WASH Infrastructure and Cholera Incidence in Somalia
Abstract:
Access to safe water and sanitation (WASH) represents the primary defense against cholera. Despite the persistent prevalence of cholera in Somalia, there is a dearth of evidence on the impact of WASH in Somalia. This study employed a mixed-methods approach, including a survey of 134 households across ten cholera-affected districts, regression analysis of WASH influence over a 24-month period, a census of WASH services in health facilities, and interviews with 17 key informants. The regression analysis satisfied all required assumptions. To reduce variable overlap, we combined access to water and sanitation into a single WASH variable. This composite WASH variable demonstrated a strong association with cholera severity (B = −0.730, SE = 0.087, β = −0.418, t (130) = −8.35, p = .001). Individuals with access to WASH were significantly less likely to contract cholera or acute watery diarrhea (OR = 0.13, 95% CI [0.05, 0.36], p = .001). The model accounted for 67.8% of the variance in severity across Somalia (R² = 0.678, F (3,130) = 91.16, p = .001). Only 36.2% of health facilities had running water, and 41.4% had adequate sanitation. The primary causes of inadequate WASH services included malfunctioning water points, open defecation in densely populated areas, and water contamination during rainfall. Improving WASH should be a top priority, along with ongoing efforts in vaccination and health care. More investment is also needed in WASH systems that can withstand flooding in the Juba and Shabelle river basins to help reduce cholera cases by 2030.References:
[1].
World
Health Organization. Cholera: global situation. Geneva: WHO; 2024.
[2].
WHO
Regional Office for Africa. Cholera in the African Region: 2025 epidemiological
update. Brazzaville: ITS AFRO; 2025.
[3].
Global
Task Force on Cholera Control. Somalia cholera: district-level case
distribution, 2020-2024 (PAMI line list). Geneva: GTFCC; 2025.
[4].
United
Nations Office for the Coordination of Humanitarian Affairs. Somalia
humanitarian needs overview 2024. New York: OCHA; 2024.
[5].
United
Nations Children's Fund. Somalia WASH situation report. New York: UNICEF; 2025.
[6].
Yusuf
H, et al. Recurrent cholera outbreaks in Somalia: a situational analysis. Int J
Epidemiol. 2025; 54(1):210-24.
[7].
Hussein
A, et al. Cholera in Somalia: burden, determinants, and health system response.
East Afr Med J. 2025; 102(1):45-58.
[8].
Wolfe
MK, et al. addressing the global burden of cholera: developing WASH-related
interventions. PLoS Negl Trop Dis. 2018; 12(1):e0005833.
[9].
Sultan
AH, et al. Risk factors for cholera in Southwest State, Somalia: a case-control
study. J Infect Dev Ctries. 2025; 19(1):12-24.
[10]. Navarro V. Medicine under capitalism. New
York: Prodist; 1976.
[11]. Doyal L, Pennell I. The political economy
of health. London: Pluto Press; 1979.
[12]. McLeroy KR, Bibeau D, Steckler A, Glanz K.
An ecological perspective on health promotion programs. Health Educ Q. 1988; 15(4):351-77.
Doi: 10.1177/109019818801500401.
[13]. Stokols D. Translating social ecological
theory into guidelines for community health promotion. Am J Health Promot?
1996; 10(4):282-98. Doi:10.4278/0890-1171-10.4.282.
[14]. Creswell JW, Plano Clark VL. Designing and
conducting mixed methods research. 3rd ed. Thousand Oaks: SAGE Publications;
2017.
[15]. Greene JC, Caracelli VJ, Graham WF. Toward
a conceptual framework for mixed-method evaluation designs. Educ Eval Policy
Anal. 1989; 11(3):255-74. Doi: 10.3102/01623737011003255.
[16]. Guest G, Bunce A, Johnson L. How many
interviews are enough? An experiment with data saturation and variability.
Field Methods. 2006; 18(1):59-82. Doi: 10.1177/1525822X05279903.
[17]. Field A. Discovering statistics using IBM
SPSS statistics. 6th ed. Thousand Oaks: SAGE Publications; 2024.
[18]. Gale NK, Heath G, Cameron E, Rashid S,
Redwood S. Using the framework method for the analysis of qualitative data in
multi-disciplinary health research. BMC Med Res Methodol. 2013; 13:117. Doi:
10.1186/1471-2288-13-117.
[19]. Lincoln YS, Guba EG. Naturalistic inquiry.
Thousand Oaks: SAGE Publications; 1985.
[20]. O'Brien BC, Harris IB, Beckman TJ, Reed DA,
Cook DA. Standards for reporting qualitative research: a synthesis of
recommendations. Acad Med. 2014; 89(9):1245-51. Doi:10.1097/ACM.0000000000000388.
[21]. O'Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. J Health Serv Res Policy. 2008; 13(2):92-8. Doi:10.1258/jhsrp.2007.007074.
