Title : Enhancing health outcomes through integrated WASH interventions in rural Ethiopia: Evidence, lessons, and implications for public health
Abstract:
Background: Unsafe water, inadequate sanitation, and poor hygiene are major contributors to diarrheal diseases among children under five, particularly in rural communities. Integrated water, sanitation, and hygiene (WASH) interventions are recognized as effective approaches for improving health outcomes through enhanced access to safe water, sanitation facilities, and hygiene practices. This study assessed the impact of an integrated WASH intervention on childhood diarrhea, household treatment costs, water and sanitation access, and participants’ knowledge, attitudes, and practices (KAP) in rural communities.
Methods: A cross-sectional survey was conducted in May 2025 across six kebele administrations (KAs), comprising three intervention and three non-intervention areas. Data were collected from 396 households with children under five years of age, equally distributed between intervention and control groups. Descriptive statistics and Propensity Score Matching (PSM) analyses were employed to estimate the effects of the intervention on child morbidity, treatment expenditures, WASH service access, and household KAP outcomes.
Results: The prevalence of diarrhea among children under five during the two weeks preceding the survey was markedly lower in intervention households (2.5%) than in control households (34.9%). PSM estimates indicated that the intervention reduced childhood diarrhea morbidity by 35% (ATT = −0.35) and decreased average treatment expenditures by ETB 387 per household. Access to safely managed water services was substantially higher among intervention households (59.6% vs. 1.0%), with all intervention households using protected water sources. Households in intervention areas spent significantly less time collecting water (13.9 vs. 55.8 minutes per trip) and consumed nearly twice as much water per capita (20.6 vs. 10.5 liters/day). Improved sanitation and hygiene outcomes were also observed, including higher latrine access (95.0% vs. 78.3%), lower open defecation practices (23.2% vs. 52.0%), and greater handwashing with soap (48.5% vs. 12.1%). Households in intervention areas demonstrated substantially better WASH-related knowledge (91.4% vs. 70.0%), more favorable attitudes (99.0% vs. 74.8%), and improved hygiene practices (85.4% vs. 26.3%) compared with control households. PSM analysis further confirmed significant gains in knowledge (ATT = +0.14), attitudes (ATT = +0.15), and practices (ATT = +0.56), indicating strong behavioral change attributable to the intervention.
Conclusions: Integrated WASH interventions significantly improve access to safe water, sanitation, and hygiene services while reducing childhood diarrhea and associated treatment costs. The intervention also strengthens WASH-related knowledge, attitudes, and practices, contributing to sustainable behavioral change and improved community health outcomes. Scaling up integrated WASH programs, alongside sustained investments in water infrastructure, community engagement, and behavior change communication, is critical for accelerating progress toward Sustainable Development Goal 6 and reducing the burden of waterborne diseases in rural settings.
