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Our ability to measure household-level food insecurity has revealed its critical role in a range of physical, psychosocial, and health outcomes. Currently, there is no analogous, standardized instrument for quantifying household-level water insecurity, which prevents us from understanding both its prevalence and consequences. Therefore, our objectives were to develop and validate a household water insecurity scale appropriate for use in our cohort in western Kenya. We used a range of qualitative techniques to develop a preliminary set of 29 household water insecurity questions and administered those questions at 15 and 18 months postpartum, concurrent with a suite of other survey modules. These data were complemented by data on quantity of water used and stored, and microbiological quality. Inter-item and item-total correlations were performed to reduce scale items to 20. Exploratory factor and parallel analyses were used to determine the latent factor structure; a unidimensional scale was hypothesized and tested using confirmatory factor and bifactor analyses, along with multiple statistical fit indices. Reliability was assessed using Cronbach's alpha and the coefficient of stability, which produced a coefficient alpha of 0.97 at 15 and 18 months postpartum and a coefficient of stability of 0.62. Predictive, convergent and discriminant validity of the final household water insecurity scale were supported based on relationships with food insecurity, perceived stress, per capita household water use, and time and money spent acquiring water. The resultant scale is a valid and reliable instrument. It can be used in this setting to test a range of hypotheses about the role of household water insecurity in numerous physical and psychosocial health outcomes, to identify the households most vulnerable to water insecurity, and to evaluate the effects of water-related interventions. To extend its applicability, we encourage efforts to develop a cross-culturally valid scale using robust qualitative and quantitative techniques., Competing Interests: The authors have declared that no competing interests exist.

We compared the concentrations of Escherichia coli quantified with Colilert ™ and the compartment bag test (CBT) in the source water and household stored drinking water (SDW) of 35 households in western Kenya. We also investigated the associations of the perceptions of organoleptic properties and overall quality with ≥ 1 MPN/100 mL E. coli in SDW. Participants who rated the taste or smell of their SDW "< 5" on a 1 = "poor" to 5 = "excellent" Likert scale were 8.71 or 7.04 times more likely, respectively, to have ≥ 1 MPN/100 mL E. coli . Organoleptic properties are innate, albeit imperfect, indicators of fecal pollution in water. Within their shared quantification range, concentrations of E. coli enumerated with Colilert and CBT were similar and had a significant correlation coefficient, 0.896 (95% confidence interval = 0.691-1.101). The methods had moderate agreement within the World Health Organization's health risk levels (Cohen's Kappa coefficient = 0.640). In low-resource settings, CBT provides comparable assessments of E. coli concentrations to Colilert.

Water insecurity (WI) is a serious and worsening problem worldwide, but its role in health outcomes among people living with HIV or pregnant women is unknown. We assessed experiences of WI in a cohort of 323 pregnant Kenyan women of mixed HIV status. The majority (77.7%) had at least one experience of WI in the previous month; it was associated with negative economic, nutrition, disease, and psychosocial outcomes. A standardized cross-culturally valid household WI scale would facilitate assessment of the prevalence and consequences of WI, and increased attention to WI could reveal an overlooked, but modifiable, cause of adverse HIV outcomes.