Water use behaviors and water access in intermittent and continuous water supply areas during the COVID-19 pandemic

Insufficient or unreliable water supply, which can exacerbate poor sanitation and inadequate hygiene practices, can fuel the spread of disease in densely populated areas. In settings with access to piped water, available water can be restricted by intermittent water supply (IWS), in which water is delivered through a piped network for a limited number of hours per day or per week. IWS can compromise the safety of delivered water, lead to increased risk of waterborne infections, and result in high household expenditures on coping costs (Andey & Kelkar 2009; Fan et al. 2014; Ercumen et al. 2015; Guragai et al. 2017; Gurung et al. 2017; Kumpel et al. 2017). Previous studies have also found that households with IWS often have very restricted volumes of water available (Kumpel et al. 2017). Furthermore, households in low-income urban communities often access water from off-premise locations, requiring that they leave home to collect water (Elliott et al. 2019; WHO/UNICEF 2021).

During the COVID-19 pandemic, governments around the world required residents to stay at home to reduce transmission and promoted hygiene measures such as handwashing. Therefore, households experiencing water insecurity from IWS during the COVID-19 pandemic faced increased demand for water for handwashing and hygiene and from increased time spent at home due to stay-at-home restrictions, while they were at the same time often restricted from leaving their homes to collect additional water. Handwashing, requiring water, is a key mechanism for reducing transmission of SARS-CoV-2; however, 2 billion people in the world lack access to adequate handwashing facilities, a challenge further compounded by the inadequate or unreliable water access provided by IWS (Brauer et al. 2020; Freeman & Caruso 2020; Ray 2020; Rohilla 2020; Sayeed et al. 2021). While governments around the world extended free water supply to citizens, deferred payments of water bills, or issued moratoria on water disconnections during the public health emergency (Lakhani 2020; NDTV 2020), in many of these places, unpaid bills entered into arrears and households faced large bills when collection resumed (Walton 2020; Rajwi 2021).

While more than one billion people in the world are served by IWS systems, there is little understanding of the impact of IWS on households during public health emergencies as compared to continuous water supply, including the impact of stay-at-home orders on household water access and the effects of IWS on COVID-19 mitigation behaviors such as handwashing and social distancing (e.g., while queuing to collect water). Given the widespread use of IWS worldwide, it is important to know whether households with IWS may have experienced differential changes in water access and water-use behaviors during public health emergencies such as the COVID-19 pandemic and whether IWS affected their ability to adhere to mitigation measures. This information can inform future policies or interventions to improve water access during public health emergencies, such as whether additional measures are needed to ensure water access, and help prioritize efforts to upgrade IWS systems to provide continuous supply.

In this study, we seek to understand water access and use during the COVID-19 pandemic among households with intermittent and continuous water supply. Specifically, the objective was to compare household water access, water usage, and adherence to disease transmission mitigation behaviors during and after the stay-at-home orders in Hubballi–Dharwad, India, in households with IWS and those with continuous (‘24×7’) water service.

Hubballi–Dharwad are twin cities in northern Karnataka, India, with a population of more than one million. In 2006 and 2007, approximately 10% of the population were changed to 24×7 water supply on a pilot scale, while the rest of the city received IWS. Details about Hubballi–Dharwad, the water system, the conversion from IWS to 24×7 supply, and the impact of the conversion on child health, household economics, and water quality are documented elsewhere (Kumpel & Nelson 2013, 2014; Burt & Ray 2014; Ercumen et al. 2015; Kumpel et al. 2017; Burt et al. 2018; Ray et al. 2018). The wards that were upgraded to 24×7 in this initial pilot conversion are referred to as ‘24×7 demonstration wards’ hereinafter. Since the initial conversion, 24×7 water supply has been introduced to additional areas of Hubballi–Dharwad; as of 2018, 19 of the cities’ 67 wards were reported to be served fully by 24×7 supply, 20 wards were partially served by 24×7 supply, and 28 wards remained on IWS. However, notably, our household survey in 2018 found that, even in wards classified by the water authority as ‘fully covered’ by 24×7 service, some households continued to have IWS. We focused the current study on the 16 wards where at least 50% of households had 24×7 supply.

In India, country-wide stay-at-home orders were implemented from March 22–June 1, 2020, with the gradual lifting of restrictions through June and July 2020. In the state of Karnataka, lockdown was ended on July 22, 2020 (ET Bureau 2020). Hubballi–Dharwad reported its first confirmed positive case of COVID-19 on March 22, 2020 (Menasinakai 2020). As of July 14, 2021, Dharwad District reported 60,275 positive cases of COVID-19 and 1,264 deaths related to COVID-19, out of 2,876,587 total cases in the state of Karnataka (GoK 2021).

We used a genetic matching algorithm (Diamond & Sekhon 2012) to select 16 IWS wards as matched controls for the 16 wards with >50% 24×7 service. Wards were matched on socioeconomic indicators, sanitation conditions, and pre-upgrade water service using a representative dataset collected before the conversion. As described in Ercumen et al. (2015), the matching variables included percentages of pukka structures (concrete or reinforced cement concrete), low-income, one-room, and self-identified slum households; illiterate females; households with own tap, receiving water less often than every 5 days, with own latrine, and with a designated garbage disposal location provided by the municipality and garbage collection service; and monthly household health expenses. During field inspection, one of the selected wards was observed to primarily contain commercial units and was dropped.

We enrolled households from the remaining 31 wards in Hubballi–Dharwad, India, with a target of approximately 20 households per ward. The 31 wards had a total of 86,627 households with 432,676 residents in 2011 (the last available census data), with 18.7% of the population designated as residing in a slum area. For each selected ward, participants were identified through snowball sampling, with the initial list generated through personal contacts at the Center for Multidisciplinary Development Research (CMDR) in Dharwad, India. Further participants were identified by asking these contacts to provide phone numbers of their personal contacts from different wards and from different socioeconomic segments of each ward until the sample size was reached. The sample size was selected based on feasibility with the snowball sampling method, which the study team estimated as 500–1,000 households total. Due to lockdown and public health protection, participants were recruited and surveyed via phone.

We enrolled 606 households from 31 wards (326 with IWS and 280 with 24×7) with a mean of 19.5 households per ward (range: 17–23). Round 1 (R1) data were collected from July 9–August 30, 2020 (after the national lockdown had lifted), Round 2 (R2) data were collected from November 15–December 30, 2020, and Round 3 (R3) data were collected from May 1–June 10, 2021 (Figure 1). Out of 606 households enrolled originally in R1, 580 households (301 with IWS and 279 with 24×7) remained in the study at the time of R2 and 560 remained in R3 (286 in IWS and 274 in 24×7). Reasons for loss to follow up included participants being out of service/unreachable and moving.

Trained enumerators from CMDR used a structured questionnaire to assess whether the household had IWS or 24×7 service and collect data on the reported frequency of water delivery, frequency and duration of any water outages, user-perceived water pressure and water quantities, water bills, and reported hygiene behaviors including handwashing, during the early stages of the pandemic. They also asked how these compared to their experience during lockdown. The survey included very limited questions on socioeconomic indicators because of the personal relationships between participants due to the snowball sampling method and potential participant discomfort disclosing socioeconomic information on a telephone survey. Each enrolled household was surveyed a total of three times over the course of approximately 1 year. The study protocol was reviewed and approved by the Institutional Review Board of the University of Massachusetts, Amherst. We also collected information on revenue collection and water service delivery from water service providers (Karnataka Urban Water Supply & Drainage Board and the Hubballi–Dharwad Municipal Corporation) in Hubballi–Dharwad.

Descriptive statistics, including tabulated percentages (for binary variables) and means, medians, and standard deviations (for continuous variables), were generated using R (R Core Team 2020). We compared self-reported household perceptions on water service and water use between the three rounds of data collection and between households with IWS vs. 24×7 service. Significance testing for quantitative data on water delivery durations and days between supplies was performed using the non-parametric Kruskal–Wallis (KW) test. Significance testing for binary values comparing IWS and 24×7 groups was performed using χ² tests. The p-values were considered significant at the p ≤ 0.05 level.

Respondents with IWS and 24×7 water service were 44 and 43% female and mean of 42 vs. 41 years old, respectively. The primary occupation of respondents' head of household was also similarly distributed between both groups: in IWS and 24×7, respectively, 41 vs. 37% held private, government, or NGO jobs, 23 and 26% were business owners, 13 and 19% were day laborers or street vendors, 7 and 5% were retired, and 6 and 5% worked in agriculture.

Households with IWS received water every 5 days for a mean of 4 h (Table 1). In R1, most households perceived that this was the same number of days between delivery (94%, n = 326) and duration of delivery (91%, n = 326) as compared to before the COVID-19 pandemic or the lockdown period. The differences in days between deliveries from R1 to R2 was 2.4 h, and from R1 and R3 was 18.8 h. The difference in supply duration from R1 to R2 was 18 min, and from R1 to R3 was 24 min. Differences in the days between deliveries were significant between the rounds (KW: p < 0.05), and differences in delivery duration were only significant between R1 and R3 (KW: p < 0.05) (Table 1). In R1, the majority of households self-reported that they perceived the same water pressure during the reporting period as prior to lockdown (79% same, 11% lower, 10% higher, n = 325). Delivery frequency and duration varied between wards; some households in the 24×7-demonstration wards and 24×7-fully covered wards still had IWS (Figure 2), consistent with our previous household survey in these wards in 2018 (unpublished).

During R1, households with 24×7 reported a mean of 0.5 outages in the last 2 weeks, with 60% of households reporting no outages, 31% experiencing one outage, and 8% experiencing two (n = 262) (Table 1). Of the households reporting an outage, households reported that, during their last outage, water was off for a mean of 2.1 h. All of the 24×7 households (100%, n = 262) said their experience with the number of outages was the same as before pandemic and most (94%, n = 272) said it was the same during lockdown, and most households (93%, n = 274) perceived a similar outage duration as before the pandemic. During R2, households reported more outages in 24×7 and with longer durations: 91% of households reported an outage in the prior 2 weeks, with an overall mean of 2.3 outages among the 24×7 households (n = 274) lasting a mean of 11.8 h (n = 173). During R3, outages reduced from R2 but were higher than R1, with 75% of households reporting an outage in the prior 2 weeks (n = 271) for a mean of 5.8 h (n = 168). Differences in outage frequency and duration were significant between all of the rounds (KW: p < 0.001) (Figure 2). More than half of the 24×7 households (56%, n = 248 in R2; 60%, n = 253 in R3) reported that the utility gave advance notice of the outages.

During R1, approximately one-third of both 24×7 and IWS households perceived using more water than before the pandemic (35 and 31%, respectively) (Table 2). Of 24×7 households, 31% perceived higher water bills in R1 than prior to the pandemic, while only 17% of IWS households perceived an increase in water bills. However, during R2 and R3, similar percentages between IWS and 24×7 perceived higher water bills, although this may be an artifact of the change in the question from less/same/more to a yes/no.

In R1, 26% (n = 326) of IWS households used a non-municipal water source compared to only 4% (n = 280) of 24×7 households (Table 3). Of those IWS households using another source, the most common was borewell water (groundwater) from a piped system (34%), a public non-piped water point (33%), or trucked water (e.g., a vehicle equipped with a water tanker) (27%) (n = 86). In R1, few households used off-premise water in either IWS or 24×7 (12 and 5%, respectively), and fewer still during R2 (7 and 1%) and R3 (4 and 3%); these were likely a mix of alternative sources and public piped water points. Of those that used off-premise water during R1, approximately half in both water supply schemes said they were able to maintain 2 m (social distance) at the water point. In R2 and R3, only CWS households were asked about their ability to maintain social distance; of the few households that used off-premise water, less than a third reported challenges in doing so (Table 3). In open-ended questions, 17 IWS households and one 24×7 household said they wore a mask and tried to maintain social distancing when collecting other sources, and 10 IWS households and no 24×7 households reported that they stopped using another source or lacked access to another source due to the pandemic.

When 24×7 households were asked whether they accessed other water sources when they had an outage during R2 and R3, many households (85% in R2 and 96% in R3) reported using another water source, primarily trucked water (91 and 89%) (Table 3). A few used borewell water from neighbors (4 and 2% in R2 and R3) or public water points (2 and 4% in R2 and R3). Few households in either IWS or 24×7 reported that the water utility had provided for water during piped water shortages (3 and 4% of IWS households in R2 and R3, and <1 and 3% of 24×7 households in R2 and R3). Seventy-one (71%, n = 326) of IWS households in R1 had a rooftop storage tank, while only 55% of households with 24×7 had a rooftop storage tank; accepting large volumes of water, such as from a truck delivering to a home, would require households to have a large amount of household storage.

All households were asked an open-ended question during R1 of how the COVID-19 pandemic lockdown and stay-at-home orders affected their water and sanitation access. When asked during R1 whether the COVID-19 pandemic affected any of their other water and sanitation-related practices, many households in IWS and 24×7 perceived no effect (37 and 41%), one-third perceived cleaning more (27 and 34%,), and one-fifth reported drinking treated water (20 and 18%) (n = 326 and n = 280). Compared to 24×7 households, IWS households reported storing more water (13 vs. 5%), using more water (7 vs. 1%), and using water more carefully (5 vs. 1%). Other responses from households included obtaining a private water source to use (e.g., neighbor's borewell), storing more treated water, drinking hot water, and washing clothes and vegetables more often. Several houses requested more frequent delivery of water or reported problems with the 24×7 delivery or water pressure.

Approximately three-quarters of both IWS and 24×7 households perceived having sufficient water for handwashing in R1 (75 and 77%, respectively), with no significant difference between IWS and 24×7 households (Table 3). During R2 and R3, the numbers were similar for IWS households. In R2, the percent reporting sufficient water for handwashing among 24×7 households dropped somewhat, potentially related to the more frequent outages experienced during R2. Most households in both IWS and 24×7 groups reported using hand sanitizers in R1 (95 and 94%, respectively), with a slight drop during R2 (89 and 88%) and a further drop in R3 (80 and 76%); there were no significant differences between IWS and 24×7 households. In an open-ended question of how the COVID-19 pandemic affected handwashing practices in R1, almost all households (91% in IWS and 97% in 24×7) reported washing their hands more frequently, while few households reported no change (7 and 4% in 24×7 and IWS). Few of the households used public toilets (3% in both IWS and 24×7 during both R1 and R2 and <1% in R3); during R1, two-thirds of those using public toilets in 24×7 areas were able to maintain social distance at public toilets, while most of those in IWS (90%) were not (n = 10). During R2, only one-third of 24×7 households using public toilets were able to maintain social distancing, while the percentage remained similar for IWS households; however, few households reported using public toilets.

The Water Board in Hubballi–Dharwad reported initial challenges in ensuring that workers were outfitted with proper personal protective equipment and identification. They provided alternative water sources to increase water availability at COVID-19 quarantine centers and public facilities (e.g., schools, hostels, community halls, and public places), including tanker trucks and drinking water barrels and bottles to low-income populations during lockdown. They did not report changes in supplying water nor unusual problems with the 24×7 area supplies but did report pipe leak issues in IWS areas. They worked at half staffing capacity in Water Board offices through lockdown.

Water billing and revenue collection were reported to be challenging during the COVID-19 pandemic. This included delays in issuing water bills and, when finally issued, that the bills then reflected 6 months of consumption. Households frequently prohibited meter readers from accessing the household to read meters. Only 10% of revenue was collected during the lockdown period (March 22–May 31, 2020), and only 40% of revenue was collected in the 2020–2021 financial year (April 2020–March 2021). This was attributed to lack of online bill payment options in 24×7 areas, while online bill payment was available in IWS areas.

Households with IWS perceived few differences in water delivery during the early months of the pandemic or during lockdown in Hubballi–Dharwad, India. The Water Board and other government offices reported no changes to their water production or delivery. Among households with IWS, days between subsequent water deliveries varied by 2–19 h and the duration of delivery varied by 18–24 min across three rounds of data collection over the course of 1 year. Since households, particularly low-income households, often wait at home to collect and store water, varying water timings can make a substantial difference for households with members working outside of the home (Burt et al. 2018; Kumar et al. 2018). Similarly, available water volumes in an IWS system can be proportional to the total amount of time the supply is on; a difference in minutes in the duration of supply can directly and substantially affect water volumes available to households (Kumpel et al. 2017). Notably, in areas with 24×7 supply, there were increases in outages during the pandemic. While we do not know the reason for this, it did pose potential challenges for households with expected 24×7 water access, especially since only half of 24×7 households had an overhead storage tank (larger in-home storage would be needed to accept larger water deliveries from trucked water). Previous studies in Hubballi–Dharwad have noted that public borewells were removed from 24×7 areas as part of the conversion to 24×7 supply, potentially threatening household water security during water outages (Burt et al. 2018). The variations in IWS service delivery and in water outages in 24×7 supply areas are consistent with seasonal changes in piped water availability observed during earlier studies of water access in Hubballi–Dharwad (Kumpel & Nelson 2013). Our first round of data collection was during the monsoon season where water supplies at the source (and electricity supplies for consistently operating the water system) tend to be higher, while the second and third rounds, collected during dryer seasons, showed more outages and potential shortages of supply. At the height of supply scarcity during the second data collection round, households with 24×7 supply reported a mean of 2.3 outages in the past 2 weeks for 11.8 h in duration (309 h of supply/336 total hours in a week, or supply on 92% of the time). During the same period, IWS households received water for 4.4 h every 4.7 days (13 h of supply/336 total hours in a week, or supply on 4% of the time).

Approximately one-quarter of households in both 24×7 and IWS areas perceived insufficient water for adequate handwashing. This finding is of notable concern due to the importance of handwashing to mitigate the spread of the COVID-19 pandemic. Households with IWS and 24×7 both reported increasing their frequency of handwashing in response to the pandemic, suggesting that changes in human behavior in response to perceived risks led to an increase in demand for water that was not satisfied by either supply scheme. These findings support previous calls for the provision of handwashing stations to interrupt SARS-CoV2 transmission in low-income communities (Freeman & Caruso 2020; Ray 2020). Notably, households in this study did adjust their reported handwashing behavior and reported dedicating scarce water resources towards handwashing.

Households also largely perceived using more water overall during the pandemic. Both IWS and 24×7 households perceived higher water bills starting during the second round of data collection. 24×7 households are metered based on consumption. Some IWS households are metered based on consumption, but many are not and are charged a flat rate no matter the consumption; perceived higher water bills may have been due to higher metered consumption or due to utility-reported delays in billing.

Of note, many residents with 24×7 and IWS collect piped water in their yard and alternative sources, such as their own or a neighbor's borewell, were available on premise or close to home. However, those households that did need to venture out for alternative water sources did report issues with social distancing at public water sources, particularly later in 2020, a finding consistent with a study of water access in a town with IWS in Zimbabwe (Zvobgo & Do 2020). These findings indicate that water insecurity negatively impacted individuals’ ability to adhere to protective public health measures (Stoler et al. 2020) and highlight the importance of on-premise, uninterrupted water access in reducing the need for collection, and therefore potential exposure, from off-premise public water points during the COVID-19 pandemic. Notably, many households at our study site reported using sources that did not require queuing, such as trucked water delivered to home or neighbors’ private sources. While water sharing has been noted as a widespread and important mechanism of ensuring household water security (Stoler et al. 2019), it has also been suggested as a mechanism for SARS-CoV2 transmission through close interaction between neighbors (Stoler et al. 2020). In particular, households with IWS frequently relied on multiple types of alternative water sources; while they appeared to have continued practices existing prior to the pandemic, it was likely further strained as water use increased and households needed to more actively manage their water supplies and use. Additionally, some households did report having to abandon the use of some water sources due to the pandemic. A notably large portion of household with 24×7 supply reported relying on trucked water due to the numerous outages in water supply experienced in rounds 2 and 3.

This study had several limitations. First, the study population was drawn from a non-random sample; due to restrictions imposed by the COVID-19 pandemic, it was not possible to travel to recruit a random sample of households from the study areas. Therefore, we relied on snowball sampling to recruit participants. We were also unable to collect detailed socioeconomic information from participants via the phone survey approach necessitated by the pandemic, and we therefore report analyses that are not adjusted for socioeconomic covariates. However, our study design relied on multivariate matching to generate well-balanced study groups (Arnold et al. 2010) and, in our prior work in Hubballi–Dharwad, matching balanced socioeconomic covariates between households with IWS and 24×7 supply (Ercumen et al. 2015). All information was self-reported, and the information about water delivery details during lockdown relied on respondents’ memories, subject to the risk of inaccurate recall.

Safe water, sanitation, and hygienic conditions are essential to protecting human health during all infectious disease outbreaks, including the COVID-19 pandemic (Stoler et al. 2020; Tortajada & Biswas 2020; Desye 2021). Our study represents the only assessment, to our knowledge, comparing water access during the COVID-19 pandemic under intermittent and continuous water supply schemes. We did not find large differences in key metrics of water service delivery and water-related behaviors between households with IWS and 24×7 supply during the COVID-19 pandemic in Hubballi–Dharwad, India. Many households had systems for accessing water, including alternative sources, that persisted during lockdown. While few households reported relying on off-premise sources, among the few households that did, maintaining social distancing while collecting water was often not feasible. Most households reported using more water overall during the pandemic, likely straining households’ water management capacities and leading to higher bills. Households with IWS and 24×7 both struggled to access sufficient quantities of water for handwashing, suggesting that water insecurity can limit their ability to adhere to COVID-19 mitigation measures. In particular, households expecting 24×7 water service but facing outages may not have been prepared to cope with the outages. Our findings highlight the role of ensuring adequate supplies of uninterrupted, reliable water during public health emergencies; and ensuring alternative supplies and sufficient household storage for households not otherwise prepared for outages.

We are thankful to households in Hubballi–Dharwad for their participation and the enumerator team for collecting the data.

Funding was provided by the UMass Amherst Department of Civil and Environmental Engineering.

Data cannot be made publicly available; readers should contact the corresponding author for details.