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 sustainable uptake. Research that considers WASH within a socioecological framework, where multi-level factors are interconnected in influencing choices, can inform more effective 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 age two participating in the ECoMiD study in northwest Ecuador. Data were inductively coded and 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 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, and local conditions are dictated by national sociopolitical context and policy decisions. Household: consistent, quality piped water for drinking and chores is the most common maternal WASH preference. WASH choices respond to financial and labor 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. This contextually grounded study draws attention to how socio-spatial, economic, and environmental constraints interact in the Ecuadorian context to shape lived experience. Improving community-level WASH and taking a multisectoral approach to health interventions would better address barriers to WASH access, and support mothers in making WASH-related choices that can ultimately improve child health and wellbeing.