Socioecological drivers of water, sanitation, and hygiene (WASH) choices: A qualitative analysis of maternal perspectives in northwest Ecuador

Household-level water, sanitation, and hygiene (WASH) interventions do not always achieve the expected health benefits. Research that considers WASH within a socioecological framework where climatic, infrastructural, economic, and individual factors are interconnected in influencing maternal choices can inform more effective WASH interventions. To understand WASH preferences and priorities under different socioeconomic and community contexts, we conducted in-depth interviews and freelisting activities with 33 mothers of children under two years of age participating in the ECoMiD study in northwest Ecuador. Data were inductively coded connected thematically to the socioecological framework. Select survey data from ECoMiD were analyzed to provide additional context. Maternal WASH choices are driven by factors at each level of the socioecological framework. Climatic: seasonal flooding decreases the appeal of WASH investments like cisterns, and household wealth facilitates access in times of climatic stress. Geographic: benefits of WASH access via proximity to piped systems are complicated by quality and consistency concerns, while access from proximity to rivers is complicated by labor requirements. Community: local infrastructure dictates individual options for accessing WASH. Piped systems improve access to water quantity irrespective of quality. Household: consistent, quality piped water for drinking and chores is the most common maternal household WASH preference. WASH utilization and purchasing priorities respond to financial and labor-related constraints. Individual: mothers value time-savings associated with WASH technologies and access. Maternal decision making operates at the terminus of a chain of broader and interconnected socioecological conditions. The burden of obtaining WASH access is greatest for the poorest households with the least community infrastructure, compounded by seasonal conditions. Improving community-level WASH access and taking a multisectoral approach to health interventions would better address individual and household level barriers to WASH access, and support mothers in making WASH-related choices that can ultimately improve child health and wellbeing.