How do rural ethiopians rate the severity of water insecurity scale items? Implications for water insecurity measurement and interventions

Recently developed scales aim to advance understanding of household water insecurity and inform interventions to address this critical global problem. The relative severity of items included in household water insecurity scales has been established as an inverse of the proportion of the population that reports experiencing the item. Here, we assess subjective perceptions of scale item severity among people who experience household water insecurity. In 2017, we surveyed 259 women in Amhara, Ethiopia, assessing both experiences of water insecurity and perceptions of item severity using a pictorial scale. The mean subjective severity of most items was at the high end of our pictorial scale. Subjective severity of items was not associated with whether or not a participant experienced the item in the last thirty days, with a participant's summary household water insecurity score, or with rural versus peri-urban residence, but was consistently associated with community of residence. Item severity as defined by the proportion of the population experiencing the item aligned with average perceptions of item severity, with one exception: drinking water that might not be safe. We discuss these findings' implications for water insecurity measurement, evaluation of interventions, and studies of the relationship between water insecurity and psychological distress.