The gap between knowledge and action in Zimbabwe: The limits of individual awareness in the face of structural violence in cholera endemicity

BACKGROUND/OBJECTIVES: Zimbabwe faces a protracted cholera crisis exacerbated by El Niño-induced droughts, transitioning from episodic outbreaks to an endemic public health emergency. While recurrent outbreaks are often attributed to poor community awareness, this study moves beyond the conventional Knowledge, Attitudes, and Practices (KAP) paradigm. Grounded in the Integrated Behavioral Model for WASH and the theory of structural violence, we investigate the structural determinants of the knowledge-practice gap to understand how infrastructural disparities constrain cholera prevention. METHODS: A quantitative cross-sectional study was conducted among 307 adult residents in rural and urban Zimbabwe using a structured online survey. To address the multidimensional nature of WASH behaviors, Exploratory Factor Analysis was performed to decompose the practice scale into two distinct dimensions: Individual Agency and Structural Access. Multiple linear regression analyses were applied to identify predictors for each dimension independently. RESULTS: Participants demonstrated high overall knowledge of cholera prevention. However, regression analysis revealed a striking divergence: while knowledge significantly predicted individual agency behaviors, it had no statistically significant effect on structural access practices. Residence and socio-economic factors heavily dictated structural access. Additionally, women exhibited higher practice scores, reflecting the disproportionate burden of sanitation insecurity rather than mere adherence to domestic gender roles. CONCLUSIONS: The persistent knowledge-practice gap in Zimbabwe's cholera endemic is not a behavioral failure but a manifestation of structural violence. Health education campaigns have reached saturation; individuals know how to protect themselves but are structurally paralyzed by decaying municipal services. Sustainable elimination requires shifting policy to climate-resilient WASH infrastructure.