Perceptions of water insecurity and psychosocial distress in Indigenous communities: a qualitative systematic review

Background Water insecurity is increasingly recognized as an important environmental and social determinant of health. For Indigenous communities, water holds material, cultural, and relational significance, meaning that disruptions in access, quality, or reliability may contribute to psychosocial distress. Although qualitative studies have explored these experiences, the evidence has not been systematically synthesized from an Indigenous-centered and place-based perspective. Objective To synthesize qualitative evidence on Indigenous communities’ perceptions of water insecurity and its relationship to psychosocial distress. Methods A qualitative evidence synthesis was conducted following ENTREQ guidelines. Qualitative and mixed-methods studies with extractable qualitative findings were identified through searches of major bibliographic databases and gray literature sources. Studies published between 1980 and 2021 examining Indigenous experiences of water insecurity and psychosocial outcomes were included. Data were synthesized using thematic synthesis, and confidence in review findings was assessed using the GRADE-CERQual approach. Results Eleven studies conducted primarily in Indigenous communities across North America and Sub-Saharan Africa met the inclusion criteria. Two higher-order analytical themes were identified: (1) water insecurity as a lived environmental stressor involving chronic worry, physical burden, economic strain, and institutional neglect; and (2) psychosocial distress as an embodied and relational experience encompassing emotional suffering, somatic manifestations of distress, gendered caregiving burdens, and collective dimensions of wellbeing. Across studies, water insecurity was consistently understood not only as a material challenge, but also as a culturally meaningful and socially mediated condition shaped by environmental precarity, unequal access to resources, and disrupted relationships with land and water. Conclusions Water insecurity is a deeply embedded, place-based determinant of psychosocial distress in Indigenous communities. Addressing water-related mental health inequities requires culturally responsive approaches that recognize water not only as a physical resource, but also as an important component of wellbeing, community life, and cultural continuity.