Health and social consequences of water collection among adolescent girls (aged 11–17) in the Yangala rural health zone, Kasai Central Province, Democratic Republic of Congo, 2024

BACKGROUND

Water is essential to life and central to global development goals, yet access remains deeply unequal especially in sub-Saharan Africa.¹ Despite international commitments like the 2030 Agenda and the Alma Ata Declaration,^2,3 millions still lack safe drinking water.^4,5 In 2021, 2% of the global population relied on surface water and 6% on unimproved sources.⁶ In Africa, the number of people without access to improved water increased from 319 million to 400 million between 2015 and 2017.⁷ Water collection, primarily performed by women and girls, can consume up to 90% of their domestic time,⁸ exposing them to physical strain,^9,10 waterborne diseases,^7,11–13 and gender-based violence.^11,14

In the Democratic Republic of Congo (DRC), despite abundant hydrological resources,^15,16 national drinking water coverage has declined to 64%, with stark disparities between urban (91%) and rural (34%) areas.^17–20 In the Yangala Rural Health Zone (ZSR), Central Kasai, access is especially precarious. The region’s sandy-clayey soil limits water retention, and the absence of a distribution network forces residents to rely on distant and often unsafe sources, frequently over 400 meters away. Adolescent girls aged 11–17 are primarily responsible for fetching water, facing risks such as musculoskeletal injuries, exposure to contaminated water, and physical or sexual violence during transit.^20,21

These conditions compromise their physical health, psychosocial well-being, and school attendance, while reinforcing household vulnerability and poverty.⁷ Systematic reviews confirm that spinal and cervical pain are common among children carrying heavy loads.²² A survey in Kongo Central found that 14% of students experienced sexual violence while fetching water at school and 16% at home mostly girls (17% vs. 5%), with perpetrators often known and rarely punished.¹⁴

This study aims to document the multidimensional impacts of water-fetching on adolescent girls aged 11 to 17 in the Yangala Rural Health Zone, to inform targeted interventions and policy responses.

II. METHODS

Study Framework

The Yangala Rural Health Zone (ZSR), located in the Bushimaie sector of Luiza territory, Kasai Central province, spans 6,023 km² and serves an estimated population of 200,038. It includes 238 villages, 216 water sources, and 29 functional health areas. However, only 24.4% of residents have access to safe drinking water. The region experiences a hot and humid tropical climate with two distinct seasons. Local livelihoods depend on subsistence farming, domestic livestock, and artisanal fishing along the Lulua and Lubilanji rivers.

Figure 1.Map of the Yangala Health Zone

Study Design

This study employs a mixed-methods descriptive cross-sectional design, integrating both quantitative and qualitative approaches. This dual strategy allows for the measurement of prevalence and associations while capturing lived experiences and contextual nuances related to water collection in households with limited access.

Study Population and Sampling

Target Population

The study targeted adolescent girls aged 11 to 17 residing in villages within the Yangala ZSR, where access to safe water is critically low. These girls face heightened exposure to environmental, physical, and psychosocial risks linked to water scarcity.

Inclusion and Exclusion Criteria

– Inclusion: Girls aged 11–17 residing in the household during the data collection period. – Exclusion: Girls outside the age range, absent during data collection, or households without eligible participants.

Statistical unit: Households with at least one eligible adolescent girl.

Sample size

It was estimated from the following formula

$$\mathbf{n \geq}\frac{\mathbf{Z}_{\mathbf{\propto}}^{\mathbf{2}}\mathbf{pq}}{\mathbf{d}^{\mathbf{2}}}\mathbf{\ \ ou\ n \geq}\frac{\mathbf{Z}_{\mathbf{\propto}}^{\mathbf{2}}\mathbf{\ p(1 - p)}}{\mathbf{d}^{\mathbf{2}}}$$

n: The sample size
p: The proportion of households traveling more than 30 minutes to collect water in rural areas in the DRC (EDSRDC, 2013-2014) is 49% or 0.49
q: the complementary (proportion of the targeted population not having the characteristic studied:

$$\mathbf{q =}\left( \mathbf{1 - p} \right)\mathbf{= 1 - 0,49 = 0,51}$$

α: The risk of error = 0.05
d: The degree of precision = 0.05,
$Z_{\propto}$ = 1,96 : coefficient de confiance à 95% pour un test unilatéral

Access to water being the most important factor for this study, it will be the parameter which will be used to calculate the sample size of this study.

$$\begin{aligned} \mathbf{n} & \mathbf{\ \geq}\frac{\mathbf{Z}_{\mathbf{\propto}}^{\mathbf{2}}\mathbf{\ p}\left( \mathbf{1 - p} \right)}{\mathbf{d}^{\mathbf{2}}}\mathbf{\ \geq\ }\frac{\left( \mathbf{1,96} \right)^{\mathbf{2}}\mathbf{*0,49}\left( \mathbf{1 - 0,49} \right)}{\left( \mathbf{0,05} \right)^{\mathbf{2}}}\\ & \mathbf{\geq} \mathbf{384\ personnes} \end{aligned}$$

Sampling Techniques

A three-stage probability sampling method was applied:

1. Eight out of 26 health areas with limited water access were randomly selected.

2. Two villages per selected health area were drawn by simple random sampling.

3. A systematic plot survey was conducted using the interval formula I=N/nI = N/n. From a randomly selected starting plot, subsequent plots were chosen by adding the interval. If multiple eligible households were present, one was randomly selected.

Data Collection

Data were collected through face-to-face interviews using a structured questionnaire during household visits. The questionnaire was digitized via SurveyCTO and administered on Android devices for secure, real-time data entry. Each household was interviewed individually. Daily downloads, cleaning, and consistency checks ensured data reliability. The principal investigator conducted daily reviews to monitor quality and adjust procedures. Open-ended questions captured qualitative insights on emotional distress, perceived safety, and coping strategies, though these were not analyzed in the present study.

Variables

• Water Collection Indicators

  – Duration of round trip (especially >30 minutes) – Frequency of collection – Distance traveled – Weight of load carried – Volume of water fetched

• Sociodemographic Variables

  – Age – Household size – Education level – Income bracket – Family relationships

• Water Source Classification

  – Improved – Unimproved (based on public health criteria)

• Health Outcomes

  – Musculoskeletal pain (spinal, cervical, lumbar) – Infectious diseases (diarrhea, skin infections)

• Academic Consequences

  – School delay – Absenteeism – Academic failure – Dropout

• Gender-Related Risks

  – Physical, sexual, and psychological violence during water-fetching – Psychological effects (fear, anxiety, trauma) Note: No standardized psychometric instruments were used.

All variables were measured using nominal, ordinal, or interval scales, depending on their nature and analytical relevance.

Data Processing and Statistical Analysis

Validated data were exported to Excel for secure archiving and then transferred to SPSS version 25 for analysis. Descriptive statistics summarized qualitative variables as frequencies and percentages, and quantitative variables as proportions. Associations were tested using the chi-square method, with significance set at p<0.05p < 0.05. Qualitative responses were thematically analyzed to explore vulnerability, coping strategies, and community perceptions

Ethical Considerations

This study received ethical approval from the Ethics Committee of the School of Public Health, University of Kinshasa. Formal authorization was also obtained from the dissertation supervisor and relevant political, administrative, and health authorities. Free and informed consent was secured from all participants, with forms translated into the local language for clarity. For minors under 18, parental or guardian assent was additionally required. Strict measures ensured anonymity and confidentiality, with no physical or psychological risk to participants. The protocol aligned with national ethical guidelines and international standards for research involving minors.

III. RESULTS

This study assessed the health and social impacts of water-fetching among adolescent girls aged 11–17 in the Yangala Rural Health Zone (ZSR), based on data from 384 households.

Sociodemographic and Economic Characteristics Most respondents were male household heads under 34 years old (97.1%), married (62.5%), and leading large families (61.2% with more than six members). Although 82.8% had attended school, 65.1% were unemployed, and 88% relied on informal income-generating activities. Female representation was low, with fewer than three women in 64.1% of households. Catholicism was the most represented religion (37%), and 60.7% of households fell into the lowest asset ownership index, indicating significant economic vulnerability. [See Table 1a -1b]

Water Collection Characteristics Surface water sources (rivers, marshes) were used by 96.9% of households, chosen not for quality or proximity but due to lack of alternatives (71.6%). Rainwater harvesting was rare (3.1%), despite the tropical climate—suggesting missed opportunities due to limited infrastructure, storage, or awareness. Most households traveled over 400 meters (81.8%) and spent more than 30 minutes per trip (93.8%), with 99.7% expressing dissatisfaction. The majority transported ≤20 liters per trip (63%) and made no more than two trips daily (68.2%), reflecting significant time and energy burdens. [See Table 2 and Figure 1]

Drinking Water Supply Methods Surface water remained the primary drinking source for 96.9% of households, exposing families to contamination risks. This near-total reliance on unimproved sources highlights the urgent need to expand safe water infrastructure and promote alternative supply strategies. [See Table 3]

Educational and Social Impacts Most household heads (95.1%) acknowledged the consequences of water-fetching. School delays (87.8%), absenteeism (83.6%), lack of time for study (82%), and academic failure (71.9%) were frequently reported. These impacts were more pronounced in households with limited adult support or low parental education. Further analysis could explore how age, household size, and caregiver involvement influence these outcomes. [See Table 4]

Social Consequences In the past three months, girls reported insults (60.4%), fear (61.5%), conflicts (29.2%), and fights (15.4%). Physical assaults were less frequent—slaps (3.1%), cuts (0.3%), injuries (1.8%)—possibly underreported due to stigma or cultural norms. Intersectional factors such as age and household composition may influence vulnerability and coping capacity. [See Table 5]

Health Consequences Reported symptoms included chronic fatigue (74.7%), headaches (70.1%), back pain (47.7%), and neck pain (23.7%), consistent with biomechanical strain. Waterborne illnesses such as diarrhea (44.8%), scabies (10.2%), and ringworm (6.3%) were also prevalent. The absence of standardized clinical tools limits comparability; future studies should consider validated health screening instruments. [See Table 6]

DISCUSSION

Key Results

The study highlights that most respondents were men under 34 years old, living in economically vulnerable households with more than six members and low female representation. Access to drinking water relied heavily on surface sources, requiring long journeys—often over 400 meters and 30 minutes—for small quantities (≤20 liters), resulting in widespread dissatisfaction. Adolescent girls, primarily responsible for water collection, faced significant health issues (back pain, fatigue, infectious diseases) and social consequences (insults, conflict). Statistical analysis revealed associations between distance traveled, source type, and exposure to threats, underscoring the gendered burden of water collection and its intersection with household structure, poverty, and inadequate infrastructure [Table 1–3].

Characteristics of the Water Chore and Its Consequences in Yangala ZSR

Water collection in Yangala ZSR is a daily constraint, particularly for women and children. Most households travel long distances and spend considerable time fetching water, leading to fatigue, stress, and reduced time for education or income-generating activities. Similar findings were reported by Sorenson et al. in Tanzania, where water collection dominates rural household routines.²³ Health consequences such as musculoskeletal pain, chronic fatigue, and waterborne diseases (diarrhea, ringworm, scabies) were prevalent, echoing Geere et al.'s findings in Kenya.²⁴

Seasonal variation, especially during dry periods when surface water becomes scarce, likely exacerbates these burdens. However, this cross-sectional design did not capture seasonal dynamics—an important limitation. Future studies should incorporate seasonal data to better understand fluctuations in risk and access.

Socially, the chore affects girls’ education and emotional well-being. Kiyombo et al. documented similar impacts in Kongo Central, including lateness, absenteeism, and school dropout.²⁵ Verbal and moral violence—insults, humiliation, threats—was common, often from family members. Smith et al. found that in West Africa, women and children spend up to four hours daily collecting water, limiting access to education and productive activities.²⁶ Johnson et al. observed similar health and social impacts in Southeast Asia.²⁷

Qualitative responses from Yangala revealed emotional distress: girls reported feeling “exhausted before school” or “afraid of going alone.” These insights support the thematic analysis and should be more prominently integrated to enrich interpretation [Table 5].

Supply Methods, Knowledge, and Practices of Household Heads

In Yangala, nearly 70% of households rely on surface water sources such as rivers and marshes, exposing them to high contamination risks. Although most household heads were aware of the health and educational consequences, this awareness did not always translate into action. Some expressed resignation—“we have no choice”—highlighting structural barriers and the absence of community-led solutions.

Bain et al. reported similar findings in sub-Saharan Africa, where reliance on unimproved sources correlates with high prevalence of waterborne diseases, particularly diarrhea.²⁸ Johnson et al. emphasized the health deterioration linked to surface water dependence in East Africa,²⁹ while Martinez et al. in Central America called for equitable public policies to ensure safe water access.³⁰

These converging findings reinforce the urgency of targeted interventions in Yangala. Priority should be given to high-risk villages identified during sampling—those with the longest travel distances and highest rates of reported violence. Establishing community-based water committees could improve local ownership, infrastructure maintenance, and accountability.

Strengths and Limitations of the Study

This study is notable for its methodological rigor, including a large sample size, probabilistic sampling, and robust statistical analysis using the Chi-square test. Data collection via SurveyCTO and analysis in SPSS enhanced reliability. The integration of quantitative and qualitative data provided a comprehensive understanding of the issue and informed relevant policy recommendations.

However, limitations must be acknowledged. Social desirability bias may have led to underreporting of sensitive issues such as sexual violence or psychological distress. The subjective nature of self-reported perceptions and the influence of timing on responses also warrant caution. Potential confounders—such as concurrent poverty, other domestic labor obligations, and seasonal water availability—were not controlled for and may have influenced observed associations.

Future research should adopt longitudinal designs to capture seasonal variation and long-term effects. Participatory mapping could help identify high-risk zones, and the use of standardized psychometric tools would improve the reliability and comparability of health and psychological assessments across contexts.

Conclusion

The study conducted in the Yangala ZSR reveals serious challenges related to water collection, including dependence on surface sources and long distances traveled, exposing young girls in particular to physical and social risks. Health consequences include musculoskeletal pain, fatigue, and infectious diseases. These challenges require urgent interventions, such as infrastructure improvements and awareness campaigns. Community involvement is essential to ensure sustainable solutions. These recommendations aim to increase access to safe drinking water and improve the well-being of rural populations.

Acknowledgements

We are grateful to the health authorities of the Yangala ZSR, local leaders, and all participants for their collaboration. Special thanks to the data collection team and field supervisors for their commitment.

Disclaimer

The views expressed in this manuscript are those of the authors and do not necessarily reflect the official position of the University of Kinshasa or its affiliated institutions.

Ethics Statement

This study received ethical approval from the Ethics Committee of the School of Public Health, University of Kinshasa (Approval No. ESP/CE/028/2023). Informed consent was obtained from all participants. For minors under 18, parental or guardian assent was also secured.

Data Availability

The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request.

Funding

This research received no external funding. The article publication charge (APC) was not funded by any specific agency.

Authorship Contributions

• TSHIMAMBU NDAYE Justin: Conceptualization, data collection, statistical analysis, manuscript drafting

• Nkongolo Bernard-Kennedy: Data analysis, manuscript review

• André Balamuange: Manuscript review and editorial input

• Joël KONDE NKIAMA NUMBI: Supervisor of the study, protocol validation, scientific oversight.

• All authors meet the ICMJE criteria for authorship and have approved the final version of the manuscript.

Disclosure of Interest

The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.

Corresponding author:

Bernard-Kennedy Nkongolo, knkongolo28@gmail.com