Over 650 million people worldwide lack access to safe water supplies, and even among those who have gained access to ‘improved’ sources, water may be seasonally unreliable, far from homes, expensive, and provide insufficient quantity. Measurement of water access at the level of communities and households remains crude, and better measures of household water insecurity are urgently needed to inform needs assessments and monitoring and evaluation. We set out to assess the validity of a quantitative scale of household water insecurity, and to investigate (1) whether improvements to community water supply reduce water insecurity, (2) whether water interventions affect women’s psychological distress, and (3) the impacts of water insecurity on psychological distress, independent of socio-economic status, food security, and harvest quality. Measures were taken before and one to six months after a community water supply improvement in three villages in rural northern Ethiopia. Villages similar in size and access to water sources and other amenities did not receive interventions, and served as controls. Household water insecurity was assessed using a 21-item scale based on prior qualitative work in Ethiopia. Women’s psychological distress was assessed using the WHO Self-Reporting Questionnaire (SRQ-20). Respondents were either female heads of household or wives of the heads of household (n = 247 at baseline, n = 223 at endline); 123 households provided data at both rounds. The intervention was associated with a decline of approximately 2 points on the water insecurity scale between baseline and endline compared to the control (beta -1.99; 95% CI’s -3.15, -0.84). We did not find evidence of impact of the intervention on women’s psychological distress. Water insecurity was, however, predictive of psychological distress (p <0.01), independent of household food security and the quality of the previous year’s harvest. These results contribute to the construct validity of our water insecurity scale, and establish our approach to measuring water insecurity as a plausible means of evaluating water interventions. Improvements to community water supplies were effective in reducing household water insecurity, but not psychological distress, in this population. Water insecurity was an important predictor of psychological distress. This study contributes to an emerging literature on quantitative assessment of household water insecurity, and draws attention to the potential impact of improved access to water on women’s mental well-being.

Household survey data from 27 sites in 22 countries were collected in 2017–2018 in order to construct and validate a cross-cultural household-level water insecurity scale. The resultant Household Water Insecurity Experiences (HWISE) scale presents a useful tool for monitoring and evaluating water interventions as a complement to traditional metrics used by the development community. It can also help track progress toward achievement of Sustainable Development Goal 6 ‘clean water and sanitation for all’. We present HWISE scale scores from 27 sites as comparative data for future studies using the HWISE scale in low- and middle-income contexts. Site-level mean scores for HWISE-12 (scored 0–36) ranged from 1.64 (SD 4.22) in Pune, India, to 20.90 (7.50) in Cartagena, Colombia, while site-level mean scores for HWISE-4 (scored 0–12) ranged from 0.51 (1.50) in Pune, India, to 8.21 (2.55) in Punjab, Pakistan. Scores tended to be higher in the dry season as expected. Data from this first implementation of the HWISE scale demonstrate the diversity of water insecurity within and across communities and can help to situate findings from future applications of this tool.

Background: Maternal mortality remains a persistent public health concern in sub-Saharan African countries such as Ethiopia. Health information technology solutions are a flexible and low-cost method for improving health outcomes with proven benefits in low- to middle-income countries’ health systems. Objective: This study aimed to develop and assess the usability of an electronic dashboard to monitor facility-level readiness to manage basic emergency obstetric care (BEmOC) in Amhara, Ethiopia. Methods: The study used three methods to iteratively refine the dashboard: (1) user-centered design sessions with individuals who interact with the BEmOC supply chain, (2) review and feedback from domain and information visualization subject matter experts (SMEs) to refine the dashboard, and (3) usability heuristic evaluation with human-computer interaction (HCI) SMEs. Results: User-centered design sessions resulted in a preliminary version of the dashboard informed by end-user preferences and perceptions, with recommendations focusing on aesthetic design, filtering and sorting, and matching with the real world. An example of an end-user recommendation included increasing font sizes on the dashboard and using a red, yellow, and green color-coding scheme. Next, domain and visualization SMEs continued the dashboard’s iterative refinement, focusing on aesthetic design and navigation, by confirming design choices incorporated from the user-centered design sessions and recommending changes to enhance user experience moving through the dashboard, such as adding more filtering options. HCI SMEs rated the dashboard as highly usable (0.82 on a scale of 0-4, with 0 being no usability concern and 4 being a catastrophic usability concern). The principle with the highest usability severity scores was a match between the system and the real world with a score of 1.4. The HCI SMEs also rated the information visualization aspects of the dashboard favorably with 2 usability principles, spatial organization and information coding, scoring 0. Conclusions: Dashboards are a novel method for promoting and tracking facility capacity to manage BEmOC. By including targeted end users and SMEs in the design process, the team was able to tailor the dashboard to meet user needs, fit it into the existing government health systems, and ensure that the dashboard follows design best practices. Collectively, the novel, customized BEmOC dashboard can be used to track and improve facility-level readiness in Amhara, Ethiopia, and similar global BEmOC facilities.

Background: For the past several decades, the Ethiopian Ministry of Health has worked to decrease the maternal mortality ratio (MMR)—the number of pregnant women dying per 100,000 live births. However, with the most recently reported MMR of 267, Ethiopia still ranks high in the MMR globally and needs additional interventions to lower the MMR to achieve the sustainable development goal of 70. One factor contributing to the current MMR is the frequent stockouts of critical medications and supplies needed to treat obstetric emergencies. Objective: This study describes the obstetric emergency supply chain (OESC) dynamics and information flow in Amhara, Ethiopia, as a crucial first step in closing stockouts and gaps in supply availability. Methods: Applying qualitative descriptive methodology, the research team performed 17 semistructured interviews with employees of the OESC at the federal, regional, and facility level to describe and gain an understanding of the system in the region, communication flow, and current barriers and facilitators to consistent emergency supply availability. The team performed inductive and deductive analysis and used the “Sociotechnical Model for Studying Health Information Technology in Complex Adaptive Healthcare Systems” to guide the deductive portion. Results: The interviews identified several locations within the OESC where barriers could be addressed to improve overall facility-level readiness, such as gaps in communication about supply needs and availability in health care facilities and regional supply hubs and a lack of data transparency at the facility level. Ordering supplies through the integrated pharmaceutical logistics system was a well-established process and a frequently noted strength. Furthermore, having inventory data in one place was a benefit to pharmacists and supply managers who would need to use the data to determine their historic consumption. The greatest concern related to the workflow and communication of the OESC was an inability to accurately forecast future supply needs. This is a critical issue because inaccurate forecasting can lead to undersupplying and stockouts or oversupplying and waste of medication due to expiration. Conclusions: As a result of these interviews, we gained a nuanced understanding of the information needs for various levels of the health system to maintain a consistent supply of obstetric emergency resources and ultimately increase maternal survival. This study’s findings will inform future work to create customized strategies that increase supply availability in facilities and the region overall, specifically the development of electronic dashboards to increase data availability at the regional and facility levels. Without comprehensive and timely data about the OESC, facilities will continue to remain in the dark about their true readiness to manage basic obstetric emergencies, and the central Ethiopian Pharmaceutical Supply Service and regional hubs will not have the necessary information to provide essential emergency supplies prospectively before stockouts and maternal deaths occur.