Water-Energy-Food Security and Health in South Africa

This scoping review examines associations between water, energy, and food insecurities and health outcomes in South Africa and explores intermediate factors that may shape pathways between insecurities and health.

Key Points

Question

How are water, energy, and food (WEF) insecurities associated with health outcomes in South Africa?

Findings

This scoping review including 137 studies and consultations with 26 academic and practitioner experts found that associations between WEF insecurity and communicable diseases, noncommunicable diseases, and injuries were mediated by inadequate water, sanitation, and hygiene; poor nutrition; and reliance on traditional fuels.

Meaning

These findings suggest that integrated approaches addressing multiple resource insecurities are likely required to reduce health risks in South Africa and similar resource-constrained settings.

Abstract

Importance

Water, energy, and food (WEF) insecurities are widespread in South Africa and are associated with adverse health outcomes. However, research has typically examined these insecurities separately, resulting in limited understanding of their interconnected associations with health and the pathways through which they may influence health outcomes.

Objective

To develop a conceptual framework describing the associations between WEF insecurities and health outcomes in South Africa by synthesizing existing evidence on the pathways through which WEF insecurities may influence health.

Evidence Review

This scoping review used an iterative process combining literature synthesis and expert consultation. A scoping review of peer-reviewed studies was conducted to identify evidence of WEF-health associations and inform a preliminary framework. This was subsequently refined through expert consultation, including 13 semistructured interviews with academic and practitioner experts (October-November 2024) and 2 in-person workshops (March 2025). Literature searches were performed between September 2024 and April 2025 using Web of Science, PubMed, and Scopus. Reference lists of retrieved articles were screened to identify additional studies. Study selection followed predefined inclusion criteria based on the population-concept-context framework: human populations in South Africa (population), associations between WEF insecurities and health outcomes (concept), and publication between 2005 and 2025 (context). Methods and results are reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Extension for Scoping Reviews guidelines.

Findings

A total of 137 articles were included in the review, and 26 experts were consulted. Evidence indicated that WEF insecurities were associated with a range of adverse health outcomes, including communicable diseases, noncommunicable diseases, and injuries. Key pathways included inadequate water, sanitation, and hygiene; poor nutrition; and reliance on traditional energy sources. Additional identified intermediating factors included increased exposure to vector-borne diseases associated with surface water, overcrowded living conditions, and intimate partner violence. While most studies examined WEF-related exposures in isolation, limiting understanding of their combined and interacting effects, this synthesis revealed interconnected pathways that may link WEF insecurity and health.

Conclusions and Relevance

The findings of this scoping review of 137 articles plus expert consultation suggest that WEF insecurities are interconnected with determinants of health in South Africa, operating through multiple pathways. The conceptual framework clarifies how intersecting WEF insecurities may jointly influence health outcomes and highlights the need for integrated research and policy approaches addressing the WEF-health nexus. Applying such integrated perspectives may support more effective strategies to reduce health risks in settings facing overlapping resource insecurities.

Introduction

The water-energy-food (WEF) nexus represents interconnected resource systems that fundamentally shape human health through environmental, socioeconomic, and infrastructural pathways.^1,2 Insecurities in these interlinked resource systems are associated with poor health outcomes, ranging from infectious and respiratory diseases to malnutrition.^3,4,5 Despite institutional silos, these insecurities do not occur in isolation: for example, food production depends on water and energy inputs for irrigation and processing, energy systems rely on water for cooling and generation, and water services require energy for abstraction, treatment, and distribution.^6,7,8

In South Africa, WEF insecurities remain pervasive: approximately 2.11 million people lack access to safe water,⁹ 3.5 million households rely on biomass for cooking or heating,¹⁰ and an estimated 14 million people experience food insecurity.¹¹ Additionally, population growth, urbanization, and climate change further intensify pressures on water, energy, and food systems, exacerbating existing insecurities.¹² These insecurities intersect with an epidemiologic context characterized by a quadruple burden of disease (ie, communicable diseases, noncommunicable diseases, maternal and child health challenges, and injuries).¹³ WEF-health interactions are a core dimension of planetary health, linking biophysical limits with the equitable resource security that underpins sustainable and resilient human well-being.^2,14 Understanding how interacting WEF insecurities shape health outcomes is therefore critical for informing integrated, cross-sectoral approaches to health and sustainable development.

Several studies have identified associations between WEF insecurity and health, but the pathways through which these associations operate remain incompletely articulated. Within the international literature, studies linking the WEF nexus to health often adopt 1 of 2 approaches. Some take a broad nexus perspective but focus on a limited set of health outcomes. For instance, Calder et al¹⁵ conceptualized bidirectional interactions between the WEF nexus and the COVID-19 pandemic, while Nuwayhid and Mohtar¹⁶ suggested adding health to the nexus, with cancer and respiratory illness framed as downstream outcomes of WEF insecurity. Albatayneh et al¹⁷ provided a systematic overview of the WEF-health nexus, covering literature, methodologic approaches, and policy implications, with health incorporated as part of a broader conceptual framing. Hirwa et al¹⁸ proposed an analytic model of a WEF-biodiversity-health nexus under climate change, with health largely operationalized through water, sanitation, and hygiene (WASH)–related diseases.¹⁹ The second approach focuses on a single WEF domain but examines a wider range of potential health outcomes. For example, Jessel et al¹⁹ found an association between energy insecurity and cardiovascular disease, mental health, and respiratory illness, among others. Studies examining resource insecurity frequently report associations across multiple domains of health and well-being, including physical and psychological outcomes, highlighting that treating health as a single or aggregated outcome obscures distinct causal pathways and limits insight into the multiple interacting pathways through which WEF insecurities may affect health.²⁰

A similar pattern emerges for research on South Africa, where investigations often focus on a single WEF component in relation to a narrow set of health outcomes, such as water insecurity to gastrointestinal disease,²¹ energy insecurity to respiratory illness,²² or food insecurity to malnutrition.²³ Some research in South Africa has started to explore connections between WEF systems and health through livelihood models,²⁴ policy analyses,²⁵ and frameworks like the water, human health, environment, and nutrition framework.²⁶ Across this literature, health is often only partially integrated, and there remains limited systematic mapping of how WEF insecurities may interact to produce distinct and potentially compound health effects. This highlights the need for research that examines the interacting pathways through which WEF insecurities influence health in order to understand and address the complex, interconnected risks they pose.

To address this gap, we aimed to develop a conceptual framework describing associations between WEF insecurities and health outcomes in South Africa. Drawing on existing evidence and expert insights, we explicitly aimed to connect resource systems and human well-being with a framework designed to provide a foundation for identifying integrated, cross-sectoral interventions to improve resource scarcity, health, and well-being.

Methods

Study Design

This scoping review combined a structured scoping review with expert consultations to inform framework development, following the approach of Arksey and O’Malley.²⁷ Included studies provided the evidence base for mapping associations between WEF insecurities, intermediates, and health outcomes. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)–Extension for Scoping Reviews reporting guideline (eFigure 1 in Supplement 1 shows the PRISMA flow diagram). The study followed established ethical principles for low-risk qualitative research.²⁸ Participants in the expert consultation received study information, and written informed consent was obtained prior to participation. Participation was voluntary, with the right to withdraw at any time. No personal or sensitive data were collected.

Intermediates were defined as factors shaping pathways between WEF insecurities and health, in alignment with the World Health Organization’s (WHO) framework on the social determinants of health.²⁹ We synthesized recurring pathways to develop a preliminary framework, which was refined through expert interviews and workshops.

Pathways were categorized as direct (within the same WEF domain) or indirect (via another WEF domain or intermediate). Health outcomes were grouped using WHO classifications while acknowledging that some conditions span multiple causal domains³⁰: (1) communicable diseases—malaria, HIV/AIDS, tuberculosis, gastrointestinal and respiratory infections, and parasitic infections; (2) noncommunicable diseases—cardiometabolic diseases, cancer, respiratory diseases, triple burden of malnutrition (ie, undernutrition, micronutrient deficiencies, and overnutrition), and mental health conditions; and (3) injuries—burns and physical trauma.

Some conditions, such as gastrointestinal infections, may act both as communicable outcomes and as upstream contributors to malnutrition. Conditions were assigned to a primary category, with cross-cutting associations captured within the pathway mapping. To ensure clarity and avoid double-counting across disease categories, health outcomes were further classified into parasitic infections (excluding gastrointestinal diseases), respiratory infections (excluding tuberculosis), and gastrointestinal diseases (excluding HIV and tuberculosis). Respiratory diseases were categorized as communicable or noncommunicable, depending on the specific outcome examined (eg, upper respiratory tract infections vs asthma). The framework was developed inductively and visualized using color-coded mapping to reflect WEF-health linkages (eFigure 2 in Supplement 1).

Definitions and Determinants of WEF Security and Health

We applied established definitions of water, energy, food security, and health from the United Nations University Institute for Water, Environment and Health; International Energy Agency; Food and Agriculture Organization; and WHO.^31,32,33,34 Water security refers to sustainable access to sufficient, safe water; energy security to reliable and affordable energy; and food security to consistent access to sufficient, safe, and nutritious food. To harmonize terminology across sectors, we used the 4 A’s framework: availability, accessibility, affordability, and acceptability (eTable 1 in Supplement 1) to characterize WEF security determinants.³⁵ These dimensions capture both quantity (availability) and quality (acceptability) aspects of resources. Health was defined as a state of physical, mental, and social well-being. Health outcomes were defined as specific diseases and health conditions (communicable diseases, noncommunicable diseases, and injuries), consistent with International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) classifications.³⁶

Data Analysis

Inclusion Criteria for Scientific Studies

Peer-reviewed, English-language studies were included based on relevance to WEF-health linkages. The population-concept-context (PCC) framework defined inclusion³⁷: population (South Africa), concept (WEF-health associations), and context (publication between 2005 and 2025) (Table 1).

Table 1. Inclusion Criteria for Scientific Studies in the Scoping Review, Based on the PCC Principle of Peters et al^a.

PCC component	Definition	Inclusion criteria applied in this scoping review
Population	Groups or demographics being studied	Human populations within South Africa
Concept	Core subject or phenomenon being studied	Linkages between WEF security and health outcomes
Context	Geographic, cultural, or situational setting of the research	Studies published between 2005 and 2025

Abbreviations: PCC, population-concept-context; WEF, water, energy, and food.

^a The PCC principle was developed by Peters et al.³⁷

Literature Search Strategy

Searches were conducted in Web of Science, PubMed, and Scopus between September 2024 and April 2025. Search terms were based on the WEF and health definitions and the 4 A’s framework (terms are listed in eTable 2 in Supplement 1). Reference lists were screened for additional studies.³⁸ Findings from this search informed the development of a preliminary conceptual framework linking WEF insecurities to health outcomes.

Expert Consultation

A structured consultation process was used to refine the preliminary conceptual framework. Experts (academics and practitioners in WEF and health in South Africa) were identified through purposive and snowball sampling (eTables 3 and 4 in Supplement 1 show participants’ expertise).³⁹ The framework was refined through 2 stages: (1) 13 semistructured interviews (approximately 60 minutes each) were conducted exploring WEF-health pathways and framework structure (October-November 2024) and (2) 2 in-person workshops were held in Stellenbosch and Johannesburg in March 2025, involving presentations, breakout discussions, and visual mapping exercises. Interviews were recorded, transcribed, and thematically reviewed. Workshop feedback was documented and validated in plenary sessions.

Results

Conceptual Framework

A total of 137 articles were included in the review,^{21,22,23,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174} and 26 experts (12 [46.2%] men and 14 [53.8%] women, with experience in their field ranging from 10+ to 40+ years) were consulted. The resulting conceptual framework maps how WEF insecurities may influence different health outcome categories (communicable diseases, noncommunicable diseases, and injuries) through various intermediates. The conceptual framework illustrates the complex and multilayered associations between WEF security and health outcomes (Figure). Specific examples of health outcomes are provided for each health category, with disaggregated results for all health outcomes shown in eFigure 3 in Supplement 1.

Figure. Conceptual Framework of Associations Between Water, Energy, and Food (WEF) Security and Health Outcomes in South Africa.

The degree of shading in the boxes on the right illustrates the comparative contribution of the studies. Hydro indicates water use for hydropower generation; TB, tuberculosis; WASH, water, sanitation, and hygiene.

Intermediates that influence multiple outcomes, such as burning of traditional fuel, inadequate nutrition, limited WASH, intimate partner violence, and overcrowding, may exert particularly broad leverage on health, given their contribution to multiple health outcomes. The color weighting of disease categories in the Figure shows that in the extant academic literature, communicable diseases were mainly associated with water-based intermediates (water security), while noncommunicable diseases and injuries were primarily associated with food-based intermediates (food security). For secondary connections, noncommunicable diseases and injuries were associated with energy security, while communicable diseases were associated with food security.

Across communicable diseases, noncommunicable diseases, and injuries, the pathways consistently showed that WEF insecurities were rarely found to act in isolation but instead intersected through overlapping intermediates. Of note, multiple WEF domains were associated with each disease category, underscoring the interdependence of water, energy, and food systems and highlighting how insecurities in any of these domains may have direct or indirect impacts on health outcomes. The framework also illustrates several important indirect interdependencies within the WEF nexus. For example, the risk of foodborne pathogens may be shaped not only by food insecurity but also by energy insecurity (which limits refrigeration) and water insecurity (which constrains safe food preparation and hygiene). Similarly, energy insecurity may undermine the functioning of WASH systems, such as by limiting electricity for water pumping, water treatment,¹⁷⁵ or safe storage of water, thereby reinforcing the health outcomes associated with limited WASH.

These cross-cutting pathways also show that indirect effects of a particular insecurity may amplify direct risks; the most consequential health outcomes may emerge not from isolated deficits in water, energy, or food but from their mutually reinforcing insecurities. Taken together, the framework suggests that WEF insecurities operate as a syndemic system: common intermediates amplify multiple health outcomes, with both direct and indirect pathways between WEF insecurities and health. Building on these overarching patterns, we next examined associations of WEF insecurities and their direct and indirect pathways with specific health outcomes, beginning with communicable diseases.

Communicable Diseases

The associations between WEF insecurities and communicable disease outcomes are summarized in Table 2, highlighting the key intermediates through which these associations operate. Full reference details for the studies providing evidence of each individual pathway are provided in eTable 5 in Supplement 1. Water insecurity played a particularly prominent role in the context of communicable diseases. Poor water security resulting in limited WASH consistently emerged as a central intermediate pathway, facilitating the transmission of parasitic infections, gastrointestinal disease (excluding parasitic disease), and respiratory infections.^40,41 Limited WASH may also increase the risk of urogenital infections; however, this was not captured in the included studies and was identified solely via expert contributions_. The pathways associated with limited WASH operate primarily through waterborne and contact transmission via direct exposure to contaminated water sources, inadequate sanitation infrastructure, and poor hygiene practices, which create environments conducive to pathogen proliferation and person-to-person spread.⁴² Another key water-related pathway is the role of surface water as a habitat for vector-borne diseases, such as malaria and schistosomiasis.^43,44 For example, stagnant or slow-moving water can facilitate the breeding of mosquitoes and snails, contributing to the transmission of malaria and schistosomiasis.

Table 2. Pathways of Associations Between WEF Insecurity and Communicable Disease Outcomes.

WEF element	Intermediate	Health outcome
Water	Limited WASH Habitat for vector-borne disease	Gastrointestinal disease (excluding parasitic disease) Parasitic infections Respiratory infections Urogenital infections
Energy	Burning of traditional fuels Overcrowding	Gastrointestinal disease Respiratory infections (excluding TB) TB
Food	Inadequate nutrition Foodborne pathogens	Gastrointestinal disease (excluding HIV and TB) HIV TB

Abbreviations: TB, tuberculosis; WASH, water, sanitation, and hygiene; WEF, water, energy, and food.

Energy insecurity may influence communicable disease risk, mainly through 2 mechanisms: (1) increased household air pollution from burning traditional fuels, which can weaken respiratory defenses and heighten susceptibility to airborne pathogens such as Mycobacterium tuberculosis and nontuberculous mycobacteria, and (2) overcrowded living conditions, which arise when limited energy access restricts heating, cooling, or lighting and forces multiple families to share confined spaces.²⁰ Both pathways are associated with tuberculosis and other respiratory infections.^45,46,47 Exposure to air pollution may contribute to gastrointestinal disease, with airborne particles potentially facilitating the conveyance of pathogens to food and water.²³ Overcrowding is also associated with increased risk of gastrointestinal disease through airborne transmission by droplets or aerosols.⁴⁷

Food insecurity was identified as another critical pathway linking WEF insecurities to communicable diseases. Inadequate nutrition can compromise immune function, which is particularly critical in the context of HIV and tuberculosis, where weakened immunity is associated with increased vulnerability and disease progression.^48,49 Limited access to safe and properly stored food is associated with gastrointestinal disease by increasing exposure to foodborne pathogens, and this risk is further heightened indirectly by energy insecurity, which constrains refrigeration and compromises safe food storage and processing.⁵⁰

The associations of WEF-related factors with health outcomes were highly interconnected. For example, tuberculosis is associated with all 3 WEF components: food insecurity through inadequate nutrition,⁴⁸ energy insecurity through burning of traditional fuels and overcrowding,⁴⁶ and water insecurity through limited WASH.⁴⁰ Gastrointestinal diseases similarly spanned the WEF nexus, as they are associated with limited WASH,⁴⁰ inadequate nutrition, and foodborne pathogens⁵¹ and with energy security through limited refrigeration (affecting food safety) and the burning of traditional fuel.^23,50 Respiratory infections are associated with energy insecurity (burning of traditional fuels, overcrowding)^46,47 and water security through limited WASH.⁴⁰ Together, these examples illustrate that communicable diseases in South Africa likely emerge from the overlapping and mutually reinforcing insecurities within WEF systems, operating through multiple transmission modes.

Noncommunicable Diseases

WEF insecurities were associated with a broad spectrum of noncommunicable diseases in South Africa. The linkages between WEF insecurities and noncommunicable disease outcomes are summarized in Table 3. Full reference details for each identified pathway are provided in eTable 6 in Supplement 1. Water insecurity may influence health via several pathways. Limited WASH may contribute to gastrointestinal disease, which can impair nutrient absorption and utilization, weakening the immune system, and it is hypothesized to affect malnutrition.^52,53 Exposure to chemically polluted water, classified as limited WASH in our framework, may be associated with certain cancers, although this was not observed in the included studies and was identified only through expert input. In addition, limited WASH may increase daily stress, contributing to anxiety and depression.⁵⁴

Table 3. Pathways of Associations Between WEF Insecurity and Noncommunicable Disease Outcomes.

WEF element	Intermediate	Health outcome
Water	Limited WASH	Cancer Mental health Triple burden of malnutrition
Energy	Burning of traditional fuels	Cancer Cardiometabolic diseases Respiratory disease Mental health
Food	Inadequate nutrition Intimate partner violence	Cardiometabolic diseases Mental health Triple burden of malnutrition

Abbreviations: WASH, water, sanitation, and hygiene; WEF, water, energy, and food.

Energy insecurity is associated with the burning of traditional fuels in poorly ventilated homes, which in turn is associated with increased household air pollution and higher risk of respiratory diseases.^55,56 Additionally, the burning of traditional fuels is associated with increased risk of cardiometabolic disease through increased inflammation and with smoking-related cancers through exposure to carcinogenic compounds.^57,58 Beyond respiratory effects, the stress of unreliable or unaffordable energy has been associated with mental health conditions such as anxiety and depression.⁵⁹

Food insecurity is hypothesized to affect noncommunicable diseases through multiple mechanisms. Pathways include inadequate nutrition, which is associated with the triple burden of malnutrition as well as with cardiometabolic diseases such as diabetes and hypertension.^60,61 Food insecurity is also associated with psychosocial stress and socioeconomic strain and has been associated with intimate partner violence and resulting poor mental health outcomes, including anxiety and depression.^62,63

These pathways illustrate how interactions between WEF insecurities may converge through shared intermediates to shape a range of noncommunicable diseases. Malnutrition develops when inadequate nutrient intake is compounded by frequent infections associated with poor hygiene, illustrating the combined health effects of food and water insecurity.^52,53 Cardiometabolic disease is associated with inadequate nutrition⁶⁰ and burning of traditional fuels,⁵⁷ highlighting interactions between food and energy insecurities. Mental health outcomes are associated with all 3 WEF components.^54,62 Respiratory diseases are associated with the burning of traditional fuels.⁵⁶ While many noncommunicable disease outcomes may be influenced by at least 2 WEF components, mental health appears uniquely sensitive to the combined effects of all 3, highlighting the cumulative burden of overlapping WEF insecurities.

Injuries

Within the WEF nexus, both energy and food insecurity are associated with injuries^62,64; however, this was the least prominent health outcome (Table 4). Full reference details for each identified pathway are provided in eTable 7 in Supplement 1. No studies were identified that linked water security to injuries. Energy-related factors, particularly the burning of traditional fuels, have been consistently associated with burn injuries in the home environment.^64,65 Food insecurity is associated with intimate partner violence, which may serve as a sociobehavioral pathway linking inadequate food access to physical harm and injury.^62,66 Together, these findings suggest that injuries can be influenced by intimate partner violence and the burning of traditional fuels, but these pathways were less frequently addressed in the literature.

Table 4. Pathways of Associations Between WEF Insecurity and Injuries.

WEF element	Intermediate	Health outcome
Water	NA	NA
Energy	Burning of traditional fuels	Injuries (burns)
Food	Intimate partner violence	Injuries (physical trauma)

Abbreviations: NA, not applicable; WEF, water, energy, and food.

Discussion

Our study presents a novel conceptual framework that delineates the pathways and intermediates through which WEF insecurities may shape health outcomes. In comparison to previous work on either a single WEF domain and linkages to health^21,22,23 or WEF-health linkages more broadly,^{15,16,17,18,24,25,26} our study integrates these approaches by addressing wide-ranging health outcomes associated with all WEF insecurities. We adopted a broad WEF nexus perspective; examined health outcomes across communicable, noncommunicable, and injury-related conditions; and explicitly identified mechanisms through which WEF insecurities can influence health.

Notably, many intermediates were associated with multiple health outcomes, such as inadequate nutrition, limited WASH, burning of traditional fuel, intimate partner violence, and overcrowding. This indicates that health impacts of WEF insecurity are interconnected and mutually reinforcing. Patterns of association suggest communicable diseases are primarily tied to water insecurity, while noncommunicable diseases and injuries are linked mainly to food insecurity.

The pathway from food insecurity to intimate partner violence and subsequently to poor mental health, while vital, is complex and warrants further investigation. Moreover, possible connections between intimate partner violence and water or energy insecurity have not been established in South Africa. Evidence from other contexts points to potential associations between water insecurity and intimate partner violence¹⁷⁶ and between energy insecurity and intimate partner violence.¹⁷⁷ The intersecting stresses of multiple insecurities across water, energy, and food can also generate fear, anxiety, and chronic stress, compounding risks for poor mental health.^20,178 While broader evidence suggests that resource insecurities, including WEF shortages, may result in interpersonal and community violence,^179,180 such links were not identified in the South African literature reviewed, highlighting a potential gap that needs to be addressed by future research.

During the expert consultation, participants highlighted several linkages between WEF security and health that have not yet been well documented in the scientific literature on South Africa. Namely, no studies were found that quantified the impact of chemically polluted water on health outcomes in South Africa, warranting further investigation. Studies that focused on chemical pollution focused primarily on the general assessment of water quality, without making explicit links to health.^181,182,183 Similarly, experts highlighted poor menstrual hygiene as a contributor to urogenital infections. While this association was included in our conceptual framework as a part of limited WASH, none of the reviewed studies included it explicitly, although it has been documented in other contexts.¹⁸⁴

Burden-of-disease estimates, expressed in years of life lost (YLL), help situate the pathways mapped in our framework within the broader health profile of South Africa. At the national level, the highest burdens were associated with cardiometabolic diseases and HIV/AIDS, followed by tuberculosis and gastrointestinal diseases, while respiratory conditions and mental health disorders represented a moderate share (eTable 8 in Supplement 1).¹⁸⁵ Malnutrition, burn injuries, and parasitic infections accounted for a smaller proportion of YLL yet remain pressing health concerns. While YLL estimates do not capture morbidity or quality of life, these estimates help illustrate how major health burdens in South Africa intersect with multiple WEF pathways, underscoring the potential for integrated, cross-sectoral interventions to reduce premature mortality and health inequalities.

By focusing specifically on South Africa, this study provided a context-specific analysis that reflects the country’s unique epidemiologic and resource-system challenges, thereby enhancing the framework’s relevance for national and subnational decision-making and intervention design. Moving forward, we recommend testing the conceptual framework on a national scale in South Africa to assess its relevance and usefulness for understanding population-based health challenges in both research and practice and to inform efforts aimed at improving health and well-being while reducing inequalities. Future research could also focus on in-depth case studies of specific communities or regions and testing the framework across different spatial scales. Understanding these variations is essential for designing interventions that improve both WEF security and health, since geographic and socioeconomic disparities within South Africa mean that pathways between WEF insecurity and health may operate differently in rural, periurban, and urban settings. Beyond South Africa, adapting the framework to other low- and middle-income countries will help identify how local contexts shape WEF-health interconnections.

Limitations

A key limitation of this study is that most of the reviewed literature was cross-sectional in design. Consequently, the conceptual framework developed herein represents plausible pathways rather than confirmed causal mechanisms. Nevertheless, the patterns presented are credible and relevant, as they were supported by consistent findings across a broad base of literature, have known underlying mechanisms, and were validated through expert consultation. Strengthening causal inference will require future research to prioritize longitudinal designs using robust, population-level data capable of capturing the multiple, interacting determinants of health within the WEF nexus, thereby informing the mechanisms articulated in our conceptual framework. Another limitation is that some of the studies included in our review relied on self-reported symptoms rather than clinical diagnoses, which introduces some uncertainty into specific pathways. Nonetheless, indicators such as coughing are well-established markers of respiratory disease.¹⁸⁶

In addition, the framework does not explicitly incorporate equity or differential vulnerability. Given South Africa’s substantial inequalities, WEF-health associations likely vary by age, sex, settlement type, and socioeconomic status, with children, women, rural households, and residents of informal settlements experiencing distinct exposure pathways and health risks.¹⁸⁷ These patterns were not directly examined and should be addressed in future research to better inform targeted and context-specific interventions. Furthermore, the literature was heavily shaped by funding availability, which may bias the evidence base toward certain diseases while leaving others underexplored.

Conclusions

In this scoping review of 137 articles, WEF insecurities were associated with a wide range of health outcomes in South Africa through overlapping pathways such as inadequate nutrition, limited WASH, and burning of traditional fuels. By integrating evidence from 137 studies and from expert consultations, we developed a systems-based conceptual framework that situates health outcomes within the interlinked WEF security nexus. These findings suggest that improving health cannot be achieved through disease-specific interventions alone but requires cross-sectoral policies that address WEF insecurities and their underlying social drivers. Future research should test and refine this framework in both local and other national contexts, taking into account geographic and socioeconomic differences that shape WEF insecurity and health outcomes. Generating longitudinal evidence on causal pathways and examining feedback loops under the pressures of climate change and inequality will help clarify how these dynamics operate across diverse settings. These findings underscore the need to move beyond siloed sectoral responses toward integrated, context-specific strategies that address overlapping WEF insecurities to advance health equity and sustainable development in South Africa and beyond.

Supplement 1.

eFigure 1. Flow Diagram of Study Selection Process for the Scoping Review Following PRISMA-ScR Guidelines

eFigure 2. Stacked Bar Chart of Health Outcomes Studied and Linkages to WEF

eTable 1. Dimensions of Resource Security Across the 4 A’s Framework

eTable 2. Scopus Search Words to Retrieve Scientific Articles on WEF and Health in South Africa

eTable 3. Expertise of Expert Interview Participants

eTable 4. Expertise of Workshop Participants

eFigure 3. Conceptual Framework of WEF and All Studied Health Outcomes

eTable 5. Communicable Disease Health Outcomes and Intermediates

eTable 6. Noncommunicable Disease Health Outcomes by Intermediate

eTable 7. Injury Health Outcomes and Literature Intermediates

eTable 8. Years of Life Lost by Disease Category in South Africa

eReferences.

Supplement 2.

Data Sharing Statement