Characterizing water-health pathways among diverse system actors in rural Guatemala: a qualitative study

Abstract Rural communities in Guatemala’s Western Highlands face heightened water-health risks due to the region’s mountainous terrain, water administration challenges, and poverty. This study applies and elaborates a three-level framework to explore proximal, intermediate, and distal water-health pathways and their perceptions among local water system actors, an unexplored approach in Latin American rural contexts. Semi-structured interviews were conducted during May–December 2023 in Tojchoc Grande, San Marcos, Guatemala. Interviews were conducted with local farming and non-farming community members ( n = 35), water managers ( n = 10), and health workers ( n = 4). Interviews were audio recorded, transcribed, and thematically analysed using an inductive approach. An adapted three-level water-health framework was used to categorize major themes under proximal, intermediate, and distal water-health pathways. Proximal pathways discussed by participants related to water infrastructure, climate variability, and sanitation issues. Intermediate pathways focused on agricultural water use and administrative challenges. Distal pathways included socio-economic factors like poverty, migration, and broader institutional issues such as state-absence. Perceptions of these pathways differed among actor groups. Community members focused on proximal pathways like water infrastructure and climate variability, whereas water managers and health workers emphasized administrative challenges and sanitation issues, respectively. This study demonstrates how a three-level framework can be adapted to characterize layered, multi-scalar water-health pathways shaped by historical and structural inequities in Guatemala’s Western Highlands. By integrating the perspectives of distinct local actors, this study contributes a novel, actor-centred application of a health framework to rural Latin American water-health research. This work underscores the need for interventions that address both proximal conditions and the distal political-economic forces shaping them.