Table 5.

Water carriage and pain or injury

First author and date	Population	Study type	Dates	Key findings	Quality
Hemson 200726	South Africa: 1052 children aged 5–17 years from 366 households, in three villages with no piped water supply	Mixed methods	NR	96% of the children reporting that their health had worsened, reported that they had a sore neck or back.	Poor* Fair†
Borah 201028	India: 30 rural women with normal blood pressure and temperature aged 21–40 years in Jorhat district of upper Brahmaputra Valley Zone of Assam	Observational study	NR	Incidence of pain during complete water fetching cycle, and with subactivities was mainly in low back region. Pain also reported in shoulder joints while drawing water and carrying it home.	Poor*
Geere 2010a46	South Africa: subgroup of 29 people interviewed, drawn from convenience sample of 39 adults and children fetching water in six rural villages of Limpopo Province	Mixed methods‡	2008	Prevalence of spinal (neck or back pain) among water carriers was 69% and back pain alone was 38%.	Poor*
Geere 2010a and b46	South Africa: 39 adults and children observed to fetch water in six rural villages of Limpopo Province	Qualitative‡	2008	Children linked water fetching to pain, spinal mobility problems and injury.	Good†
Rauniyar 201129	Pakistan: 1301 ‘treatment’ households of rural water and sanitation project villages and 1301 matched comparison households in non-project villages	Cross-sectional survey	2008	A significant 5% (p<0.001) reduction in ‘drudgery’ defined as pain from fetching water due to muscle strain, back ache or blisters, attributed to water and sanitation projects; remained highly significant for lowest socioeconomic group in subgroup analyses.	Poor*
Domènech 201247	Nepal: 120 households of 10 communities (2 communities from each district) of Kaski, Syangja, Palpa, Gulmi and Doti districts	Mixed methods§	2008–2009	Rain water harvesting at the house reported to reduce ‘numbers of accidents and injuries during water collection’.	Fair†
Singh 201233	India: 100 agricultural workers (50 male and 50 female) engaged in agricultural tasks in last 10 years, from villages of Udaipur district of Rajasthan	Cross-sectional survey	NR	Male and female respondents reported severe neck and shoulder pain during water fetching; severe lower back pain felt by female respondents during water fetching.	Poor*
Asaba 201331	Uganda: survey of 602 (~35%) households in Makondo Parish, and in-depth interviews, focus group discussions and participant observation in four villages	Mixed methods	2011–2012	Three cases of a child drowning at open wells or ponds reported; accidental injury due to slips and falls while water fetching and fear of animal attacks also reported; among men and women, and male and female youths and children, carrying water was perceived to cause chest pain (33.3%–64.4%); headache (5.7%–23.1%); nasal bleeding (0.8%–4.0%); back pain (0.8%–1.9%); spinal problems (0.3%–0.8%) and no problem (11.1%–32.9%).	Poor* Fair†
Robson 201332	Malawi: 1504 children aged 9–18 years from 12 field sites in each of 3 regions	Mixed methods	2006–2009	35% of children reported pains and health problems as their biggest difficulty in carrying water; headaches and neck aches most frequently cited (26%). Of children citing water carrying as their heaviest load, 5% more girls than boys reported bodily aches and pain in the last week. Supported by qualitative evidence from adults and children. Children (22%) reported hazards or risks of water fetching, such as rough terrain, stream/river crossings, snake or dog attacks, vehicles or risk of being swept away or drowning during floods.	Poor*†1 2
Bisung 201552	Kenya: convenience sample of 8 women living in Usoma, 15 km from Kisumu	Qualitative (photovoice)	2013	Photograph used to illustrate that children fetch water bare footed and are exposed to injuries.	Good†
Sarkar 201553	Canada: 37% of adults and 100% of high school students living in the sub-Arctic Inuit community Black Tickle-Domino, located on the remote Island of Ponds, off the coast of southern Labrador	Mixed methods§	2013	Study participants attributed chronic back and shoulder injuries to carrying heavy water buckets every day. Some men required surgery, but indefinitely postponed surgery due to ‘the unavailability of alternative persons to retrieve water for their families’.	Good†
Subbaraman 201554	India: interviews with 40 adults in Mumbai slum; 3 focus groups (FG) of 6–9 women; 3 FG of 6–9 men	Qualitative	2011	Physical strain occurs from water fetching, particularly impacting negatively the elderly, women and children.	Good†
Berrian 201639	South Africa: 256 surveys within four purposively selected villages of Mnisi study area, Bushbuckridge Local Municipality, Mpumalanga	Cross-sectional survey	2013	224 (85%) respondents believed that shared water sources among people, livestock and wild animals could be a health risk; 118 (45%) reported household water collection from places shared with animals. ‘Most’ survey participants dislike wildlife around their community, perceived as a threat to personal safety.	Poor*
Ayoade 201758	Nigeria: 800 girls aged 5–15 years in periurban areas of Abeokuta, Ogun Stat	Qualitative	2013–2014	788 (95%) experienced neck and back pain from carrying an excessive load of water and most reported a belief that their back pains worsened during menstruation as a results of heavy water carrying; 90% have experienced some form of violence (fights or punishment) and injury (slips, stepping on nails/glass); 166 (21%) experienced injury from physical fights at water points; 345 (41%) witnessed friends or neighbours struck by moving vehicles while fetching water.	Poor†
Mercer 201759	Canadian subarctic: seven purposively selected households (21 people) in Black Tickle-Domino Inuit community	Mixed methods¶	NR	40.92% reduction in water retrieval time with rain water harvesting, explained by participants to mean less lifting and carrying of heavy water containers and potentially fewer injuries. Reported fear and anxiety of polar bear attack during water retrieval.	Good†
Geere 201843	South Africa, Ghana, Vietnam: 1 adult and 1 child from 673 households with at-house and off-plot water supply	Cross-sectional survey	2012–2013	People who previously carried water had increased risk of pain in hands (RR 3.62, 95% CI 1.34 to 9.75) and upper back (RR 2.27, 95% CI 1.17 to 4.40), as did people who currently carry water (RR hand pain 3.11, 95% CI 1.34 to 7.23; RR upper back pain 2.16, 95% CI 1.25 to 3.73) compared with people who never carried water. Mean ‘axial compression’ factor score (correlated with pain in head, upper back, chest/ribs, hands, feet and abdomen/stomach) associated with current (0.30, 95% CI 0.17 to 0.43) or previous (0.21, 95% CI 0.01 to 0.42) water carriage. Mean ‘soft tissue strain’ factor score (correlated with pain in the neck, shoulders/arms, lower back and hips/pelvis or legs), negatively associated with currently (−0.18, 95% CI −0.32 to −0.04) carrying water.	Fair*

*Methodological quality rating of cohort study or cross-sectional survey.

†Methodological quality rating of qualitative study or reporting of qualitative findings as part of a mixed methods study.

‡Quantitative data reported by Sarkar et al and Domènech et al were water quality testing.

§No quantitative health data were collected for analysis against water retrieval time.

¶Small mount of qualitative data presented in Geere 2010a are drawn from study reported in Geere 2010b.

RR, relative risk.