1.   Background

Access to water

Access to water is viewed as a human right and as being central to sustainable development, as enshrined in the SustainableDevelopment Goal (SDG) 6, to ‘Ensure availability and sustainable management of water and sanitation for all’ (United Nations,2015). According to the ‘United Nations Report on Global Issues – Water,’ 71% of the world population has access to safe water on their own premises but this is not true for the remaining one third of the 2.1 billion people worldwide, most of whom live in rural areas (United Nations,2018a). Inconsistent access to potable water is thus a global issue affecting many water-scarce countries such as South Africa, and is exacerbated by climate change and population growth (United Nations,2018b).

Access to water resources has historically been inequitable in South Africa. The separate development policy meant the majority of the Black population resided in specifically allocated areas known as homelands, where limited basic infrastructure, such as piped water supplies, was developed (Wrisdale et al., 2017). The resultant inequity in terms of water access perpetuates the exclusion of communities from opportunities to overcome poverty. “Indeed, apartheid created physical, legal and social barriers in its separate development, producing a disabling environment with unequal access to water and sanitation” (Wrisdale et al., 2017) p. 275). 

Despite the implementation of progressive water policies in South Africa since 1994, the 2011 Census showed only 38% of households had access to piped water inside their dwellings, or on site in rural areas (StatsSa, 2012).  By2014, the Human Rights Commission Report on ‘Access to Water and Sanitation inSouth Africa’ reported that this figure had increased to 46.3%. The same report stated that 85% of South African households had stable municipal water supplies in place that met the RDP standard by being closer than 200 m from the dwelling. This is consistent with the 2016 Community Survey Statistical Release, which showed that 15.5% of households were found to still access water from outside their yards and 10.1%of households had no access to piped drinking water (Statistics South Africa, 2016).

Despite the improvements challenges remain, with many South Africans living in rural less-resourced areas still having limited access to water within their homesteads (Report on the Right to Access Sufficient Water and Decent Sanitation in South Africa: 2014, 2014). Furthermore, the impact of not having access to a safe water supply is particularly significant for women and girls, as it most often falls to them to fetch water, at great expense in terms of energy expenditure, time and exposure to attack (“WASH and livelihoods”, n.d.; Water, 2017; UnitedNations, 2018a).

Access to electricity

The rollout of electricity connections throughout South Africa was accelerated subsequent to the first democratic elections in 1994, when the ruling AfricanNational Congress included an agreement with the South African electricity utility, Eskom, for the electrification of 2.5 million households within their 1994 election manifesto. This strategy also formed part of the government’s Reconstruction and Development Programme (RDP) and was reinforced by the 1998 White Paper on Energy Policy, which emphasised the importance of households having access to adequate electricity to meet their needs for cooking, heating,lighting and communication (Department of Minerals and Energy, 1998). The successful implementation of the strategy is supported in reports produced by Stats SA, which showed that while only 35% of households nationally had access to electricity in 1994, 84% had access to electricity by 2011 (StatsSa, 2012). This number rose to almost 90% of households throughout South Africa by 2015, but was found to be significantly lower, at 60.1%, in Limpopo Province (Statistics South Africa, 2018).

Many rural households continue to rely on fuelwood as their primary energy source for cooking and heating due to financial constraints despite significant rollout of electrification that has taken place in South Africa within the 23 years of democracy (Shackleton, Gambiza & Jones, 2007; Matsika, Erasmus & Twine, 2013). Against the backdrop of widespread poverty, households remain dependent on collecting cheap or free fuelwood (Matsika et al., 2013; Twine, Moshe, Netshiluvhu, & Siphungu, 2003). Communities living in rural and traditional areas have historically been the hardest hit regarding access to electrification. Limpopo Province has the highest consumption of fuelwood as the primary source of fuel for domestic use in the country, with over 40% of households relying on fuelwood fires for cooking and heating water (Thom, 2000; Statistics South Africa, 2018). It follows that the limited household amenities available inside homes in less-resourced rural South African contexts affects the way individuals conduct their ADLs.

Impact of access to resources on ADLs

Numerous studies regarding access to water and fuelwood in rural less-resourced contexts point to the fact that the type and form of ADLs is related to the household amenities that are available (Aggarwal & Romano, 2001; Shackleton, Gambiza & Jones, 2007; Geere, Hunter &Jagals, 2010). Access to adequate water and energy sources are arguably the most important amenities when it comes to performance of ADLs. Drinking water is essential for survival, and a water supply impacts on food security as it allows for cultivation of vegetables and being able to keep domestic animals as a food source for domestic requirements. Water is also essential for the performance of personal and household hygiene tasks. An adequate supply of electricity opens up the potential for a household to make use of labour-saving household appliances, which have an impact on the way ADL tasks are done. For example, the presence of an electrical geyser to heat indoor-piped water for personal hygiene and doing laundry would eliminate the necessity for fuelwood to heat water on a fire.

ADL data collection

Scrutiny of the bADL and iADL assessment instruments utilised in the South African studies demonstrated that collection of water and fuelwood were not included in any domains or items. However, a number of the studies did make mention of the limited access to piped water, electricity and sanitation in the literature, study setting or discussion sections (Nyirenda etal., 2012; Xavier Gómez-Olivé et al., 2014; Payne et al., 2017; Schatz et al.,2018; Harling et al., 2019)

Five epidemiological studies aimed at evaluating the associations between functional disability and various social and health status variables were found to have used the WHODAS-2.0 as one the of the data collection instruments, (Nyirenda etal., 2012, 2015; Phaswana-Mafuya et al., 2013; Xavier Gómez-Olivé et al., 2013,2014; Schatz et al., 2018). The study conducted in the Agincourt area by Schatz et al (2018) makes reference to older persons carrying out strenuous household activities such as collecting water and firewood, and the SES score, which includes access to water, sanitation and electricity, is included as a variable in the study. Gender role disparities in terms of  care responsibilities, including ‘strenuous activities’, are mentioned, and the need for further research regarding the factors linked to disability in the aging population is acknowledged (Schatz etal., 2018).

A number of the clinical outcomes and epidemiological South African studies found that walking and mobility were the bADLs with the highest level of reported impairment (Phaswana-Mafuyaet al., 2013; Cunningham & Rhoda, 2014; Payne et al., 2017). Even though water and fuelwood collection are not mentioned, given that walking mobility is a prerequisite for completion of these tasks, presumably this could translate into difficulties with collecting water and fuelwood from sources outside of the homestead. Although some studies included variable known as Household assets and Socioeconomic circumstances,which included availability of piped water, electricity and sanitation, none of the studies carried out direct comparisons of household amenities and walking or mobility impairment (Nyirenda etal., 2012; Xavier Gómez-Olivé et al., 2014).

It should be noted, however, that the distances measured in the studies that used the WHODAS-2.0, which refers to ‘Walking a long distance such as a kilometre (or equivalent)’, were lower than the 200m South African RDP Water Policy (WorldHealth Organization, 2010). In a further study also carried out in Agincourt, 42% of participants reported experiencing musculoskeletal pain, and the high musculoskeletal pain scores correlated with bad or very bad functional ability according to the WHODAS-2.0. In a different study carried out in KwaZulu-Natal, water collection was reported as the activity for which most assistance was needed, with 93% of those that reported receiving care stating that they needed help with fetching water. The study made recommendations that community support systems need to be put in place to assist older people with strenuous activities like drawing water.

The differences in the way South Africans living in non-Westerncontexts carry out bADL tasks was explored in a recent validity study on the applicability of the Modified Barthel Index to the South African stroke population. Two factors leading to bADLs being done differently in these contexts were identified, namely resource and accessibility barriers. Limited access to running water and electricity within households was linked to socio-economic status and led to increased demands in terms of carrying out bADLs such as when emptying a basin of dirty water out after completing personal hygiene, as well as walking over rough terrain to reach outdoor toilet facilities. Given the limitations in access to water, sanitation and electricity described earlier in this chapter, it is not surprising that the functional mobility domain was ranked highest for inclusion in the SouthAfrican version of the MBI and the addition of an item to reflect obtaining supplies necessary to carry out bADLs was recommended. While the author concluded that the MBI could be appropriate for the South African stroke population, the importance of the MBI not assuming a Western bias in terms of household amenities was emphasised (Breytenbach, 2016).

The absence of individual ICF codes for water and fuelwood collection, as well as associated changes to codes relating to the manner in which ADL tasks are performed in households without indoor piped water and electricity, translates into these significant aspects not being included in clinical and research instruments, including the WHODAS. This therefore contributes significantly to inconsistent and inadequate data related to performance of contextual ADL tasks.

2.  Proposed changes to ICF

Against the above mentioned background of the pervasive limited access to water and electricity in rural South Africa, the relevant ICF codes for domestic activities and environment are critiqued and this proposal regarding changes to the ICF codes is thus summarised as follows:

• Millions of people globally do not have access to safe water supply nor adequate energy for household use
• Activities of daily living (ADLs) which require water and energy are done differently in contexts where there are limited household amenities like piped water and an electricity supply
• water has to be collected daily (often multiple times) from sources outside of the homestead, like a communal tap in a nearby street, a communal tap for a whole village or area, or from a river. This has high time and physical demands, as water has to be carried or pushed in a wheelbarrow over extensive distances
• once water has been collected from the source outside of the homestead, it is stored in drums or other containers. When it is needed for domestic tasks or personal care, it has to be carried from the storage area to where it will be used. The dirty water after bathing and doing laundry also needs to be disposed of within the yard
• fuelwood has to be collected, often daily, from forest areas surrounding villages. This also involves extensive time and physical demands, as loads of wood have to be carried back to the homesteads
• when the fuelwood is to be used for heating water or cooking etc, it has to be carried from the woodpile to the outdoor fireplace (McAdam, Franzsen & Casteleijn, 2019).
• The ICF, together with most other ADL instruments utilised in the South African studies, are silent on occupations relevant to less-resourced contexts, such as fetching water or fuelwood. Thus, consideration should be given to adding individual codes for water collection and fuelwood collection from communal sources outside of the homestead, in contexts where utilities are not provided to each household by e.g. the municipality.

·        There are a number of existing codes that refer to gathering of daily necessities and systems for the provision ofutilities / household amenities. The code and descriptor for gathering daily necessities, d62010, is viewed as an example of inadequate provision of descriptors for less-resourced settings.While mention is made of water and fuel collection, these tasks are grouped together with harvesting vegetables and fruits. The time, distances and physical effort required for water and fuel collection, as well as the global scale of limited domestic water access in less resourced settings described in the literature above do not appear to be adequately reflected.

·        In addition, an examination of the language used in the ICF item descriptors shows they also do not adequately consider the limited household amenities typical of rural less-resourced settings. An examination of the descriptors for the bathing bADL illustrates how the phraseology of the domains and items appear to be based on the assumption that the homes of the individuals being evaluated have household amenities. The use of the terms bath or shower imply the availability of piped water and Western bathroom fixtures.

The ICF code d510 is the overall code descriptor for washing oneself and makes mention of appropriate materials and methods for doing so, such as bathing, showering or washing individual body parts. The coded5100 also appears to pertain to washing individual body parts, as opposed tocode d5101 which specifies washing of the whole body. While the descriptor ford5100 could be construed as being inclusive of household settings without a bath tub, a shower or piped water, the reference to these amenities in the d510and d5101 descriptors seems to exclude settings where the whole body would be washed using a mobile receptacle such as a plastic basin in the absence of indoor plumbing.

• This proposal relates to the following criteria in the guideline:
• Water and fuelwood collection from communal sources outside of the homestead possible qualify as a new classification entity (more than being under the umbrella of ‘gathering daily necessities’
• The current coding around utilities and gathering daily necessities does not seem to describe ICF situations in all cultures / contexts. There seems to be an underlying assumption that utilities like water and electricity are in place. Seems to be reflective of a bias towards the Global North, as it excludes the context of millions worldwide who spend vast quantities of time and physical effort daily to gather water and fuelwood resources for survival.
• Do the descriptors for the d620 and d6201 codes adequately cover the less-resourced context that I have described above? Does ‘procuring utilities’ mean purchasing or paying the bill for water and electricity, as opposed to actually walking to collect the water and fuelwood from a source outside of the homestead and then carrying it back? Does ‘getting water’ mean collecting it from a tap within the homestead as opposed to walking many kilometres to fetch it?

§  The ICF does not seem to talk to context where utilities like piped water are not provided to every household.  The coding of the environmental factors does provide for ‘Complete barrier’ but the descriptors seem to describe a well-resourced context. The introduction to the chapter indicates that it refers to resources within the immediate environment. Needs to be more clarity as to what that means in terms of water and fuelwood collection ie does immediate environment refer to within the home? Within the homestead including the yard? Or within the areas surrounding the homestead, such as the village or suburb? Assuming the immediate environment includes the home and the yard, then the finding that millions of people walk large distances each day to collect water and fuelwood needs to be more effectively reflected somewhere.

§  Do the codes e530 and e5300 regarding utilities services adequately describe contexts where household amenities such as water and electricity are not provided inside every home?

3.  Conclusion

It is clear that most frameworks that guide the evaluation and treatment of ADL dysfunction have historically been developed in Western and Global North contexts (Hammell, 2011). Despite the fact that limited access to water, sanitation and energy are global issues and affect billions of people, the daily task of accessing these essential resources does not appear to be included to an adequate extent in the ICF. It is therefore critically important for rehabilitation therapists be able to evaluate performance accurately in ADLs in a range of contexts, including those in less-resourced areas with limited household amenities. The paucity of literature regarding ADLs in less-resourced settings in South Africa and globally is significant as it highlights a gap in frameworks that do not take the increased physical demands of ADL tasks in the rural context into account  (Breytenbach,2016; Naidoo, Van Wyk & Joubert, 2016; Naidoo et al., 2017).

While the ICF includes a code for collecting daily necessities, this single code does not adequately convey the amount of daily time and effort required, nor the global prevalence of household circumstances that necessitate collecting water and fuelwood for survival (World Health Organization,2001). This highlights the concern that these occupations have historically not been included in the traditional ADL theory base nor ADL assessment tools, which arguably reflects an inadvertent yet pervasive bias locally and internationally, towards Western and well-resourced contexts. This inherent bias in the ICF towards well-resourced developed settings needs to be rectified to ensure that rehabilitation therapists globally gain insight into the daily occupations performed by millions world-wide, in order for consistent collection of standardized data, together with associated reporting and comparability.

The recognition of collection of water and fuelwood as separate ICF codes will contribute to the transformation of the paradigms underpinning the rehabilitation professions by challenging the existing unspoken assumptions regarding household amenities. 

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CSAC secretariat (26 Feb 2020): IRG review completed: proposal moved to FDRG layer.

CSAC secretariat (May 5, 2020): FDRG review completed: proposal moved to Open Discussion layer.

CSAC Secretariat (Jul 20, 2020): proposal moved to Closed Discussion Layer.

CSAC (Oct 30, 2020): proposal moved back to Open Discussion Layer for further work.