Water availability & promotion interventions

Evidence Rating  
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Disparity Rating  
Disparity rating: Potential to decrease disparities

Strategies with this rating have the potential to decrease or eliminate disparities between subgroups. Rating is suggested by evidence, expert opinion or strategy design.

Health Factors  
Date last updated

Regular placement of drinking fountains, water coolers, or bottled or boxed water in vending machines can make water readily available in various settings. Remediating or replacing drinking water infrastructure such as plumbing and water fountains, and testing tap water quality can make water consumption more appealing. State legislation, school district wellness policies, and child care licensing rules can support water availability, restrict sales of sugar sweetened beverages (SSBs), support water consumption campaigns, or require health education about the importance and benefits of water consumption1, 2. Increased water consumption promotes healthy body systems3.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Increased water consumption

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Improved health outcomes

  • Improved dietary choices

  • Improved cognitive function

What does the research say about effectiveness?

There is strong evidence that making water readily available and promoting its consumption increases water intake4, 5, 6, 7, 8, 9. Frequent water consumption can also have positive effects on eating and drinking decisions10, 11, improve physical health and body functions12, and potentially reduce children’s overweight risk8, 13, 14. Increasing water availability is also a suggested strategy to improve nutrition and cognitive function in children and adolescents15, 16.

Drinking water before meals can reduce energy (calorie) intake during meals and increase weight loss for middle-aged and older adults affected by overweight or obesity17, 18. When water consumption replaces sugar sweetened beverage (SSB) consumption it is linked with reduced energy intake12, 19, 20 and improved health outcomes among children, including reduced risk of overweight or obesity8, 14. Among children and adolescents, increasing water consumption through water provision, education, and promotion can reduce SSB consumption21, 22, 23.

One study suggests that water consumption increases more with the introduction of alternative water delivery systems such as filtered water dispensers or water cooler stations, than with the addition of traditional water fountains7. Alternative water delivery systems often cost less than improving or replacing deteriorating drinking water fountains and plumbing24. Implementing water delivery systems that allow people to fill reusable stainless steel water bottles instead of offering single-use plastic water bottles reduces greenhouse gas emissions and plastic pollution, with even greater effects if people drink water instead of sugar-sweetened beverages25. In a New York City-based study, cafeteria workers reported that water dispensers are easy to operate and maintain9.

How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by expert opinion.

Experts suggest that interventions to increase and promote water availability, especially by addressing water infrastructure remediation or replacement, have the potential to reduce disparities in access to safe drinking water between communities of color, Native communities, and communities with lower incomes and white communities with higher incomes31. People with low incomes, people of color, and those living in rural areas are more likely to have limited access to clean, uncontaminated drinking water than people with higher incomes and white people31, 32, 33. Populations with lower levels of education and older adults may also experience hardships around water accessibility32. Historical discrimination, underinvestment in water infrastructure, lack of regulation enforcement, and failure to protect tribal water rights have resulted in Native American, Black, Hispanic, and other communities of color and residents with lower incomes shouldering the greatest health and economic burdens from water insecurity. Diminished federal investment in water infrastructure has shifted maintenance costs to state and local agencies, who pass them on to consumers, causing an affordability crisis31.

Water can become contaminated in countless ways; some examples include deteriorating systems of pipes and plumbing, naturally occurring elements and minerals (e.g., arsenic, radon, and uranium), and manufacturing or industrial processes. Individuals getting drinking water from private wells typically bear higher contamination risks as regulation of these water sources is outside of federal government authority31. In rural areas, livestock grazing and concentrated animal feeding operations along with the use of fertilizers or pesticides for agriculture, and manufacturing runoff can all contaminate drinking water, while sewer overflow and manufacturing runoff are often the culprits in more urban neighborhoods with residents with low incomes31, 34. While some water-based contaminants are common across the U.S., others are more specific to certain regions or small communities34.

Experts suggest using culturally meaningful and appropriate messaging when designing and implementing water availability and promotion interventions to reach all members of a community, including immigrants, and to avoid increasing disparities in effects on water consumption and health outcomes35.

What is the relevant historical background?

In the 1800s, as American cities grew, water infrastructure was developed to supply urban residents with water from wells, lakes, and streams36. Discriminatory housing, lending, and exclusionary zoning policies in the era of Jim Crow and government-sanctioned segregation led to the redlining practices of the Federal Housing Administration and concentrated poverty in designated neighborhoods37. Poverty levels in an area significantly impact the funding and infrastructure available to residents. These discriminatory practices have led to more than 20 million Americans being provided with water service from community water systems that are in violation of at least one health-based regulation standard and nearly two million individuals living without running water and indoor plumbing31. In the U.S., almost half of Native households are unable to access reliable water due to the neglect and failure of the U.S. government to protect water rights31. The federal government has also shifted maintenance costs of water supplies and wastewater treatment to states and local agencies; since 1990, costs for water rates have tripled and continue to rise faster than inflation and incomes31.

In the present day, formerly redlined neighborhoods are frequently near sources of pollution, toxins, and other health hazards, such as coal-fired power plants or hazardous waste disposal sites, which may contaminate water supplies and are more likely to include older homes in poorer condition often with lead pipes providing water service31, 38. Flint, Michigan, a community with high rates of poverty, unemployment, and racism, along with aging and deteriorating housing, is one of the most notable recent examples of contaminated drinking water in the U.S. In 2014, the water system became severely contaminated when the supply switched from Lake Huron to Flint River as a cost saving measure; the water distribution pipes corroded, leaching lead into the water and poisoning children and adults alike39, 40. As of 2022, the city is still working to replace 30,000 lead pipes and reestablish safe access to drinking water41.

Federal policies such as the Clean Water Act, passed in 1972, and technological advancements including the manufacturing of dams and reservoirs came about primarily in response to poor water quality and limited supply which had created disasters, like waterborne diseases and uncontrolled fires36, 42. Water infrastructure requires constant monitoring and maintenance to prevent contamination43; however, in the U.S., much of the water infrastructure is currently in dire need of replacement, with some cities’ systems dating back to the 19th century36.

Access to clean drinking water is important for everyday health and growth3. In 2010, the Healthy, Hunger-Free Kids Act was passed, federally mandating that all schools make fresh drinking water readily available to students during mealtimes; in addition to increasing access to drinking water, this law also promotes the importance of substituting water for other high calorie beverages44.

Equity Considerations
  • Is clean drinking water accessible to all members of your community? Which neighborhoods lack access to clean drinking water or face barriers to accessing water?
  • Can you partner with community organizations, schools, workplaces, and public health advocates to improve water availability? Who else can promote water access?
Implementation Examples

The Healthy, Hunger Free Kids Act of 2010 requires schools to make water available during National School Lunch Program meal service26. During the 2011-12 school year, 86% of elementary, 87% of middle, and 89% of high schools met this drinking water requirement, most often through existing water fountains. In many of these schools, efforts to improve water quality, the condition of water fountains, and ease of water consumption with cups or recyclable bottles could help all students have water, especially during lunchtime27. State laws can strengthen requirements for healthy beverages and further increase water availability in schools and child care centers, for example the 2012 Healthy Beverages in Childcare law in California28, 29.

School districts across the country require water quality testing and have efforts underway to improve drinking water quality, for example, Chicago Public Schools have been testing water quality on a regular schedule since 201630. Some schools have installed alternative water delivery systems, as in Oakland, California and New York City. Public-private partnerships can support efforts to improve drinking water infrastructure, as in Utah2.

Implementation Resources

Resources with a focus on equity.

CDC-Data and research on water consumption - Centers for Disease Control and Prevention (CDC). Get the facts: Drinking water and intake.

CDC-School water toolkit 2014 - Centers for Disease Control and Prevention (CDC). Toolkit: Increasing access to drinking water in schools. 2014.

ChangeLab-Water - National Policy & Legal Analysis Network to Prevent Childhood Obesity (NPLAN). Water access in schools: Model wellness policy language. Oakland: ChangeLab Solutions; 2012.

Ritchie 2012 - Ritchie L, Rausa J, Patel AI, Braff-Guajardo E, Hecht K. Providing water with meals is not a concern for young children: Summary of the literature & best practice recommendations. Oakland: California Food Policy Advocates (CFPA); 2012.

Water in Schools-Resources - Water in Schools. Resources: Organizations, reports and toolkits, programs, and additional resources.

HOST-Healthy eating - Healthy Out-of-School Time (HOST) Coalition. Resources: Healthy eating.

National Drinking Water Alliance - National drinking water alliance. Access.

CDC-School water access - Centers for Disease Control and Prevention (CDC). Healthy schools. Water access microlearning videos.


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3 CDC-Water and healthier drinks - Centers for Disease Control and Prevention (CDC). Water and healthier drinks.

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21 Moghadam 2020 - Moghadam SD, Krieger JW, Louden DKN. A systematic review of the effectiveness of promoting water intake to reduce sugar-sweetened beverage consumption. Obesity Science and Practice. 2020;6(3):229-246.

22 Grummon 2019 - Grummon AH, Cabana MD, Hecht AA, et al. Effects of a multipronged beverage intervention on young children’s beverage intake and weight: A cluster-randomized pilot study. Public Health Nutrition. 2019;22(15):2856-2867.

23 Kenney 2015 - Kenney EL, Gortmaker SL, Carter JE, et al. Grab a cup, fill it up! An intervention to promote the convenience of drinking water and increase student water consumption during school lunch. American Journal of Public Health. 2015;105(9):1777-1783.

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25 UCRCB&H-Sugary drinks - University of California Research Consortium on Beverages and Health (UCRCB&H). The heavy environmental impact of sugary drinks.

26 Child nutrition reauthorization 2010 - Let’s Move! Child nutrition reauthorization: Healthy, hunger-free kids act of 2010.

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29 Ritchie 2015a - Ritchie LD, Sharma S, Gildengorin G, et al. Policy improves what beverages are served to young children in child care. Journal of the Academy of Nutrition and Dietetics. 2015;115(5):724-730.

30 CPS-Water Quality Testing - Chicago Public Schools (CPS). Water quality testing.

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34 US DHHS ATSDR-Drinking water - U.S. Department of Health and Human Services (U.S. DHHS), Agency for Toxic Substances and Disease Registry (ATSDR). Access to safe drinking water.

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43 IWA-History of water and health - International Water Association (IWA). A brief history of water and health from ancient civilizations to modern times.

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