Bridging the gap: knowledge and practices related to water, sanitation, and hygiene (WASH) for cholera prevention in previous cholera hotspots of Addis Ababa, Ethiopia: a mixed-methods study

Cholera remains a recurring public health concern in Ethiopia, particularly within densely populated urban sub-cities such as Addis Ketema and Akaki/Kality. This study evaluated community knowledge, attitudes, and reported practices (KAP) regarding water, sanitation, and hygiene (WASH) and cholera, while exploring contextual barriers to disease prevention in these high-risk urban settings. A convergent mixed-methods cross-sectional study was conducted between March and May 2023. Quantitative data were gathered from 846 systematically sampled household respondents using a WHO-adapted KAP questionnaire and analyzed using descriptive statistics and multivariable logistic regression. Concurrently, qualitative data were collected via six focus group discussions with community leaders and 24 key informant interviews with local health and WASH personnel, followed by thematic analysis. Fewer than half of the respondents demonstrated good knowledge of WASH (44.4%) and cholera (48.6%), whereas positive attitudes toward WASH (70.1%) and cholera prevention (69.6%) were widely reported. Preventive practices were generally poor for both WASH (mean practice scores ~ 43%) and cholera (~ 33%). Educational attainment was independently associated with higher knowledge scores, and positive attitudes predicted reported preventive practices ( p < 0.05). Qualitative accounts highlighted that while residents understood preventive principles, adherence was substantially hindered by contextual factors, including intermittent municipal water supply, poor perceived water quality, high population density, overflowing shared latrines, household financial constraints, and delayed infrastructure maintenance. In high-risk urban areas of Addis Ababa, favorable community attitudes toward cholera prevention do not consistently translate into practice because of structural and infrastructural constraints. Sustainable cholera risk reduction requires addressing practical health knowledge gaps alongside improvements in reliable water supply, sanitation, waste management, and coordinated multi-sectoral action.