Changing rainfall patterns, household water use and health: risks and household responses in rural Gambia

Many countries, such as The Gambia, are experiencing a shift in their rainfall patterns due to climate change. The effects of these changes on household water insecurity and in turn health remains underexplored in research, particularly for regions such as West Africa. In this thesis I utilised a multimethod approach to understand the health risks associated with rainfall, and the pathways through which rainfall might affect the health of rural populations in The Gambia. In particular, I focused on identifying household behavioural responses to changes in weather patterns and the health implications of these responses. I used three methods: a systematic review on the health effects of rainfall in Low- and Middle-Income Countries (LMICs); qualitative research on the perceptions of rural communities in The Gambia related to the relationship between weather, water and health; and an epidemiological analysis of the association between rainfall and clinic visits for diarrheal diseases and skin infections. In the systematic review of 177 studies, I found that there was a dearth of research that quantified the relationship between rainfall and diarrheal diseases in West Africa. The evidence was even more limited, in LMICs generally, on other water-related diseases that share similar pathways, such as skin infections. The findings of this review informed the subsequent research in this thesis, including the structure of the epidemiological analysis. Through the qualitative research, I was able to develop a framework to depict the complex ways in which weather, specifically rainfall, might affect water security and health. Multiple environmental and behavioural pathways were identified. I found that many people in rural Gambia face seasonal challenges to their water security, including reductions in water availability and quality, and that these issues are exacerbated following extreme weather events. When faced with water shortages people utilised a variety of coping mechanisms, which could pose health risks. Lastly, using time-series regression models, I found that increases in weekly rainfall, up to a threshold of ~30mm, increased the risk of both diarrheal and skin infection visits at a rural health facility in The Gambia. The risks associated with rainfall varied by age. Synthesising the evidence generated across these different methods, and examining the synergies and discrepancies, has enabled a more holistic understanding of the pathways through which rainfall might impact health. This thesis demonstrates the benefit of conducting multimethod research to empirically investigate these complex relationships. These findings also highlight the importance of investing in climate-resilient infrastructure to better address the current and future risks of rainfall. Additionally, addressing the drivers of water insecurity can help mitigate the potential risks to both physical and mental health, and limit the need for risky coping strategies.