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The gendered burden of water, sanitation, and hygiene: A mixed-methods study on public health impacts and pathways to empowerment
*Corresponding author: Zerai Hagos, School of Global Health and Bioethics, Euclid University, Banjul, Gambia. hagos@euclidfaculty.net
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Received: ,
Accepted: ,
How to cite this article: Hagos Z. The gendered burden of water, sanitation, and hygiene: A mixed-methods study on public health impacts and pathways to empowerment. Sri Ramachandra J Health Sci. 2025;5:71-4. doi: 10.25259/SRJHS_19_2025
Abstract
Objectives:
Inadequate water, sanitation, and hygiene (WASH) disproportionately affect women in rural Ethiopia due to gendered roles in water collection and household hygiene. This mixed-methods study examines WASH access, health outcomes, time use, stress, and safety risks among women in Sidama Region.
Material and Methods:
A convergent parallel mixed-methods design was employed in Sidama Region (May 2024–October 2024). Quantitative data came from structured questionnaires completed by a stratified random sample of 384 women aged 15–49 from 10 woredas; qualitative data comprised in-depth interviews with 30 women. Hospital records and regional WASH statistics provided secondary data. Quantitative and qualitative findings were merged during interpretation to provide a comprehensive understanding of the gendered WASH burden.
Results:
Only 48% of participants had access to clean water and 38% to improved sanitation; 49% practiced open defecation. Women spent a mean of 2.3 h daily fetching water (4.1 h in the dry season). In the past 6 months, 52% experienced waterborne diseases (e.g., diarrhoea, typhoid, intestinal parasites) and 28% reported maternal complications linked to poor hygiene (e.g., puerperal sepsis and urinary tract infections). High stress (≥7/10) was reported by 61%; 29% reported fear or experience of gender-based violence during water collection. Lack of WASH access was independently associated with high stress (adjusted odds ratio [OR] 3.4, 95% confidence interval [CI] 1.9–6.1, P < 0.001) and waterborne disease (adjusted OR: 2.7, 95% CI: 1.5–4.8, P = 0.001).
Conclusion:
WASH deficits constitute a gendered public health crisis in Sidama. Community-managed proximal water points, gender-segregated sanitation with menstrual hygiene facilities, and women-led WASH committees are urgently needed. The cross-sectional design and modest sample size limit causal inference and generalizability.
Keywords
Ethiopia
Gender
Hygiene
Public health
Sanitation
Sidama
Water
INTRODUCTION
Access to safe water, sanitation, and hygiene (WASH) is a recognized human right and cornerstone of public health.[1] In low- and middle-income countries, women and girls bear the primary responsibility for water collection and household sanitation due to entrenched gender norms, resulting in a triple burden of health risks, time poverty, and exposure to violence.[2-4]
Sidama Region, which became Ethiopia’s tenth regional state in 2020 after separation from the former Southern Nations, Nationalities, and Peoples’ Region, faces acute WASH challenges driven by rapid population growth (approximately 5.5 million people), ensete-based agriculture, mountainous topography, and climate variability.[5] National coverage remains low, with only 59% of rural Ethiopians having basic water services and 7% basic sanitation.[6-8] In Sidama, coverage lags further behind urban centers, and interventions often remain gender-blind.
This study is guided by a conceptual pathway linking inadequate WASH access → increased time and physical burden → reduced economic and educational opportunities → heightened psychosocial stress and gender-based violence (GBV) risk → poorer physical and reproductive health outcomes.[9] By quantifying these associations and amplifying women’s lived experiences, the study aims to inform gender-transform = No gender-transformative WASH programming in Sidama and similar highland Ethiopian contexts.
MATERIAL AND METHODS
Study design and setting
A convergent parallel mixed-methods design was conducted in Sidama Region, Ethiopia, from May to October 2024. Quantitative and qualitative data were collected simultaneously and integrated during analysis and interpretation.
Sampling and participants
The target population was women aged 15–49 years. Ten woredas (five predominantly rural, five peri-urban) were purposefully selected from Sidama’s 37 woredas to capture agro-ecological (highland/lowland) and urbanization gradients while remaining logistically feasible. Within each woreda, three kebeles were randomly selected, followed by systematic random sampling of households from kebele registries. The sample size (n = 384) was calculated for a finite population proportion with 95% confidence, 5% margin of error, and expected prevalence of 50%. Response rate was 96.2% (384/399).
For the qualitative component, 30 women were purposively selected (three per woreda) to achieve variation in age, residence, and WASH experience until thematic saturation.
Data collection
The quantitative questionnaire was adapted from the World Health Organization/United Nations Children’s Fund joint monitoring program core questions, Ethiopia demographic and health survey, and validated stress/GBV instruments (Cronbach’s α = 0.81[8] for stress scale; 0.79 for GBV module). Stress was measured using a 10-point Likert scale; GBV exposure was assessed through four behaviorally specific questions. Interviews followed a semi-structured guide covering daily routines, health, safety, and aspirations. Interviews were conducted in Sidama language or Amharic by trained female researchers, audio-recorded, transcribed, and back-translated for accuracy.
Secondary data included gender-disaggregated records from five zonal hospitals (May 2024–October 2024) and 2023/24 regional WASH reports.
Analysis
Quantitative analysis used Statistical Package for the Social Sciences v28: Descriptive statistics, χ2 tests, independent t-tests, and multivariate logistic regression adjusted for age, education, marital status, wealth quintile (constructed via principal component analysis of household assets), and distance to primary water source. Qualitative data were analyzed thematically in NVivo 14 (κ = 0.86). Joint displays and narrative weaving integrated strands.
Ethics
Ethical approval was obtained from Euclid University IRB. Written informed consent (or assent plus parental consent for ages 15–17) was secured. Sensitive GBV disclosures triggered referral to trained counselors and nearby health facilities using an established protocol. All data were anonymized.
RESULTS
Socio-demographics
The mean age was 34.8 years (standard deviation [SD] = 8.2). 62% were married, 42% farmers, 28% homemakers. 18% had no formal education.
WASH Access
Access to WASH facilities was limited overall, with notable disparities between rural and peri-urban areas. Only 48% of participants reported access to clean water sources, 38% had improved sanitation facilities, and 49% practiced open defecation. Rural residents faced greater challenges, with lower access rates compared to peri-urban counterparts see Table 1 for details. These findings were corroborated by regional WASH reports, highlighting persistent gaps in infrastructure.
| Indicator | Rural (%) | Peri-urban (%) | Total (%) |
|---|---|---|---|
| Clean water access | 39 | 68 | 48 |
| Improved sanitation | 31 | 52 | 38 |
| Open defecation | 56 | 35 | 49 |
WASH: Water, sanitation, and hygiene
Health outcomes
52% reported at least one waterborne disease episode in the past 6 months (diarrhea 41%, typhoid 9%, intestinal parasites 17%). 28% reported maternal complications attributable to poor hygiene (puerperal sepsis 11%, urinary tract infections 19%). Hospital records (n = 1,842 WASH-related admissions) showed 64% were female.
Time and economic burden
Mean daily water-collection time: 2.3 h (SD 1.1); 4.1 h (SD 1.4) in dry season. 71% reported lost income-generating or educational time.
Psychosocial and safety outcomes
Mean stress score: 6.1/10 (SD 2.3); 61% scored ≥7/10. 29% reported fear or experience of harassment/assault during water collection.
Multivariate analysis
Multivariate logistic regression, adjusted for age, education, marital status, wealth quintile, and distance to water source, revealed significant associations between WASH deficits and adverse outcomes [Table 2]. Lack of WASH access was independently associated with high stress (adjusted OR 3.4, 95% CI 1.9–6.1, P < 0.001) and waterborne disease (adjusted OR 2.7, 95% CI 1.5–4.8, P = 0.001). Additional predictors included GBV exposure for stress (adjusted OR 2.8, 95% CI 1.6–4.9, P = 0.002) and distance >30 min for disease (adjusted OR 2.3, 95% CI 1.4–3.9, P = 0.004). P-values indicate statistical significance at <0.05, with exact ranges as shown (e.g., <0.001 denoting highly significant associations; statistical test: multivariate logistic regression).
| Outcome | Predictor | Adjusted OR (95% CI) | P-value |
|---|---|---|---|
| High stress (≥7/10) | No WASH access | 3.4 (1.9–6.1) | <0.001 |
| GBV exposure | 2.8 (1.6–4.9) | 0.002 | |
| Rural residence | 1.7 (1.1–2.8) | 0.03 | |
| Wealth quintile (lowest vs. highest) | 2.1 (1.3–3.6) | 0.01 | |
| Waterborne disease | No WASH access | 2.7 (1.5–4.8) | 0.001 |
| Distance >30 min | 2.3 (1.4–3.9) | 0.004 |
Significance range: P< 0.05 is considered statistically significant. Statistical test used: Multivariate logistic regression. OR: Odds ratio, CI: Confidence interval, WASH: Water, sanitation, and hygiene, GBV: Gender-based violence
Qualitative findings
Four major themes emerged: (1) Physical toll (“Carrying 20–25 L uphill every day has destroyed my back”); (2) Time poverty (“Water takes my whole morning; I cannot sell anything at the market”); (3) Safety risks (“Young men wait near the spring and harass us; now we only go in groups”); (4) Menstrual stigma (“During my period I stay home because there is no private latrine”).
DISCUSSION
The 48% clean-water and 38% improved-sanitation coverage in Sidama remains lower than national rural averages[6,7] and mirrors findings from neighboring Gedeo and Wolayita zones.[10] Time burdens (2.3–4.1 h/day) exceed those reported in Uganda (1.8 h) and Western Kenya (2.6 h),[11,12] reflecting Sidama’s mountainous terrain. The 29% GBV risk aligns with multi-country evidence that journeys >30 min significantly increase assault likelihood.[13] Similar gender issues in sanitation access have been reported in low-income settings in India.[4,14]
Qualitative narratives directly explain quantitative associations: Long collection distances (quantitative predictor) generate both opportunity for harassment (qualitative safety theme) and chronic stress (61% high stress). Women explicitly linked lack of private sanitation to menstrual absenteeism and dignity loss, corroborating Ethiopian school-based menstrual hygiene management (MHM) studies.[15]
Recommendations are grounded in participants’ own suggestions: (a) Community-managed water points within 500 m[14] (addressing time and GBV); (b) gender-segregated latrines with MHM materials (addressing dignity and infections); (c) women-led WASH committees (voiced repeatedly in interviews as a pathway to voice and sustainability).
Limitations
The cross-sectional design can only demonstrate associations, not causation. Self-reported outcomes may be affected by recall or social-desirability bias, although triangulation with hospital records reduced this risk. The sample, while statistically powered and geographically diverse within Sidama, is modest and may not fully represent all 37 woredas.
CONCLUSION
In Sidama Region, inadequate WASH imposes intersecting health, economic, and safety burdens that fall disproportionately on women. Gender-responsive, community-driven solutions – particularly closer water points, safe sanitation, and women’s leadership in WASH governance – are essential to transform a daily struggle into a platform for health equity and empowerment, aligning with the Sustainable Development Goals.
Acknowledgments:
Sincere thanks to Professor Laurent Cleenewerck, Sidama Regional Health Bureau, data collectors, and the courageous women who shared their stories.
Ethical approval:
The research/study approved by the Euclid University Institutional Review Board (IRB), number EUIRB-2024-001, dated 15th April 2024.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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