The gendered burden of water, sanitation, and hygiene: A mixed-methods study on public health impacts and pathways to empowerment

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.