(1), 199. https://doi.
org/10.1186/s12916-018-1179-3
Hutton, G., & Varughese, M. (2016). The costs of meeting the 2030 sustainable development goal targets on drinking water, sanitation, and
hygiene. World Bank Group. https://doi.org/10.1596/k8543
Indarti, N., Rostiani, R., Megaw, T., & Willetts, J. (2019). Women's involvement in economic opportunities in water, sanitation and hygiene
(WASH) in Indonesia: Examining personal experiences and potential for empowerment. Development Studies Research, 6(1), 76–91.
https://doi.org/10.1080/21665095.2019.1604149
IRC. (2020). IRC Annual Report 2020. Retrieved from https://www.ircwash.org/sites/default/files/irc_2020_annual_report_0.pdf.
Irfan, A., & St Jean, D. T. (2021). COVID-19 & sociocultural determinants of global sanitation: An aide-mémoire and call to decolonize global
sanitation research & practice. Annals of Global Health, 87(1), 91. https://doi.org/10.5334/aogh.3358
Kaczan, D. J., & Orgill-Meyer, J. (2020). The impact of climate change on migration: A synthesis of recent empirical insights. Climatic
Change, 158(3), 281–300. https://doi.org/10.1007/s10584-019-02560-0
Kangmennaang, J., & Elliott, S. J. (2021). Linking water (in)security and wellbeing in low-and middle-income countries. Water Security, 13,
100089. https://doi.org/10.1016/j.wasec.2021.100089
Kapur, D. (2020). Decolonisation of WASH knowledge: addressing institutional bias. Retrieved from https://www.ircwash.org/blog/
decolonisation-wash-knowledge-addressing-institutional-bias.
Kayser, G. L., Rao, N., Jose, R., & Raj, A. (2019). Water, sanitation and hygiene: Measuring gender equality and empowerment. Bulletin of
the World Health Organization, 97(6), 438–440. https://doi.org/10.2471/BLT.18.223305
Kearns, J. (2019). Moving towards transformational WASH. The Lancet Global Health, 7(11), e1493. https://doi.org/10.1016/S2214-109X(19)
30394-8
Kearns, J. (2020). The role of chemical exposures in reducing the effectiveness of water–sanitation–hygiene interventions in Bangladesh,
Kenya, and Zimbabwe. WIREs Water, 7(5), e1478. https://doi.org/10.1002/wat2.1478
Khan, M. A. (2022). Livelihood, WASH related hardships and needs assessment of climate migrants: Evidence from urban slums in
Bangladesh. Heliyon, 8(5), e09355. https://doi.org/10.1016/j.heliyon.2022.e09355
Kose, M. A., Ohnsorge, F., & Sugawara, N. (2021). A mountain of debt: Navigating the legacy of the pandemic. CEPR Discussion Paper
No. DP16637, p. 41. Retrieved from https://ssrn.com/abstract=3960219.
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Inter-
nal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Leder, K., Openshaw, J. J., Allotey, P., Ansariadi, A., Barker, S. F., Burge, K., Clasen, T. F., Chown, S. L., Duffy, G. A., Faber, P. A.,
Fleming, G., Forbes, A. B., French, M., Greening, C., Henry, R., Higginson, E., Johnston, D. W., Lappan, R., Lin, A., … Brown, R. (2021).
Study design, rationale and methods of the Revitalising informal settlements and their environments (RISE) study: A cluster randomised
controlled trial to evaluate environmental and human health impacts of a water-sensitive intervention in informal settlements in
Indonesia and Fiji. BMJ Open, 11(1), e042850. https://doi.org/10.1136/bmjopen-2020-042850
Levy, K., & Eisenberg, J. N. S. (2019). Moving towards transformational WASH. The Lancet Global Health, 7(11), e1492. https://doi.org/10.
1016/S2214-109X(19)30396-1
Lin, A., Mertens, A. N., Rahman, M. Z., Tan, S., Il'yasova, D., Spasojevic, I., Ali, S., Stewart, C. P., Fernald, L. C. H., Kim, L., Yan, L.,
Meyer, A., Karim, M. R., Shahriar, S., Shuman, G., Arnold, B. F., Hubbard, A., Famida, S. L., Akther, S., … Granger, D. A. (2021). Effects
of drinking water, sanitation, handwashing and nutritional interventions on stress physiology, oxidative stress, and epigenetic pro-
gramming in young children living in rural Bangladesh: A randomized clinical trial. medRxiv, 1–28. https://doi.org/10.1101/2021.
11.24.21266798
Lin, A., Mertens, A. N., Tan, S., Rahman, M. Z., Hester, L., Kim, L., Arnold, B. F., Karim, M. R., Shahriar, S., Ali, S., Shoab, A. K.,
Hossen, M. S., Mutsuddi, P., Famida, S. L., Akther, S., Rahman, M., Unicomb, L., Butzin-Dozier, Z., Hemlock, C., … Dhabhar, F. S.
(2021). Effects of drinking water, sanitation, handwashing, and nutritional interventions on immune status in young children: A cluster-
randomized controlled trial in rural Bangladesh. medRxiv, 1–33. https://doi.org/10.1101/2021.11.10.21266206
Luby, S. P., Rahman, M., Arnold, B. F., Unicomb, L., Ashraf, S., Winch, P. J., Stewart, C. P., Begum, F., Hussain, F., Benjamin-Chung, J.,
Leontsini, E., Naser, A. M., Parvez, S. M., Hubbard, A. E., Lin, A., Nizame, F. A., Jannat, K., Ercumen, A., Ram, P. K., … Colford, J. M.,
Jr. (2018). Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural
Bangladesh: A cluster randomised controlled trial. The Lancet Global Health, 6(3), e302–e315. https://doi.org/10.1016/S2214-109X(17)
30490-4
Luseka, E. (2020). Initiating de-colonisation of WASH sector knowledge. Retrieved from https://medium.com/@euphresia_luseka/initiating-
de-colonization-of-wash-sector-knowledge-c8ad0a9f8d6.
Ma, T., Peden, A. E., Peden, M., Hyder, A. A., Jagnoor, J., Duan, L., Brown, J., Passmore, J., Clapham, K., Tian, M., Rahman, A. K. M. F., &
Ivers, R. Q. (2020). Out of the silos: Embedding injury prevention into the sustainable development goals. Injury Prevention, 27, 166–171.
https://doi.org/10.1136/injuryprev-2020-043850
MacArthur, J., Carrard, N., & Willetts, J. (2020). WASH and gender: A critical review of the literature and implications for gender-
transformative WASH research. Journal of Water, Sanitation and Hygiene for Development, 10(4), 818–827. https://doi.org/10.2166/
washdev.2020.232
Mack, E. A., Bunting, E., Herndon, J., Marcantonio, R. A., Ross, A., & Zimmer, A. (2021). Conflict and its relationship to climate variability
in sub-Saharan Africa. Science of the Total Environment, 775, 145646. https://doi.org/10.1016/j.scitotenv.2021.145646
Mactaggart, I., Baker, S., Bambery, L., Iakavai, J., Kim, M. J., Morrison, C., Poilapa, R., Shem, J., Sheppard, P., Tanguay, J., & Wilbur, J.
(2021). Water, women and disability: Using mixed-methods to support inclusive WASH programme design in Vanuatu. The Lancet
Regional Health - Western Pacific, 8, 100109. https://doi.org/10.1016/j.lanwpc.2021.100109
Mahon, T., & Fernandes, M. (2010). Menstrual hygiene in South Asia: A neglected issue for WASH (water, sanitation and hygiene)
programmes. Gender and Development, 18(1), 99–113. https://doi.org/10.1080/13552071003600083
Marcos-Garcia, P., Carmona-Moreno, C., L opez-Puga, J., & Ruiz-Ruano García, A. M. (2021). COVID-19 pandemic in Africa: Is it time for
water, sanitation and hygiene to climb up the ladder of global priorities? Science of the Total Environment, 791, 148252. https://doi.org/
10.1016/j.scitotenv.2021.148252
Mraz, A. L., Tumwebaze, I. K., McLoughlin, S. R., McCarthy, M. E., Verbyla, M. E., Hofstra, N., Rose, J. B., & Murphy, H. M. (2021). Why
pathogens matter for meeting the united nations' sustainable development goal 6 on safely managed water and sanitation. Water
Research, 189, 116591. https://doi.org/10.1016/j.watres.2020.116591
Mushavi, R. C., Burns, B. F. O., Kakuhikire, B., Owembabazi, M., Vořechovska, D., McDonough, A. Q., Cooper-Vince, C. E., Baguma, C.,
Rasmussen, J. D., Bangsberg, D. R., & Tsai, A. C. (2020). “When you have no water, it means you have no peace”: A mixed-methods,
whole-population study of water insecurity and depression in rural Uganda. Social Science & Medicine, 245, 112561. https://doi.org/10.
1016/j.socscimed.2019.112561
Null, C., Stewart, C. P., Pickering, A. J., Dentz, H. N., Arnold, B. F., Arnold, C. D., Benjamin-Chung, J., Clasen, T., Dewey, K. G.,
Fernald, L. C. H., Hubbard, A. E., Kariger, P., Lin, A., Luby, S. P., Mertens, A., Njenga, S. M., Nyambane, G., Ram, P. K., &
Colford, J. M. (2018). Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in
rural Kenya: A cluster-randomised controlled trial. The Lancet Global Health, 6(3), e316–e329. https://doi.org/10.1016/S2214-109X(18)
30005-6
Octavianti, T., & Staddon, C. (2021). A review of 80 assessment tools measuring water security. WIREs Water, 8(3), e1516. https://doi.org/10.
1002/wat2.1516
Omasete, J., Forster, J., & Geere, J.-A. (2021). Water, sanitation and hygiene: The foundation for building resilience in climate-vulnerable
communities. Retrieved from https://washmatters.wateraid.org/sites/g/files/jkxoof256/files/water-sanitation-and-hygiene-the-foundation-
for-building-resilience-in-climate-vulnerable-communities_2.pdf.
Pearson, A., Mack, E., Ross, A., Marcantonio, R., Zimmer, A., Bunting, E., Smith, A., Miller, J., Evans, T., & HWISE-RCN. (2021). Interper-
sonal conflict over water is associated with household demographics, domains of water insecurity, and regional conflict: Evidence from
nine sites across eight sub-Saharan African countries. Water, 13(9), 1150. https://doi.org/10.3390/w13091150
Peloso, M., & Morinville, C. (2014). ‘Chasing for water’: Everyday practices of water access in peri-urban Ashaiman, Ghana. Water Alterna-
tives, 7(1), 121–139.
Pickering, A. J., Arnold, B. F., Prendergast, A. J., Null, C., Winch, P. J., Njenga, S. M., Rahman, M., Ntozini, R., Benjamin-Chung, J.,
Stewart, C. P., Colford, J. M., Luby, S., & Humphrey, J. H. (2019). Moving towards transformational WASH—Authors' reply. The Lancet
Global Health, 7(11), e1494–e1495. https://doi.org/10.1016/S2214-109X(19)30401-2
Pickering, A. J., Null, C., Winch, P. J., Mangwadu, G., Arnold, B. F., Prendergast, A. J., Njenga, S. M., Rahman, M., Ntozini, R., Benjamin-
Chung, J., Stewart, C. P., Huda, T. M. N., Moulton, L. H., Colford, J. M., Luby, S. P., & Humphrey, J. H. (2019). The WASH benefits and
SHINE trials: Interpretation of WASH intervention effects on linear growth and diarrhoea. The Lancet Global Health, 7(8), e1139–e1146.
https://doi.org/10.1016/S2214-109X(19)30268-2
Piperata, B. A., Lee, S., Mayta Apaza, A. C., Cary, A., Vilchez, S., Oruganti, P., Garabed, R., Wilson, W., & Lee, J. (2020). Characterization of
the gut microbiota of Nicaraguan children in a water insecure context. American Journal of Human Biology, 32(1), e23371. https://doi.
org/10.1002/ajhb.23371
Pommells, M., Schuster-Wallace, C., Watt, S., & Mulawa, Z. (2018). Gender violence as a water, sanitation, and hygiene risk: Uncovering vio-
lence against women and girls as it pertains to poor WaSH access. Violence Against Women, 24(15), 1851–1862. https://doi.org/10.1177/
1077801218754410
Ranganathan, M. (2014). ‘Mafias’ in the waterscape: Urban informality and everyday public authority in Bangalore. Water Alternatives, 7(1),
89–105.
Redman-MacLaren, M., Barrington, D. J., Harrington, H., Cram, D., Selep, J., & MacLaren, D. (2018). Water, sanitation and hygiene systems
in Pacific Island schools to promote the health and education of girls and children with disability: A systematic scoping review. Journal
of Water, Sanitation and Hygiene for Development, 8(3), 386–401. https://doi.org/10.2166/washdev.2018.274
Rhodes-Dicker, L., Brown, N. J., & Currell, M. (2022). Unpacking intersecting complexities for WASH in challenging contexts: A review.
Water Research, 209, 117909. https://doi.org/10.1016/j.watres.2021.117909
Richard, D., & Kiani, S. (2019). Rapid review of disability and older age inclusion in humanitarian WASH interventions. Retrieved from
https://www.elrha.org/wp-content/uploads/2019/05/WASH-Rapid-Review.pdf.
Robina-Ramírez, R., Sañudo-Fontaneda, L. S., & McCallum, S. (2020). Human dignity as a mediator effect for the rights and duties of
accessing water and sanitation. Transactions of the Royal Society of South Africa, 75(2), 203–212. https://doi.org/10.1080/0035919X.2020.
1724208
Roque, A., Wutich, A., Quimby, B., Porter, S., Zheng, M., Hossain, M. J., & Brewis, A. (2022). Participatory approaches in water research: A
review. WIREs Water, 9(2), e1577. https://doi.org/10.1002/wat2.1577
Rosato-Scott, C., Barrington, D. J., Bhakta, A., House, S. J., Mactaggart, I., & Wilbur, J. (2020). Incontinence: We need to talk about leaks. In
Frontiers of sanitation: Innovations and insights 16. IDS. https://doi.org/10.19088/SLH.2020.005
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. Social Science & Medicine, 291, 114490. https://doi.org/10.1016/j.socscimed.2021.114490
Rosinger, A. Y., & Young, S. L. (2020). The toll of household water insecurity on health and human biology: Current understandings and
future directions. WIREs Water, 7(6), e1468. https://doi.org/10.1002/wat2.1468
Ross, I. (2022). Using water-adjusted person years to quantify the value of being water secure for an individual's quality of life. Water
Research, 227, 119327. https://doi.org/10.1016/j.watres.2022.119327
Ross, I., Greco, G., Opondo, C., Adriano, Z., Nala, R., Brown, J., Dreibelbis, R., & Cumming, O. (2022). Measuring and valuing broader
impacts in public health: Development of a sanitation-related quality of life instrument in Maputo, Mozambique. Health Economics,
31(3), 466–480. https://doi.org/10.1002/hec.4462
Sadoff, C. W., Borgomeo, E., & Uhlenbrook, S. (2020). Rethinking water for SDG 6. Nature Sustainability, 3(5), 346–347. https://doi.org/10.
1038/s41893-020-0530-9
Schouten, T., & Moriarty, P. (2013). The triple-S theory of change. Retrieved from https://www.ircwash.org/sites/default/files/2013_wp3_
theory_of_change_1.pdf.
Shields, K. F., Barrington, D. J., Meo, S., Sridharan, S., Saunders, S. G., Bartram, J., & Souter, R. T. (2022). Achieving development outcomes
by building practical authority in WASH participatory collectives in Melanesia. Water Alternatives, 15(2), 363–412. Retrieved from
https://www.water-alternatives.org/index.php/alldoc/articles/vol15/v15issue2/660-a15-2-2/file.
Shreyaskar, P. P. (2016). Contours of access to water and sanitation in India: Drawing on the right to live with human dignity. Economic and
Political Weekly, 51(53), 144–151.
Sidote, M. N., Goodman, Z. T., Paraggio, C. L., Tutu, R. A., & Stoler, J. (2022). Measurement invariance of a household water insecurity met-
ric in Greater Accra, Ghana: Implications for test-retest reliability. International Journal of Hygiene and Environmental Health, 240,
113922. https://doi.org/10.1016/j.ijheh.2022.113922
Smiley, S. L., & Stoler, J. (2020). Socio-environmental confounders of safe water interventions. WIREs Water, 7(3), e1438. https://doi.org/10.
1002/wat2.1438
Sommer, M., Kjellén, M., & Pensulo, C. (2013). Girls' and women's unmet needs for menstrual hygiene management (MHM): The interac-
tions between MHM and sanitation systems in low-income countries. Journal of Water, Sanitation and Hygiene for Development, 3(3),
283–297. https://doi.org/10.2166/washdev.2013.101
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7.
Archives of Internal Medicine, 166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092
Splash. (2018). Theory of change 2018–2023. Retrieved from https://splash.org/assets/docs/Splash_2018-2023_Theory_of_Change1.pdf.
Stoler, J., Brewis, A., Kangmennang, J., Keough, S. B., Pearson, A. L., Rosinger, A. Y., Stauber, C., & Stevenson, E. G. J. (2021). Connecting
the dots between climate change, household water insecurity, and migration. Current Opinion in Environmental Sustainability, 51, 36–
41. https://doi.org/10.1016/j.cosust.2021.02.008
Stoler, J., Jepson, W., Brewis, A., & Wutich, A. (2023). Frontiers of household water insecurity metrics: Severity, adaptation, and resilience.
BMJ Global Health, 8, e011756. https://doi.org/10.1136/bmjgh-2023-011756
Stoler, J., Miller, J. D., Brewis, A., Freeman, M. C., Harris, L. M., Jepson, W. E., Pearson, A. L., Rosinger, A. Y., Shah, S. H., Staddon, C.,
Workman, C., Wutich, A., Young, S. L., & HWISE-RCN. (2021). Household water insecurity will complicate COVID-19 prevention and
response: Evidence from 29 sites in 23 low- and middle-income countries. International Journal of Hygiene and Environmental Health,
234, 113715. https://doi.org/10.1016/j.ijheh.2021.113715
Stoler, J., Pearson, A. L., Rosinger, A. Y., Lee, A. E., Bombardi, R., Brewis, A., Keough, S. B., Lopez-Carr, D., Shrader, C.-H., Stauber, C. E.,
Stevenson, E. G. J., Sullivan, A., & Tutu, R. A. (2022). The role of water in environmental migration. WIREs Water, 9(3), e1584. https://
doi.org/10.1002/wat2.1584
Stoler, J., Pearson, A. L., Staddon, C., Wutich, A., Mack, E., Brewis, A., Rosinger, A. Y., & HWISE-RCN. (2020). Cash water expenditures are
associated with household water insecurity, food insecurity, and perceived stress in study sites across 20 low- and middle-income coun-
tries. Science of the Total Environment, 716, 135881. https://doi.org/10.1016/j.scitotenv.2019.135881
Taing, L. (2022). Is safe water, sanitation, and hygiene a pipe dream? One Earth, 5(2), 126–128. https://doi.org/10.1016/j.oneear.2022.01.004
Thavarajah, W., Verosloff, M. S., Jung, J. K., Alam, K. K., Miller, J. D., Jewett, M. C., Young, S. L., & Lucks, J. B. (2020). A primer on emerg-
ing field-deployable synthetic biology tools for global water quality monitoring. Npj Clean Water, 3(1), 18. https://doi.org/10.1038/
s41545-020-0064-8
The Lancet Public Health. (2020). Will the COVID-19 pandemic threaten the SDGs? The Lancet Public Health, 5(9), e460. https://doi.org/10.
1016/S2468-2667(20)30189-4
UNICEF. (2021). Theory of change, UNICEF Strategic Plan, 2022–2025. UNICEF. Retrieved from https://www.unicef.org/media/107936/file/
Theory_of_Change%2C_UNICEF_Strategic_Plan%2C_2022%E2%80%932025.pdf.
United Nations. (2018). Standard questions on international migration. United Nations. Retrieved from https://unstats.un.org/unsd/
demographic-social/migration-expert-group/methodology/Standard%20set%20of%20migration%20questions.pdf.
USAID. (2022). U.S. government global water strategy 2022–2027. USAID. Retrieved from https://www.globalwaters.org/sites/default/files/
us_global_water_strategy_2022.pdf.
Venkataramanan, V., Geere, J. A., Thomae, B., Stoler, J., Hunter, P. R., Young, S. L., & HWISE-RCN. (2020). In pursuit of “safe” water: The
burden of personal injury from water-fetching in 21 low- and middle-income countries. BMJ Global Health, 5, e003328. https://doi.org/
10.1136/bmjgh-2020-003328
Vila-Guilera, J., Parikh, P., Chaturvedi, H., Ciric, L., & Lakhanpaul, M. (2021). Towards transformative WASH: An integrated case study
exploring environmental, sociocultural, economic and institutional risk factors contributing to infant enteric infections in rural tribal
India. BMC Public Health, 21(1), 1331. https://doi.org/10.1186/s12889-021-11353-z
WASH Alliance International. (2016). Theory of change for accelerating sustainable WASH services. Retrieved from https://wash-alliance.
org/wp-content/uploads/sites/36/2016/06/Theory-of-Change-For-accelerating-sustainable-WASH-services.pdf.
Water For People. (2019). Water for people theory of change. Retrieved from https://thewashroom.waterforpeople.org/wp-content/uploads/
sites/2/2020/01/Water-For-People-Theory-of-Change-Dec-2019.pdf.
Wayland, J. (2017). Constraints on foreign aid effectiveness in the water, sanitation, and hygiene (WaSH) sector. Journal of Water, Sanitation
and Hygiene for Development, 8(1), 44–52. https://doi.org/10.2166/washdev.2017.095
WHO. (2019). Safer water, better health. World Health Organization. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/
329905/9789241516891-eng.pdf?ua=1.
WHO/UNICEF. (2021). Progress on household drinking water, sanitation and hygiene 2000–2020: Five years into the SDGs. WHO. Retrieved
from https://data.unicef.org/wp-content/uploads/2022/01/jmp-2021-wash-households_3.pdf.
Wolf, J., Hubbard, S., Brauer, M., Ambelu, A., Arnold, B. F., Bain, R., Bauza, V., Brown, J., Caruso, B. A., Clasen, T., Colford, J. M.,
Freeman, M. C., Gordon, B., Johnston, R. B., Mertens, A., Prüss-Ustün, A., Ross, I., Stanaway, J., Zhao, J. T., … Boisson, S. (2022). Effec-
tiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in
low-income and middle-income settings: A systematic review and meta-analysis. The Lancet, 400(10345), 48–59. https://doi.org/10.1016/
S0140-6736(22)00937-0
Workman, C. L., Cairns, M. R., de los Reyes, F. L., & Verbyla, M. E. (2021). Global water, sanitation, and hygiene approaches: Anthropologi-
cal contributions and future directions for engineering. Environmental Engineering Science, 38(5), 402–417. https://doi.org/10.1089/ees.
2020.0321
Workman, C. L., Stoler, J., Harris, A., Ercumen, A., Kearns, J., & Mapunda, K. M. (2021). Food, water, and sanitation insecurities: Complex
linkages and implications for achieving WASH security. Global Public Health, 17(11), 3060–3075. https://doi.org/10.1080/17441692.2021.
1971735
Workman, C. L., & Ureksoy, H. (2017). Water insecurity in a syndemic context: Understanding the psycho-emotional stress of water insecu-
rity in Lesotho, Africa. Social Science & Medicine, 179, 52–60. https://doi.org/10.1016/j.socscimed.2017.02.026
Worsham, K., Sylvester, R., Hales, G., McWilliams, K., & Luseka, E. (2021). Leadership for SDG 6.2: Is diversity missing? Environmental
Health Insights, 15, 11786302211031846. https://doi.org/10.1177/11786302211031846
Wrisdale, L., Mokoena, M. M., Mudau, L. S., & Geere, J.-A. (2017). Factors that impact on access to water and sanitation for older adults and
people with disability in rural South Africa: An occupational justice perspective. Journal of Occupational Studies, 24(3), 259–279. https://
doi.org/10.1080/14427591.2017.1338190
Wutich, A., Brewis, A., & Tsai, A. C. (2020). Water and mental health. WIREs Water, 7(5), e1461. https://doi.org/10.1002/wat2.1461
Wutich, A., Rosinger, A., Brewis, A., Beresford, M., Young, S., & HWISE-RCN. (2022). Water sharing is a distressing form of reciprocity:
Shame, upset, anger, and conflict over water in twenty cross-cultural sites. American Anthropologist, 124(2), 279–290. https://doi.org/10.
1111/aman.13682
Wutich, A., Rosinger, A. Y., Stoler, J., Jepson, W., & Brewis, A. (2020). Measuring human water needs. American Journal of Human Biology,
32, e23350. https://doi.org/10.1002/ajhb.23350
Young, S. L., Bethancourt, H. J., Ritter, Z. R., & Frongillo, E. A. (2021). The individual water insecurity experiences (IWISE) scale: Reliability,
equivalence and validity of an individual-level measure of water security. BMJ Global Health, 6(10), e006460. https://doi.org/10.1136/
bmjgh-2021-006460
Young, S. L., Boateng, G., Jamaluddine, Z., Miller, J., Frongillo, E., Neilands, T., Collins, S., Wutich, A., Jepson, W., Stoler, J., & HWISE-
RCN. (2019). The household water InSecurity experiences (HWISE) scale: Development and validation of a household water insecurity
measure for low- and middle-income countries. BMJ Global Health, 4(5), e001750. https://doi.org/10.1136/bmjgh-2019-001750
Young, S. L., Miller, J. D., Frongillo, E. A., Boateng, G. O., Jamaluddine, Z., Neilands, T. B., & HWISE-RCN. (2021). Validity of a four-item
household water insecurity experiences scale for assessing water issues related to health and well-being. The American Journal of Tropi-
cal Medicine and Hygiene, 104(1), 391–394. https://doi.org/10.4269/ajtmh.20-0417
Zaveri, E., Russ, J., Khan, A., Damania, R., Borgomeo, E., & Jägerskog, A. (2021). Ebb and flow, volume 1: Water, migration, and development.
World Bank. Retrieved from https://openknowledge.worldbank.org/handle/10986/36089.
How to cite this article: Stoler, J., Guzman, D. B., & Adams, E. A. (2023). Measuring transformative WASH: A
new paradigm for evaluating water, sanitation, and hygiene interventions. WIREs Water, 10(5), e1674. https://
doi.org/10.1002/wat2.1674

WIREs Water - 2023 - Stoler - Measuring Transformative WASH A New Paradigm For Evaluating Water Sanitation and Hygiene

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

WIREs Water - 2023 - Stoler - Measuring Transformative WASH A New Paradigm For Evaluating Water Sanitation and Hygiene

Uploaded by

Copyright:

Available Formats

Received: 15 December 2022 Revised: 11 April 2023 Accepted: 16 May 2023

Measuring transformative WASH: A new paradigm for

Justin Stoler 1,2 | n 3,4

Funding information This article is categorized under:

WIREs Water. 2023;10:e1674. wires.wiley.com/water 1 of 16

5 | M EAS URING TRANSFORMATIVE WAS H

5.1 | Water and sanitation insecurity experiences

5.2 | Mental health

5.3 | Gender roles

5.4 | Reproductive health

5.7 | Life course noncommunicable diseases

5.8 | Climate resilience and migration

5.9 | Emerging contaminants

6 | TRANSFORMATION THROUGH DECOLONIZATION

CONFLICT OF INTEREST STATEMENT

DATA AVAILABILITY STATEMENT

You might also like