Dissertations and Theses

Date of Degree


Document Type


Degree Name

Doctor of Philosophy (Ph.D.)


Community Health and Social Sciences


Nicholas Grosskopf

Committee Members

Betty Levin

Andrew Maroko

Matthew Freeman

Subject Categories

Public Health


Ethiopia, Water, Sanitation, Hygiene, Psychosocial factors


Background: The absence of potable drinking water from an improved source combined with inadequate sanitation and hygiene contributed to an estimated 1.9% of the global burden of disease in 2016. The estimated number of diarrheal deaths in 2016 was 1.4 million, of which 829,000 could have been prevented through improved drinking water and sanitation services, and hand-washing with soap. Despite the clear link between poor water and sanitation access and hygiene practices, 785 million people do not have access to water and two million do not have access to basic sanitation services. However, access does not automatically result in increased usage. Healthy water, sanitation, and hygiene (WASH) behaviors are sometimes not adopted due to perceptions of perceived risk (that a behavior will lead to illness), belief benefit (believing there is an actual benefit to engaging in healthful WASH behavior), and personal beliefs related to one’s capacity to modify behavior. Moreover, social constructs, such as collective efficacy (the ability of the community to make a change & a belief the collective group will make a change), descriptive and social norms or traditions, and social identity (how a person wants to be perceived in their social circle/community), are important for the sustained uptake of WASH interventions, but are not often taken into account during intervention design and delivery. Given the limited research on the relation between inter-personal behavioral factors and collective WASH behavior, evidence on how these factors impact WASH practice is needed. This mixed-method dissertation aimed to examine psychosocial factors (perceptions and behaviors) related to water and hygiene practices in the Amhara Region of Ethiopia, as well as to quantify the extent of the association between psychosocial factors and behavioral WASH outcomes. The following specific aims were addressed:

Aim 1: Explore perceptions, motivations, and behaviors as they relate to water, sanitation, and hygiene practices in four woredas (districts) in Amhara, Ethiopia.

Aim 2: Explore community capabilities, opportunities, motivations, and behaviors as they relate to water, sanitation, and hygiene practices in one woreda of Amhara, Ethiopia.

Aim 3: Describe the association among psychosocial factors (e.g., internalized risk and capability perceptions, attitudes, and norms) and behavioral outcomes related to improved sanitation, personal hygiene, and household environmental sanitation practices.

Methods: Data from this study was collected as part of the Andilaye Trial, a demand-side sanitation and hygiene program, based on community demand versus external encouragement, designed to examine inter-personal factors and the association between sustained behavioral adoption and the downstream health impact. This dissertation utilized three distinct datasets from the Andilaye Trial: (1) formative qualitative research from one-on-one interviews with key informants (2) formative qualitative research from focus group discussions (FGDs) with community members, and (3) quantitative data collected as part of the baseline for the Trial. All three aims used the capability, opportunity, motivation and behavior (COM-B) model and risk, attitude, norms, ability and the self-regulation (RANAS) approach to assess psychosocial factors and the relation to WASH behavior. For Aims 1 & 2, a thematic analysis that was grounded in the COM-B framework. For Aim 1, data from the interviews with key informants were used to conduct two analyses. The first analysis focused on identifying psychosocial behavioral factors related to hygiene and water usage practices, including face washing, hand-washing, bathing and drinking, and sanitation behavior related to latrine use and latrine construction. The second analysis focused on understanding community reactions, challenges, and recommendations for the latrine component of the WASH intervention, Community led total sanitation and hygiene (CLTSH). Aim 2 used qualitative data from the FGDs to assess psychosocial behavioral factors associated with water usage, hygiene behavior, latrine use and construction, open defecation, and urination. Analyses conducted as part of Aim 2 also examined differences and similarities between genders and across households based on their perceptions of water security. Aim 3 used baseline survey data to conduct a quantitative cross-sectional analysis to assess psychosocial associations with open defecation, hand-washing, face-washing and fecal removal practices in three woredas in the Amhara region of Ethiopia. Multivariate logistic regression analysis models were developed for each outcome of interest: latrine use, face-washing, hand-washing & fecal removal.

Results: In Aim 1, key informants indicated that reflective motivation to prevent illness strongly influenced hygiene and sanitation practices. Having access to water also played a key role on reflective decision making (involves evaluating choices as part of decision making) on how water is used. Two automatic motivations (automatic process, such as our desires, impulses, and inhibitions), attitudes and social opportunities around norms (or a belief that one should practice a behavior), determined how water is prioritized and also influenced latrine use and latrine construction. The analysis of the CLTSH intervention indicated that for communities to achieve Open Defecation Free (ODF) status, active engagement of multiple stakeholders is needed, having households that model latrine construction and latrine use, community ownership of the program, and consistent monitoring are important aspects needed to achieve sustainable change. For Aim 2, community members rarely mentioned knowledge as a barrier to engaging in WASH practices. Norms, attitudes, and water insecurity influenced how water is prioritized for face-washing, hand-washing, and bathing. Lack of access to latrines was noted as a barrier to use. Gender influenced where bathing occurs and how water is used, with women bathing at home whereas men are expected to bathe at the river. Regarding defecation practices, women reported having to restrict defecation to early mornings and evenings to avoid the shame of being caught in the act, whilst men reported being able to defecate at any time without the same fear. Aim 3 used a study sample of 1,264, of which 65% had at least one latrine in their household. None of the psychosocial factors included in the regression model for latrine use showed an association. Household latrine access was associated with lower odds of practicing open defecation (OR=0.48, CI: 0.30-0.80, p=0.01). None of the demographic or psychosocial factors were associated in the face washing model. In the hand-washing model, none of the demographic factors were associated. The psychosocial factor knowledge and acknowledgement of vulnerability (related to perceived risk) was associated with lower odds of hand-washing. In the regression model on fecal removal, none of the psychosocial factors showed an association. There were significantly higher odds (OR=0.35, CI: 0.19-0.62, pp=0.01) when compared to heads of households that had not attended school and were illiterate. There were lower odds that households in CLTSH triggered communities would have removed or buried fecal matter (OR= 0.30, CI: 0.12-0.76, p=0.01; OR= 0.24, CI: 0.07-0.90, p=0.02), when compared to non-triggered communities.

Conclusion: The research conducted in this dissertation demonstrates that there are many complexities around the psychosocial factors that influence WASH behavior. The influences on one behavior, such as hand-washing, may differ from the influences on what is thought to be a similar behavior, such as face-washing. Qualitative findings from this research showed that the desire to prevent illness influences WASH behavior and practice. Moreover, attitudes and social norms impact behavioral outcomes, and both can encourage and discourage healthful WASH behavior. The quantitative analysis showed limited association between the psychosocial predictors and the WASH outcomes of interest. More research is needed to better understand this relationship, so that it is possible to design behavioral interventions and policies that will result in long term behavior change. Despite the incongruence between the qualitative and quantitative findings, the qualitative analysis did provide important insight into the importance of gender and water security as it related to WASH behavior, which can be used to strengthen existing interventions and to inform the design of evidence-based interventions in Ethiopia and across Africa.

Available for download on Saturday, May 18, 2024

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