Assessing the effects of household water, sanitation, and hygiene (WASH) on child health under different socioeconomic and community contexts: A mixed-methods study in northwest Ecuador

Abstract

Water, sanitation, and hygiene (WASH) access is both a direct determinant of health and an in-direct determinant of numerous other conditions important to well-being. The WASH-related health burden – primarily enteric infections and poor child growth – falls disproportionately on the poorest households. This dissertation seeks to understand how WASH access, household wealth, and child health intersect at the numerous scales at which WASH operates, from the individual to the household, community, and broader geographic and environmental contexts. We ground our work in an understanding of the sociopolitical and historical processes which have shaped inequitable access to WASH and health today, and center the voices and experiences of community members and mothers as crucial context for our research. In Chapter 2, we utilize mixed-methods and a socioecological framework to understand maternal preferences and priorities related to WASH access in ten communities spanning an urban to rural gradient in northwest Ecuador. We conducted 33 in-depth interviews with mothers participating in the ECoMiD study, and identified drivers and constraints to WASH access at the individual (time and labor), household (WASH access and costs), community (infrastructure quality), geographic (natural resources, remoteness), and environmental (seasonal impacts) levels. Mothers were hesitant to invest in WASH in the absence of secure, permanent housing. In Chapter 3, we assess the relationship between household wealth and household WASH in the ECoMiD communities across the urban to rural gradient. To complete this analysis, we used qualitative data from Chapter 2 to create a community-informed measure of socioeconomic status, constructed using multiple correspondence analysis on asset ownership. We found that wealth was significantly associated with increased access to complete WASH, a metric that includes access to basic or limited water, basic or limited sanitation, and basic hygiene in a household. Among these components, wealth was most strongly associated with increased sanitation access. High wealth thresholds were identified to own priority WASH items. In Chapter 4, we test if household WASH and household wealth have a protective effect against enteric infection and stunting using linear and logistic multivariable regression models, adjusting for location on the urban-rural gradient and other covariates. We found that household WASH was protective against high concentrations of enteric infection (four+ co-infections) at six months of age, but we did not find evidence of an association with stunting at two years. We did not find evidence that household wealth was protective against enteric infection or stunting, but wealth was associated with higher mean length-for-age Z-scores. Household WASH coverage appeared to mitigate seasonal variation in enteric infections, particularly in the dry season. Our results can inform interventions that aim to increase WASH coverage, improve child health, and move towards health equity globally. We suggest that structural constraints to WASH access will need to be addressed to enable individual decision making around WASH that can improve child health. Pro-poor, women-oriented, climate resilient, community-level interventions that target multiple drivers of health and well-being, including poverty alleviation and housing stability, are crucial to ensure Sumak Kawsay – good living for all. Ultimately, WASH interventions should to respond to community needs and address local priorities to succeed.