Abstract
Access to adequate sanitation remains a major public health challenge, particularly in areas with limited resources. This study examined the factors influencing sanitation practices among women, focusing on socioeconomic, knowledge, and environmental determinants. A cross-sectional survey was conducted among women. Data on sociodemographic characteristics, household wealth, sanitation knowledge, water availability, and conflict exposure were collected and analyzed using multivariable logistic regression. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were computed to identify significant predictors of poor sanitation practices. The findings revealed that wealth status, knowledge, water availability, and exposure to conflict were significant determinants of sanitation behavior. Women from poor households had 3.5 times higher odds of practicing poor sanitation compared to those from rich households (AOR = 3.5; 95% CI: 2.10–5.60; P < .001). Similarly, women with poor knowledge of sanitation were 3 times more likely to engage in inadequate sanitation practices than those with good knowledge (AOR = 3.0; 95% CI: 1.60–5.40; P < .001). Limited access to water also strongly increased the likelihood of poor sanitation (AOR = 3.2; 95% CI: 1.90–5.40; P < .001), and women living in conflict-affected areas had double the odds of poor sanitation practices compared to those in stable settings (AOR = 2.0; 95% CI: 1.10–3.60; P = .02). Age and occupational status were not significant predictors. These results highlight that poverty, inadequate knowledge, limited water availability, and conflict exposure substantially compromise sanitation behaviors. Interventions should therefore combine targeted health education, improved water and sanitation infrastructure, and context-specific strategies for populations in conflict-affected or underserved areas. Strengthening these measures can enhance hygiene practices and reduce the burden of sanitation-related diseases.
Introduction
Access to safe sanitation is a fundamental human right, recognized by the United Nations as essential for the realization of all other human rights. Yet, as the world moves past the midway point of the 2030 Agenda for Sustainable Development, the global community remains dangerously off-track in achieving Sustainable Development Goal (SDG) 6.2: ‘achieving access to adequate and equitable sanitation and hygiene for all’. According to the latest Joint Monitoring Programme (GMP) report by world Health organization (WHO) and United Nations Children’s Fund (UNICEF) approximately 3.5 billion people worldwide still lack safely managed sanitation services. Of these, 419 million still practice open defecation, a behavior that remains the primary driver of soil-transmitted helminth infections and waterborne pathogens. 1
The global economic burden of poor sanitation is equally staggering. Inadequate Water, Sanitation, and Hygiene (WASH) services contribute to nearly 10% of the global disease burden, leading to an estimated 1.4 million preventable deaths annually, primarily among children under 5 in developing nations. Beyond mortality, poor sanitation is intrinsically linked to stunted growth and cognitive impairment due to chronic enteric infections and environmental enteropathy. Furthermore, the global climate crisis has introduced new vulnerabilities; extreme weather events ranging from catastrophic flooding to prolonged droughts regularly destroy sanitation infrastructure, contaminating communal water sources and reversing decades of progress in hygiene promotion. 2
Sub-Saharan Africa (SSA) remains the epicenter of the global sanitation crisis. While other regions have seen rapid improvements, SSA has struggled to keep pace with its booming population and rapid, unplanned urbanization. Research by the African Development Bank (2023) indicates that while access to basic water supply has improved, sanitation coverage has stagnated or, in some informal urban settlements, declined. In many African cities, the sanitation value chain from containment and transport to treatment and disposal is broken. Over 70% of urban residents in SSA rely on onsite sanitation systems (pit latrines or septic tanks) that are frequently poorly constructed, prone to overflowing during rainy seasons, and rarely emptied safely. 3
The gendered dimension of this crisis in Africa cannot be overstated. For women and adolescent girls, the lack of private, safe, and clean sanitation facilities is not merely a health issue but a matter of safety and dignity. United Nation (UN) report on women highlights that sanitation poverty forces women to wait until dark to relieve themselves, significantly increasing the risk of physical and sexual violence. Moreover, the absence of gender-sensitive sanitation facilities in public spaces and workplaces hinders women’s economic participation and girls’ school attendance, particularly during menstruation. 2
Ethiopia, the second-most populous nation in Africa, faces a complex WASH landscape characterized by stark disparities between urban and rural settings. The Ethiopian Government has demonstrated high-level political commitment through the One WASH National Program (OWNP) and the Health Extension Program (HEP). These initiatives successfully reduced open defecation from 79% in 2000 to approximately 20% by 2020. However, the transition from basic to safely managed sanitation has been agonizingly slow. 4
As of 2024, the Ethiopian Ministry of Health (MOH) reports that millions of households still utilize unimproved latrines that do not effectively separate human waste from human contact. The country’s progress has been significantly hampered by a triple threat: high population growth, persistent poverty, and recurrent internal instability. Recent studies in various Ethiopian regions have shown that even where latrines are present, their utilization is often inconsistent due to poor structural quality, lack of water for flushing or handwashing, and deeply ingrained cultural taboos. 5 Furthermore, the World Bank (2024) notes that the financing gap for Ethiopia’s WASH sector remains a major bottleneck, with current investments meeting less than 30% of the required capital to achieve universal access. 6
Moving to the specific local context, Finote Selam Town, the capital of the West Gojjam Zone in the Amhara Region, presents a microcosm of Ethiopia’s broader sanitation struggles, compounded by localized stressors. Despite its status as a growing urban hub, the town’s infrastructure has struggled to support its expanding population. A recent hydraulic study of the town’s water system revealed that the distribution network meets only 66% of the required demand, leaving large sections of the community with intermittent or non-existent water access. 7 Without reliable water, even households with latrines are unable to maintain the hygiene triad of handwashing, bathing, and facility cleanliness.
Furthermore, the year 2024 marks a period of significant recovery and ongoing challenge for the Amhara region. The impact of northern Ethiopia’s regional conflicts has had a devastating effect on public health infrastructure in towns like Finote Selam. Conflict-induced displacement has placed an enormous strain on existing communal sanitation facilities, while the diversion of government resources toward emergency response has slowed the implementation of the HEP. Evidence suggests that women in conflict-affected areas are particularly vulnerable to poor sanitation practices due to the loss of household assets, psychological stress, and the breakdown of community-based hygiene monitoring. While various studies have explored sanitation in Ethiopia, few have integrated the combined impacts of socioeconomic status, sanitation literacy, water scarcity, and conflict exposure in a single urban assessment in 2024. Most existing research focuses on rural latrine coverage rather than the nuanced behavioral practices of urban women, who manage the majority of household hygiene responsibilities. 8
There is an urgent need to understand why despite decades of hygiene promotion many women in Finote Selam still exhibit poor sanitation practice. Is it a lack of knowledge, a lack of resources, or the overarching instability of the region? This study addresses this critical gap by providing empirical evidence on the predictors of sanitation practices among women in Finote Selam Town. The findings are intended to guide local health offices and non-governmental organization in developing resilient, gender-sensitive WASH interventions that can withstand the pressures of both poverty and regional instability.
Methods and Materials
Study Area Description
Located in the northwestern reaches of Ethiopia’s Amhara National Regional State, Finote Selam serves as the administrative and economic capital of the West Gojjam Zone. 9 The town supports an estimated population of 57 391 residents, whose livelihoods are built on a diverse economic foundation. While a significant portion of the population is traditionally engaged in agriculture and local commerce, 10 the town’s role as a zonal hub has established government employment as a major sector. This workforce includes hundreds of healthcare professionals at the Finote Selam General Hospital and various public health facilities, as well as administrative staff across zonal and woreda offices. 11
Despite its administrative importance, Finote Selam faces persistent public health challenges, primarily regarding communicable diseases. While the town possesses water and sanitation infrastructure, access is characterized by localized service gaps and neighborhood inequalities rather than a total absence of safe water. A critical driver of this burden is the frequent water supply interruptions that plague the municipal system. These interruptions, often caused by rapid urbanization and management challenges, force residents to rely on unprotected or poor-quality secondary sources, such as the Lah River, which has been found to have high pollution levels during certain seasons. The combination of service instability and uneven sanitation infrastructure contributes to the continued prevalence of waterborne diseases, including diarrhea, cholera, and typhoid fever. Research indicates that nearly 90% of diarrheal deaths in such settings are linked to unsafe drinking water and poor sanitation, with school-aged children being particularly vulnerable. 12 Ultimately, the public health risks in Finote Selam are exacerbated by these systemic service interruptions and infrastructure disparities, highlighting the need for more consistent and equitable water management.
Study Design and Period
A community-based cross-sectional survey was carried out from September to November in 2024 among 389 women in Finote Selam Town.
Source and Study Populations
The source population consisted of all women who resided in Finote Selam town during the study period. These women embodied the broader community of the town, and the individuals who would become potential participants thus reflect the socio-economic, cultural, and environmental characteristics of the area.
From this source population, a study population was selected through a multi-stage sampling technique. Therefore, the women who fulfilled the inclusion criteria such as being within the designated age range, having lived in Finote Selam town for at least 6 months, and being both available and willing to participate were eligible for inclusion.
Inclusion Criteria
Participants had to be women because the research focused on sanitation practices among women. In addition, participants had to be women 18 years or older to ensure that they were all legally adults who could give informed consent. Participants had to be permanent residents in the selected districts in northwestern Ethiopia, living in the area for at least 6 months prior to data collection, so they would have had sufficient exposure to local environmental factors such as water availability. Further, eligible participants needed to effectively communicate in the local language, Amharic, to understand and respond to the questionnaire accurately. Finally, only those who were willing and able to give informed consent and who were available during the period of 3 months were enrolled in the study.
Sample Size Determination
The study targeted a representative sample of women from the study population. The sample size was calculated based on the desired level of precision, confidence intervals, and estimated prevalence of key variables. This calculation is important to ensure statistical significance and generalizability to the broader population of women in Finote Selam Town. This sample size was determined using a single population proportion formula with a 5% margin of error (d), a 95% CI (Z = 1.96), and the P-value taken from practice about sanitation among households (HHS) in the Tigray region, which was 49.2% 13 and Z is the standardized normal distribution curve value for the 95% confidence interval (1.96).
=384 (sample size for practice). After considering 10% non-response rate the total sample size becomes 422 women.
Sampling Methods and Procedure
Multi-stage sampling techniques were used in which all the women living in Finote Selam town, which was the source population, were grouped into 6 kebeles. Then, households were listed in each kebele and a random selection of households was made. Finally, in each selected household, the eligible women were identified and recruited to form the study sample (Figure 1).
The schematic diagram of sampling procedures among women in Finote Selam Town, northwest Ethiopia, September 2024 to November 2024 (N = 422).
Variables and Operational Definitions
Dependent Variable
Sanitation Practices Among Women
Sanitation practice was categorized as good sanitation practice when a woman fulfilled at least 80% of the predefined sanitation indicators namely: use of an improved sanitation facility (flush/pour-flush toilet, ventilated improved pit latrine, or pit latrine with slab); regular handwashing at critical times (after defecation, before food preparation, before eating, and after cleaning a child) using water and soap or ash; appropriate menstrual hygiene management (use of clean absorbent materials, changing materials at least 2 to 3 times per day, washing the body with water and soap, and safe disposal of used materials); and safe household waste disposal (use of covered pit, municipal collection, or designated disposal site). Women who fulfilled less than 80% of these indicators were categorized as having poor sanitation practice. 14
Independent Variables
Wealth Status
Wealth status was assessed using a composite wealth index constructed from urban household assets, including indicators of income, housing characteristics, and ownership of selected durable goods. Principal Component Analysis (PCA) was applied to categorize households into low, middle, and high wealth groups, following the standard methodological approach described by. 15
Knowledge About Sanitation
Knowledge about sanitation was measured through a series of knowledge-based questions assessing awareness of proper hygiene practices, disease transmission routes, and sanitation-related health risks. Responses were scored to categorize knowledge levels as poor, moderate, or good. 16
Water Availability
Water availability was measured based on the reliability, quantity, and accessibility of water sources. It was assessed by determining the average daily water consumption per household, distance to the water source, and the frequency of water supply interruptions, categorized as adequate or inadequate. 17
Attitude Toward Sanitation
Attitude toward sanitation was measured using Likert-scale statements to assess perceptions, beliefs, and attitudes toward hygiene and sanitation practices. Scores were categorized as positive, neutral, or negative attitudes. 18
Sanitation Facilities
Conflict Situation
Conflict situation was assessed as a binary variable, with ‘Yes’ indicating that war or armed conflict disrupted household sanitation practices, and ‘No’ indicating no such disruption.
Socio-demographic Characteristics of Participants
Socio-demographic characteristics of participants were assessed using age, family size, marital status, and occupational status. Age was grouped into 15 to 30, 31 to 45, and ⩾45 years. Family size was categorized as ⩽5 or >5 members. Marital status included unmarried, married, divorced, and widowed. Occupational status was classified as government or non-governmental employee.
Data Collection Techniques
Data collection instruments included structured questionnaires to collect data on sanitation practices, wealth status, knowledge, attitudes, and related factors. Observational checklists were used to objectively assess the household sanitation and hygiene conditions. A team of 8 data collectors was involved in the study to administer the questionnaires and collect data from the respondents. In addition, 1 field supervisor was assigned to oversee the process of data collection to ensure that the data collected was of high quality and also to guide and assist the data collectors in case problems arose in the field.
Data Analysis
First, the data collected in the study were cleaned and prepared for analysis to make sure that they were complete and accurate. This involved checking for missing values, making necessary corrections of data entry errors, and coding variables correctly, where appropriate. Descriptive statistical methods were used to summarize the socio-demographic information of participants and other key variables; frequencies, percentages, means, and standard deviations were calculated. The results were presented in tables for clarity.
Bivariate analysis was conducted to evaluate the various associations of the independent variables: wealth status, knowledge and water availability, with the dependent variable sanitation practices. Variables with a P-value < .25 at the bivariate analysis were selected for multivariable logistic regression analysis.
Multivariable logistic regression analysis was done to identify factors that were independently associated with sanitation practices, adjusting for potential confounders. The measures of the strength of associations were calculated using adjusted odds ratios and their 95% CIs. The model’s goodness-of-fit was checked using the Hosmer-Lemeshow test. The presence of multicollinearity was checked by the Variance Inflation Factor, among predictors.
Data Quality Assurance
Throughout the study, a series of measures in data quality assurance were taken to ensure reliability and validity. First, pretests of the questionnaires were done on a small 5% of sample from the population that would be survey participants to verify that the questions were unambiguous and consistent. Extensive training was undertaken with data collectors and supervisors on the goals of the research, techniques for data collection, and ethical concerns surrounding it, as well as how to handle the data collection tools in a way that would limit problems related to error and bias.
Field activities during data collection were closely monitored by supervisors to ensure that data were collected both accurately and consistently. Supervisors have regularly conducted spot checks and re-interviews on a sub-sample of participants targeted with data collection instruments to verify the completeness and accuracy of the data collected. Besides, daily meetings have been held with data collectors to discuss various challenges encountered in the field and provided immediate feedback for continuous improvement.
After the collection of data, the data were reviewed for completeness, consistency, and accuracy before entry into statistical software. Double data entry was done in order to minimize entry errors; any inconsistencies noted were cross-checked against the original questionnaires. Further, data cleaning procedures-checking for outliers, missing values, and logical inconsistencies-were carried out prior to final analysis to ensure the integrity of the data set.
Results
Socio-Demographic Characteristics of Participants
A total of 389 (92.2% response rate) women participated in the investigation of sanitation practices in northwestern Ethiopia. The mean age of the sample was 36.8 years (SD ± 9.5). More than half (54.0%) of the sample were between the ages of 31 and 45 years old, while the next largest group was composed of participants between 15 and 30 years old (25.2%). The majority of women were married (74.8%), while 14.9% were single, 8.2% divorced, and 2.1% widowed. Approximately half (51.9%) of all households included more than 5 members. The largest proportion of women were government employees (69.7%); 30.3% were employed in other sectors (NGOs or informal work). Regarding wealth status, the majority of respondents were classified as poor (29.8%); 54.0% of respondents were considered medium wealth; and 16.2% of respondents were classified as rich. 39.0% of respondents had poor knowledge about sanitation, whereas approximately 40.0% of the total sample displayed a positive attitude toward sanitation practices. All the sociodemographic characteristics are shown below in Table 2.
Principal Component Analysis (PCA) for Wealth Index
Principal Component Analysis (PCA) was conducted using selected household asset variables, housing characteristics, and access to basic utilities to generate a composite household wealth index. Prior to extraction, the suitability of the data for PCA was evaluated. The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was 0.73, indicating acceptable adequacy, and Bartlett’s test of sphericity was statistically significant (P < .001), confirming sufficient intercorrelation among variables to justify factor analysis.
Based on the eigenvalue greater than 1 criterion, the first principal component accounted for 38.6% of the total variance and represented the largest proportion of socioeconomic variation among households. Subsequent components explained smaller proportions of variance and were not retained for wealth index construction, consistent with standard demographic and health survey-type approaches. The first component showed strong positive loadings for ownership of durable household assets, improved housing materials, electricity access, and improved water sources, while negative or weak loadings were observed for unimproved water sources, traditional housing materials, and absence of sanitation facilities. These loading patterns indicate that the first principal component appropriately captured household socioeconomic status.
Household factor scores derived from the first principal component were ranked and categorized into 3 tertiles poor, middle, and rich which were subsequently used in regression analyses to assess factors associated with sanitation practice. All PCA analysis results are shown in Table 1.
Principal Component Analysis (PCA) Results for Household Wealth Index, Showing Sampling Adequacy, Variance Explained, Factor Loadings, and Wealth Tertile Classification.
Only the first principal component was used to generate the wealth index.
Bivariable Logistic Regression Results
Several variables showed significant associations (P < .25) with sanitation practices in the bivariable logistic regression and were therefore considered important candidates for multivariable analysis.
Wealth index showed a strong association with sanitation practice. Women from poor households had 4.4 times higher odds of having poor sanitation practice compared to those from rich households (COR = 4.4, 95% CI: 2.90–5.60, P < .001). Similarly, women with poor knowledge were 3.8 times more likely to have poor sanitation practices than those with good knowledge (COR = 3.8, 95% CI: 1.90–5.50, P = .001).
Water availability was another important factor. Respondents experiencing limited water access had 4 times greater odds of poor sanitation practice compared to those with adequate access (COR = 4.0, 95% CI: 2.50–6.90, P < .001). In addition, women living in conflict-affected areas demonstrated a significantly higher likelihood of poor sanitation practice (COR = 1.88, 95% CI: 1.30–4.80, P = .005).
Age and occupational status also met the P < .25 criterion. Women aged ⩾ 45 years had increased odds of poor sanitation practice compared to those aged 15 to 30 years (COR = 2.6, 95% CI: 0.95–3.20, P = .08). Likewise, those in non-governmental or informal occupations had 30% lower odds of good sanitation practice (COR = 0.7, 95% CI: 0.40–1.20, P = .18), though the association was not statistically significant but remained eligible as a candidate variable. All bivariable logistic regression analysis results are shown below (Table 2).
Bivariable Logistic Regression Analysis of Factors Associated with Sanitation Practice Among Women, Northwestern Ethiopia, 2024 (N = 389).
Model Fitness and Multicollinearity Diagnosis
The goodness-of-fit of the multivariable logistic regression model was assessed using the Hosmer–Lemeshow test. The test result was not statistically significant (χ2 = 12.46, df = 8, P = .07), indicating that the model adequately fits the data.
Multicollinearity among independent variables was examined using the Variance Inflation Factor (VIF). The VIF values ranged from 1.12 to 3.00, showing no evidence of significant multicollinearity among the predictor variables.
A Multivariable Logistic Regression Analysis Results
In the multivariable logistic regression model, several factors were independently associated with poor sanitation practices among women in Northwestern Ethiopia. Wealth index, sanitation-related knowledge, household water availability, and conflict situation remained significant predictors after adjusting for potential confounders.
Women from poor households were 3.5 times more likely to have poor sanitation practices compared to those from rich households (AOR = 3.5; 95% CI: 2.10–5.60; P < .001). Similarly, participants with poor knowledge regarding sanitation were 3.0 times more likely to engage in poor sanitation practices than those with good knowledge (AOR = 3.0; 95% CI: 1.60–5.40; P < .001). Limited household water availability was strongly associated with poor sanitation practices; women with restricted access to water had over 3 times the odds of poor sanitation compared to those with adequate water (AOR = 3.2; 95% CI: 1.90–5.40; P < .001). In addition, women living in areas affected by conflict had twice the odds of poor sanitation practices compared to those in peaceful settings (AOR = 2.0; 95% CI: 1.10–3.60; P = .02).
Other socio-demographic variables, including age and occupational status, were not significantly associated with sanitation practices after adjustment. Although women aged ⩾ 45 years had higher odds of poor sanitation in the bivariable analysis, this association was attenuated in the multivariable model (AOR = 1.6; 95% CI: 0.80–3.20; P = .18). Likewise, occupational status showed no independent effect (AOR = 0.9; 95% CI: 0.50–1.50; P = .65). The multivariable logistic regression analysis results are summarized below in (Table 3).
Multivariable Logistic Regression Analysis of Factors Associated with Poor Sanitation Practice Among Women, Northwestern Ethiopia, 2024.
Discussion
This study aimed to assess various factors associated with sanitation practices among women, with a particular focus on socio-demographic factors, knowledge, attitudes, access to water and conflicts. Our findings revealed significant associations between wealth status, knowledge level, water access, conflict and sanitation practices, supporting the importance of these factors in shaping public health outcomes.
One of the most prominent findings of this study was the significant association between wealth status and sanitation practices. The results showed that women in lower wealth categories were more likely to engage in poor sanitation practices. Specifically, those in the poor wealth index category exhibited a higher prevalence of poor sanitation practices compared to those in the wealthier groups. This finding aligns with previous studies that have identified poverty as a major determinant of poor sanitation outcomes. 21 Lower wealth often correlates with limited access to improved sanitation facilities, reduced access to quality water sources, and inadequate infrastructure, all of which contribute to poor hygiene and sanitation practices. 22 These results suggest that efforts to reduce poverty and improve household wealth could lead to improvements in sanitation behaviors, especially in low-income communities. Furthermore, our study revealed that wealthier women were more likely to practice good sanitation, with those in the medium and high wealth index categories having better sanitation practices than their poorer counterparts. The association between wealth and improved sanitation has been well-documented in global studies. 23 Economic disparities often lead to unequal access to sanitation infrastructure, and addressing these inequities may be key to achieving improved sanitation outcomes in resource-limited settings. However, some studies have highlighted that the relationship between wealth and sanitation is not always straightforward. For instance, in certain contexts, sociocultural factors, behavioral norms, or community infrastructure have been found to influence sanitation practices independently of household wealth, suggesting that poverty alone does not fully explain sanitation behavior disparities. 24 Moreover, research on WASH and child health outcomes has shown that poor sanitation may not always translate into worse health outcomes once other factors (eg, maternal education, water access, and caregiving practices) are accounted for, indicating that broader determinants beyond economic status can modify the impact of wealth on sanitation practices and their health effects. 25 These contrasting findings imply that while wealth is a significant predictor, multifaceted interventions addressing education, social norms, and infrastructure may be required to improve sanitation practices comprehensively.
Another significant determinant of sanitation practices in our study was the level of knowledge. Women with poor knowledge about sanitation and hygiene were significantly more likely to practice poor sanitation, which is consistent with findings from previous studies that emphasize the importance of health education in improving sanitation behaviors. 26 Poor knowledge of sanitation practices, such as proper handwashing techniques and menstrual hygiene management, can contribute to a higher incidence of preventable diseases. 27 The findings highlight the need for effective knowledge dissemination and educational programs aimed at improving awareness about the links between sanitation, hygiene, and health outcomes. Interestingly, while moderate knowledge was associated with slightly higher odds of bad sanitation practices, this relationship was not statistically significant. This could indicate that a moderate level of knowledge may not be sufficient to change sanitation behaviors, suggesting that comprehensive and targeted health education programs that promote practical, actionable knowledge may be more effective. 28 However, some studies have reported that knowledge alone does not necessarily lead to improved sanitation behavior. Research in South Africa found that despite high awareness of hygiene importance, actual hygiene practices were inconsistent, largely due to barriers such as lack of facilities and infrastructure, underscoring that knowledge must be coupled with enabling environments to influence behavior (eg, learners knew about handwashing but did not practice it frequently due to barriers). 29 Similarly, evidence from an Indonesian study among food handlers showed no significant correlation between knowledge and sanitation practice, suggesting that individual attributes, resource availability, and organizational support can mediate whether knowledge translates into practice. 30 These contrasting findings highlight that while knowledge is an important determinant, structural factors, facility access, and behavioral incentives also play critical roles in shaping sanitation practices.
Water availability emerged as another critical factor influencing sanitation practices. Our study found that limited access to water sources was significantly associated with poor sanitation practices. Women with inadequate access to water were more likely to engage in bad sanitation practices, which aligns with research highlighting the essential role of water access in sanitation behaviors. 31 Inadequate water availability restricts opportunities for regular handwashing, cleaning, and maintaining sanitation facilities, thereby contributing to poor hygiene practices and an increased risk of waterborne diseases. The importance of water availability in shaping sanitation behaviors cannot be overstated. Previous studies have shown that access to clean and sufficient water is a key determinant of hygiene and sanitation practices. 32 In rural and underserved communities, water scarcity can exacerbate poor sanitation practices and undermine public health. Therefore, improving access to water sources, particularly in disadvantaged areas, should be prioritized as part of broader efforts to enhance sanitation and hygiene outcomes. However, some research suggests that improving water access alone may not necessarily lead to substantial improvements in sanitation behaviors. For example, studies in peri-urban settings have found that even where water availability is relatively adequate, sanitation practices remain suboptimal due to behavioral, cultural, and infrastructural barriers such as entrenched open defecation norms or lack of functional sanitation hardware (eg, latrines). 33 Similarly, evidence from a multi-country evaluation in South Asia indicated that water access did not automatically translate into improved hygiene practices unless accompanied by targeted behaviors change interventions (eg, handwashing promotion with cues and reminders) and investments in sanitation facilities. 34 These findings highlight that while water availability is a fundamental enabler, it must be integrated with behavioral change strategies and improved sanitation infrastructure to achieve lasting improvements in hygiene and public health outcomes.
An additional important finding in our study was the significant association between conflict and sanitation practices. Specifically, women living in areas affected by conflict were more likely to engage in poor sanitation practices compared to those in peaceful regions. Conflict situations often lead to the destruction of infrastructure, including sanitation facilities, and disrupt access to clean water. These disruptions severely limit opportunities for proper hygiene and waste management, contributing to a decline in sanitation practices. The increased prevalence of poor sanitation in conflict-affected areas is consistent with findings from other studies that have shown how conflict exacerbates health vulnerabilities, especially in terms of water and sanitation access. 35 The association between conflict and poor sanitation practices calls for the integration of conflict-sensitive approaches in sanitation interventions. Efforts to improve sanitation in conflict zones must consider the unique challenges posed by instability, such as the need for portable sanitation solutions, emergency water access, and rebuilding critical infrastructure. This insight emphasizes the importance of addressing the broader socio-political and environmental factors, including conflict, to improve sanitation outcomes in affected areas.
Implications of the Study
The findings of this study have important implications for practitioners, policymakers, and the research community in addressing sanitation challenges, particularly in resource-limited and conflict-affected settings.
From a practice perspective, the results suggest that general awareness alone is insufficient to improve sanitation behavior. Health education strategies should therefore shift toward practical, skill-based training in areas such as handwashing and menstrual hygiene management, enabling individuals to translate knowledge into daily practice. In addition, sanitation interventions implemented in unstable or conflict-prone environments should adopt flexible and resilient approaches. Portable sanitation options, rapid-repair water point kits, and emergency waste management systems are more suitable than fixed infrastructure that may be easily disrupted. The findings also highlight the necessity of integrating water, sanitation, and hygiene services rather than implementing stand-alone sanitation projects. Because water scarcity strongly predicts poor sanitation outcomes, effective hygiene promotion must be delivered together with reliable water provision.
From a policy standpoint, the study underscores the importance of pro-poor financial support mechanisms. Targeted subsidies or micro-financing schemes for sanitation infrastructure especially for women in the lowest wealth categories are essential to reduce inequities in sanitation access. Policymakers should also prioritize the resilience of national water and sanitation infrastructure by promoting decentralized systems capable of maintaining service continuity even when major facilities are damaged during conflict. Furthermore, the multidimensional nature of sanitation challenges calls for stronger inter-sectoral collaboration among health, water, and social welfare sectors to address poverty, water access, and health education in a coordinated manner.
Regarding future research, the observed association between conflict and poor sanitation indicates the need for longitudinal studies that follow sanitation practice across conflict and post-conflict periods to better understand recovery or further deterioration. Additional investigation is also required to determine the threshold at which knowledge leads to sustained behavioral change, as moderate knowledge alone was insufficient in this study. Finally, qualitative research exploring the lived experiences and economic trade-offs faced by women in low-wealth households such as choosing between purchasing soap or food would provide deeper insight for designing effective and context-sensitive economic and sanitation support programs.
Strength and Limitations
This study has some limitations. The cross-sectional design limits the ability to establish causal relationships between sanitation practices and associated factors. Self-reported data may also be subject to recall and social desirability bias. In addition, the findings may not be fully generalizable to other regions with different socio-economic or conflict conditions. Despite these limitations, the study provides important evidence for improving sanitation interventions in resource-limited and conflict-affected settings.
Conclusions and Recommendations
This study highlights that sanitation practices among women are significantly influenced by wealth status, knowledge, water access, and conflict. Women from lower-income households and those with limited knowledge were more likely to engage in poor sanitation practices, emphasizing the need for economic support and hygiene education. Additionally, inadequate water access was a major barrier to proper sanitation, while conflict-affected areas showed worsened sanitation behaviors, stressing the importance of infrastructure resilience and emergency interventions. Ensuring reliable water supply and targeted awareness programs can significantly improve hygiene practices and public health outcomes.
To address these challenges, enhancing water accessibility, expanding sanitation education, and implementing economic empowerment initiatives are essential. Governments and organizations should invest in sustainable water supply projects, promote community-based hygiene education, and support income-generating activities for women. Special attention should be given to vulnerable groups, ensuring free or subsidized sanitation resources. Additionally, policy advocacy and collaborative efforts must focus on equitable resource distribution and integrating conflict-sensitive sanitation interventions. By adopting these strategies, long-term improvements in sanitation and public health can be achieved.
Footnotes
Acknowledgements
We are thankful to Debre Markos University creating this research opportunity. Also, we are deeply grateful to Kebeles and the Finote Selam town health office administrations for their help and important information during the data-collection time. Lastly, and perhaps most importantly, we would want to express our gratitude to the woman for their voluntary involvement in the study.
Ethical Considerations
The 1964 Helsinki Declaration, its updates 36 are strictly followed during this investigation. Ethical clearance and approval were obtained from Debre Markos University College of Medicine and Health Sciences ethical review committee (ERC-251/2024) and an official letter of support was provided by the Finote Selam Town Health Office and each kebele administration. Finally, the women provided their informed, signed consent.
Author Contributions
BA, AA initiated, analyzed and interpreted the research. YB, MG, and AT contributor in writing the manuscript. All authors read and approved the final manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The corresponding author can provide the datasets gathered and/or examined during the current investigation upon justifiable request.
