Linking WASH systems, behaviour, and service functionality to faecal-oral disease risk in north-western Ghana

ABSTRACT

Graphical abstract showing associations between WASH infrastructure, hygiene behaviour, and self-reported faecal–oral disease risk among 400 households across four districts in Ghana’s Upper West Region. WASH infrastructure (water source and sanitation type) has a weak, statistically non-significant association with disease risk (Spearman’s ρ = −0.01 to −0.06; ns), while handwashing behaviour and system reliability show a strong association (ρ = 0.843, p < 0.001). The key takeaway is that reliable WASH practices may matter more than infrastructure type for reducing faecal–oral disease risk.

This study examined links between rural water, sanitation, and hygiene (WASH) systems and faecal-oral disease transmission in households across four districts in Ghana's Upper West Region. A convergent mixed-methods design combined a household survey of 400 households with key informant interviews, focus group discussions, and structured field observations. Quantitative data were analysed using descriptive statistics, while qualitative data were analysed thematically to contextualise observed patterns. The findings indicate that although access to water infrastructure and hygiene programmes is relatively high, faecal-oral disease prevalence remains high. Households without functional handwashing facilities and safe hygiene practices were more likely to report disease, highlighting behaviour as a critical exposure pathway. Intermittent water system functionality and inadequate maintenance weakened service reliability, forcing reliance on alternative, potentially unsafe sources. Variability in local governance capacity, particularly among Water and Sanitation Management Teams, further influenced system performance and sustainability. These findings suggest that WASH infrastructure alone cannot reduce disease risk. Instead, health outcomes are shaped by interactions among behavioural, infrastructural, and institutional factors, with important implications for strengthening WASH service delivery in similar settings.