Knowledge, attitude, and practice of water, sanitation, and hygiene among internally displaced persons in Somalia

Abstract

Introduction

Access to clean water, adequate sanitation, and hygiene services is a basic human right. Despite this, it remains one of the major challenges that internally displaced persons face in Somalia. This study assesses the knowledge, attitudes, and practices of Internally Displaced Persons regarding Water, sanitation, and hygiene.

Methods

A cross-sectional study was conducted among Internally Displaced Persons in eight high-density camps in Mogadishu and Baidoa. A 3-stage sampling technique was used to select 8 high-density camps, households, and 728 participants. A structured questionnaire was used for data collection. The questionnaire included scoring systems for knowledge, attitude, and practices, measured on a point scale; for example, knowledge scores were categorized as poor or good based on a predefined cutoff point, with similar criteria for attitude and practice ratings. Data analysis was done using descriptive statistics and chi-square testing at p < 0.05.

Results

The study found that most participants had 71.2% poor knowledge, 70.3% negative attitudes, and 80.2% demonstrated poor practices towards water, sanitation, and hygiene. The study found that there is a significant association between sociodemographic factors and the levels of knowledge, attitude, and practice. Specifically, there were significant associations between knowledge levels and age (p < 0.001), marital status (p = 0.001), level of education (p = 0.048), employment status (p < 0.001), family size (p < 0.001), duration of stay in Internally Displaced Persons camp (p < 0.001), and utilization of healthcare services (p < 0.001). Similarly, negative attitude towards water, sanitation, and hygiene was significantly associated with younger age groups (p < 0.001), marital status (p = 0.004), educational attainment (p < 0.001), employment (p < 0.001), household size (p < 0.001), duration of camp residency (p < 0.001), and healthcare access (p < 0.001). Furthermore, the level of education, employment status, household size, and duration of stay in camp were significantly associated with water, sanitation, and hygiene practices at p < 0.001.

Conclusion

The study indicates that poor knowledge, negative attitudes, and inadequate practices concerning water, sanitation, and hygiene are prevalent among Internally Displaced Persons in Somalia. To address these issues, it is essential to implement targeted educational programs aimed at improving awareness of water, sanitation, and hygiene practices, enhancing access to hygiene facilities, and involving community leaders in promoting behavioral change. Additionally, improving the availability of clean water and sanitation services in Internally Displaced Persons camps is crucial for improving health outcomes and overall well-being among this population.

Introduction

Water, sanitation, and hygiene (WASH) are fundamental human rights critical to promoting public health. Adequate access to WASH services is essential for infection prevention, especially in healthcare settings where clean water and sanitation facilities are paramount [1]. This issue is acknowledged globally as part of Goal 6 of the Sustainable Development Goals (SDGs), which aims to enhance access to and sustainable management of water and sanitation services [2]. Insufficient sanitation practices and inadequate facilities contribute significantly to the spread of infectious diseases. Each year, millions die from WASH-related illnesses, with children under five particularly vulnerable; approximately 300,000 child deaths from diarrhea are linked to inadequate WASH conditions [3, 4].

Globally, 2.3 billion people lack access to basic sanitation services, and 892 million individuals still practice open defecation. In addition, 844 million individuals are unable to avail clean water services, while 2.5 million people are without improved sanitation facilities [5]. It has also been reported that diarrheal disease constitutes the third leading cause of child deaths worldwide, killing an estimated 443,832 infants every year. This disease is caused mainly due to the poor quality of the environment, particularly unsafe food and water sources. Around 780 million people do not have access to clean drinking water, while 2.5 billion people do not have adequate sanitation facilities globally [6].

In sub-Saharan African countries, limited access to water, sanitation, and hygiene was threatened by public health status and affected about 319 million people whom 58% had no access to safe drinking water, and inversely, only 15% had access to hand washing facilities [7]. Furthermore, diarrheal diseases affected approximately 4 million children due to inadequate sanitation, which 90% attributed to poor hygiene practices [8].

In Somalia, the Internally Displaced Persons (IDPs) experience significant obstacles in accessing clean water and sanitation, and only 45% of the population has reliable access to improved water sources, driven by sporadic rains, conflict, and maintenance problems [9]. Only one in four respondents indicated having access to improved sanitation facilities at a reasonable distance [10]. Accordingly, open defecation becomes highly prevalent and poses an alarming public health risk, with waterborne diseases, especially diarrhea, becoming the leading to 1.8 million deaths annually [11]. Hygiene practice among Internally Displaced Persons is poor due to limited access to basic sanitation items, including soap and clean water for handwashing [12]. A previous study conducted by the International Organization for Migration (IOM) showed that only 35% of Internally Displaced Persons knew the role of handwashing for disease prevention [13].

Despite substantial research on WASH issues globally, there remains a significant gap in understanding specific challenges faced by Internally Displaced Persons, particularly in Somalia. Recent studies have highlighted that the unique vulnerabilities of Internally Displaced Persons, exacerbated by conflict and environmental factors, necessitate focused investigations into their WASH knowledge and practices [14, 15]. Moreover, systematic reviews have demonstrated the critical need for tailored WASH interventions in humanitarian settings to improve health outcomes, underscoring the lack of data on WASH behaviors among Internally Displaced Persons in this region [16–18]. This study is essential not only to fill the existing literature gap but also to inform targeted interventions that address the unique needs of this vulnerable population.

Climate change, conflict, and insecurity have exacerbated ongoing challenges in Somalia, making the environment vulnerable among Internally Displaced Persons, and outbreaks of waterborne diseases occur due to scarcity of safe water, poor knowledge about improved hygiene practices, and insufficient WASH Programs. Despite efforts by the government and local and international NGOs to address this issue, there is a notable gap in understanding the knowledge, attitudes, and practices of Internally Displaced Persons regarding WASH, hindering the development of effective interventions. This study aims to assess the knowledge, attitudes, and practices relating to water, sanitation, and hygiene among internally displaced persons in Somalia, informing targeted interventions to improve their health and well-being.

Materials and methods

Study design and setting

Cross cross-sectional study was conducted in eight selected highly populated and easily accessible Internally Displaced Persons camps in Mogadishu and Baidoa. Mogadishu is Somalia’s largest and most populous city and the country’s capital. It is home to more than 2.7 million people [19]. The city is divided into eighteen administrative districts and hosts the largest estimated protracted internally displaced population in the country, and is home to nearly 400,000 Internally Displaced Persons, which is over one-third of the overall internally displaced population in Somalia. About 55% of the IDPs are concentrated in two of Mogadishu’s peripheral districts [20]. Baidoa is the main hub of the Somali inter-riverine region and the state capital of Bay Region. It has the highest record of drought-related displacement, with the number of Internally Displaced Persons in the town now estimated at 600,000 people [21].

Study population

The target population was participants aged 18 years or older living in selected Internally Displaced Persons camps in Mogadishu and Baidoa for a minimum last three months and willing to participate in the study after informed consent. The camps selected were most populated density and humanitarian need were particularly high. Participants were selected regardless of household headship; therefore, any individual aged 18 years or older living in the household who consented to participate was included.

Sample size and sampling procedure

The sample size was calculated using Cochran’s formula for estimating proportions. Assuming a proportion of good knowledge on WASH (Water, Sanitation, and Hygiene) of 42.2%, derived from a previous study in Ethiopia [7], with a 95% confidence interval and a margin of error of 3.7%, the calculated sample size was 685. To account for potential non-responses, the sample size was increased by 10%, yielding a final sample size of 751 participants.

The participants were recruited using a multistage sampling technique to ensure a representative sample of the Internally Displaced Persons (IDPs) population. In the first stage, we identified and randomly selected four camps in Mogadishu and four camps in Baidoa, based on their population size and accessibility. In the second stage, within each camp, households were identified and randomly selected. Within each selected household, the individual who was either the head of the household or any adult aged 18 years or older present at the time of data collection was selected to participate. In the final stage, we employed systematic random sampling to select participants within those camps. This involved listing all IDP households in the selected camps and using a predetermined interval (n) to select every nth household to participate in the study, ensuring that every individual within the IDP population had an equal chance of being included in the study, thus enhancing the representativeness and reliability of our findings.

Data collection procedure

A structured questionnaire from a previous study [22–28] was adopted to assess Knowledge, Attitudes, and Practices towards Water, Sanitation, and Hygiene. The KAP questionnaire was designed with specific scoring and rating criteria for each section. Knowledge was measured using 10 yes/no questions, with each correct answer scored as 1 point and incorrect answers scored as 0. The total knowledge score ranged from 0 to 10, with a predefined cut-off point: scores below 5 indicated “poor” knowledge, and scores of 5 or above indicated “good” knowledge. Attitude was assessed using 10 yes/no questions, with responses scored similarly (1 for positive attitude, 0 for negative). The total attitude score ranged from 0 to 10, with scores above 6 considered “positive” attitude, and scores 6 or below considered “negative.” Practices were evaluated with 10 yes/no questions, scored in the same manner, with higher scores indicating better practices. The practice score ranged from 0 to 10, with scores above 5 classified as “good” practice and scores 5 or below as “poor” practice. The questionnaire was interviewer-administered, with trained enumerators conducting face-to-face interviews with participants. The questionnaire was translated back and forth by a linguistic expert and pre-tested on 42 internally displaced persons to validate its effectiveness and appropriateness. The questionnaire has four sections: Sociodemographic section, Knowledge section, Attitude section, and Practice section. The sociodemographic section has 9 questions, the knowledge, Attitude, and practice section has 10 questions each, which have yes/no responses. The detailed KAP questionnaires can be found in Appendix 1. Fourteen trained enumerators conducted face-to-face interviews with participants over four weeks. Informed consent was obtained from each participant before the interview, ensuring confidentiality and adherence to ethical standards.

Data quality control

To ensure the integrity and trustworthiness of the data, a combination of structured training, monitoring systems, and validation methods was implemented to ensure the reliability and validity of the findings. Before beginning, enumerators took part in a training exercise to standardize data collection methods and address possible biases. The follow-up was a three-tier monitoring system: daily review of completed questionnaires by field supervisors, weekly debriefing sessions to discuss issues and resolve inconsistencies, and random verification of 10% of completed interviews to verify the accuracy of the data. In addition, data was double-entered into a statistical software program to minimize human errors during transcription. Another round of data validation was performed during analysis by running built-in software validation tests to ensure that the responses were in line with expected formats and logical coherence.

Data analysis

Data were analyzed using IBM SPSS Statistics Version 26.0. Descriptive statistics were computed to summarize the demographics of the participants and KAP scores. The determination of cut-off points for the KAP categories involved a multi-step process grounded in empirical evidence. Initially, a pilot testing phase was conducted with a sample of participants who completed the KAP assessment; this was designed to establish thresholds that accurately reflect their knowledge, attitudes, and practices. During this pilot phase, participants’ responses were thoroughly analyzed, and statistical methods, including frequency distributions and measures of central tendency, were employed to identify the percentage of correct responses for knowledge and practice, as well as the distribution of attitude responses. The cut-off points were then set based on these analyses, where knowledge was deemed “poor” if the score was below 50% (less than 5 correct answers out of 10) and “good” if 50% or above (5 or more correct answers). Attitude responses were categorized as “negative” or “positive” using a threshold of 60% (scores above 6 out of 10) to denote a positive attitude, derived from a consensus on the minimum level of agreement required for a favorable perspective. For practice scores, a percentage cut-off of ≤ 50% (5 or fewer correct answers) was defined as “poor” practice, while scores of > 50% (6 or more correct answers) were classified as “good” practice. This criterion was validated through discussions among expert reviewers and feedback from participants, ensuring that the cut-off points were contextually relevant and statistically valid. Chi-square tests were performed to identify any significant associations between demographic variables and KAP levels. Significance was set at a p-value of less than 0.05.

Results

Socio-demographic characteristics of the participants

A total of 728 participants were surveyed, yielding a response rate of 96.9%. The mean age of the participants was 37.7 ± 11.5 years. The majority, 621 (85.3%), of the participants were female. The participants were predominantly in the age groups of 25 to 34 years, 220 (30.2%), and 35 to 44 years, 221 (30.4%). A majority of the participants, 527 (72.4%), were married. The education levels among participants were predominantly low, with 624 (85.7%) having received informal education. A significant portion, 551 (75.7%), of the participants were unemployed. The vast majority, 702 (96.4%), reported an income of less than $200 per month. Most families, 428 (58.8%), had fewer than five members. Nearly half of the participants, 354 (48.6%), had been in the Internally Displaced Persons camp for six months to two years. A majority of the participants, 466 (64.0%), reported having access to healthcare services within the Internally Displaced Persons camp (See Table 1).

Table 1.

Sociodemographic characteristics of the participants (n = 728)

Variables	Frequency	Percentage
Sex
Male	107	14.7
Female	621	85.3
Age
18–24	99	13.6
25–34	220	30.2
35–44	221	30.4
45–54	111	15.3
55 and above	77	10.6
Marital status
Single	15	2.1
Married	527	72.4
Divorced	102	14.0
Widowed	84	11.5
Level of education
Informal education	624	85.7
Primary	24	3.3
Secondary	13	1.8
Tertiary	67	9.2
Occupation
Employed	177	24.3
Unemployed	551	75.7
Income
< $200	702	96.4
≥ $200	26	3.6
Number of family members in the Household
< 5	428	58.8
6–10	273	37.5
> 10	27	3.7
Length of time in the Internally Displaced Persons camp
Less than 6 months	154	21.2
6 months to 2 years	354	48.6
More than 2 years	220	30.2
Access to healthcare services in the Internally Displaced Persons camp
Yes	466	64.0
No	262	36.0

Overall knowledge, attitude, and practice levels of the participants towards water, sanitation, and hygiene

The study revealed that a significant majority of participants, 518 (71.2%), demonstrated poor knowledge of water, sanitation, and hygiene (WASH) practices. Similarly, a substantial portion of the participants, 512 (70.3%), harbored a negative attitude toward WASH. Furthermore, the analysis highlights alarmingly inadequate practical application of WASH principles, with 584 (80.2%) of participants demonstrating poor practices (See Fig. 1).

Fig. 1.

Overall knowledge, attitude, and practice levels of the participants towards water, sanitation, and hygiene among internally displaced persons in Somalia

Association between knowledge level and sociodemographic characteristics of the participants

A significant association was found between age groups and knowledge level (p < 0.001). Participants aged 25–34 demonstrated poorer knowledge of WASH compared to older age groups. The analysis revealed a significant relationship between marital status and knowledge level (p = 0.001), with divorced individuals exhibiting lower knowledge levels than their counterparts. Education level was also found to be significantly associated with knowledge levels regarding WASH (p = 0.048); respondents with tertiary education had markedly poorer knowledge levels compared to those with other educational backgrounds. A highly significant association was identified between employment status and knowledge levels (p < 0.001), with unemployed participants showing significantly poorer knowledge about WASH compared to those who were employed. The number of family members was also significantly associated with WASH knowledge (p < 0.001), with participants from smaller households (fewer than 5 members) demonstrating better knowledge, likely due to less crowded living conditions facilitating better access to information. A strong association was found with the length of time spent in the Internally Displaced Persons camp (p < 0.001); participants who had been in the camps for less than 6 months displayed significantly poorer knowledge levels compared to those who had resided there for longer durations. A significant relationship was also observed between access to healthcare services and knowledge levels (p < 0.001); participants with access to healthcare services demonstrated better knowledge of WASH compared to those without access. These findings underscore the need for targeted educational interventions that address the specific knowledge gaps of younger, single, less-educated, and unemployed individuals, particularly those living in larger households or newly displaced in camps. By prioritizing these demographics, WASH initiatives can be more effective in improving overall community health and hygiene practices. Additionally, leveraging healthcare access as a means to disseminate WASH knowledge can enhance the effectiveness of educational campaigns (Table 2).

Table 2.

Association between knowledge, attitude, and practice levels, and sociodemographic characteristics among internally displaced persons in Somalia (n = 728)

Variables	Knowledge Level		P-value	Attitude Leve		P-value	Practice Level		P-value
	Good n (%)	Poor n (%)		Positive n (%)	Negative n (%)		Good n (%)	Poor n (%)
Sex
Male	38 (35.5)	69 (64.5)	0.099	37 (34.6)	70 (65.4)	0.229	17 (15.9)	90 (84.1)	0.274
Female	172 (27.7)	449 (72.3)		179 (28.8)	442 (71.20		127 (20.5)	494 (79.5)
Age
18–24	24 (24.2)	75 (75.8)	< 0.001	27 (27.3)	72 (72.7)	< 0.001	17 (17.2)	82 (82.8)	0.113
25–34	43 (19.5)	177 (80.5)		43 (19.5)	177 (80.5)		32 (14.5)	188 (85.5)
35–44	74 (33.5)	147 (66.5)		74 (33.5)	147 (66.5)		53 (24.0)	168 (76.0)
45–54	35 (31.5)	76 (68.5)		38 (34.2)	73 (65.8)		25 (22.5)	86 (77.5)
55 and above	34 (44.2)	43 (55.8)		34 (44.2)	43 (55.8)		17 (22.1)	60 (77.9)
Marital status
Single	7 (46.7)	8 (53.3)	0.001	5 (33.3)	10 (66.6)	0.004	4 (26.7)	11 (73.3)	0.848
Married	140 (26.6)	387 (73.4)		143 (27.1)	384 (72.9)		106 (20.1)	421 (79.9)
Divorced	25 (24.5)	77 (75.5)		29 (28.4)	73 (71.6)		18 (17.6)	84 (82.4)
Widowed	38 (45.2)	46 (54.8)		39 (46.4)	45 (53.6)		16 (19.0)	68 (81.0)
Level of education
Informal	182 (29.2)	442 (70.8)	0.048	192 (30.8)	432 (69.2)	< 0.001	134 (21.5)	490 (78.5)	< 0.001
Primary	11 (45.8)	13 (54.2)		9 (37.5)	15 (62.5)		8 (33.3)	16 (66.7)
Secondary	5 (38.5)	8 (61.5)		7 (53.8)	6 (46.2)		1 (7.7)	12 (92.3)
Tertiary	12 (17.9)	55 (82.1)		8 (11.9)	59 (88.1)		1 (1.5)	66 (98.5)
Occupation
Employed	102 (57.6)	75 (42.4)	< 0.001	99 (55.9)	78 (44.1)	< 0.001	68 (38.4)	109 (61.6)	< 0.001
Unemployed	108 (19.6)	443 (80.4)		117 (21.2)	434 (78.8)		76 (13.8)	475 (86.2)
Income level
< $ 200	200 (28.5)	502 (71.5)	0.270	205 (29.2)	497 (70.8)	0.151	137 (19.5)	565 (80.5)	0.352
> $ 200	10 (38.5)	16 (61.5)		11 (42.3)	15 (57.7)		7 (26.9)	19 (73.1)
Number of family members in HH
< 5	140 (32.7)	288 (67.3)	< 0.001	145 (33.9)	283 (66.1)	< 0.001	105 (24.5)	323 (75.5)	< 0.001
6–10	54 (19.8)	219 (80.2)		58 (21.2)	215 (78.8)		38 (13.9)	235 (86.1)
> 10	16 (59.3)	11 (40.7)		13 (48.1)	14 (51.9)		1 (3.7)	26 (96.3)
Length of time in the camp
> 6 months	10 (6.5)	144 (93.5)	< 0.001	9 (5.8)	145 (94.2)	< 0.001	9 (5.8)	145 (94.2)	< 0.001
6 months − 2 yrs.	156 (44.1)	198 (55.9)		146 (41.2)	208 (58.8)		109 (30.8)	245 (69.2)
> 2 years	44 (20.0)	176 (80.0)		61 (27.7)	159 (72.3)		26 (11.8)	194 (88.2)
Access to healthcare services in the camp
Yes	189 (40.6)	277 (59.4)	< 0.001	188 (40.3)	278 (59.7)	< 0.001	137 (26.2)	329 (73.8)	< 0.001
No	21 (8.0)	241 (92.0)		28 (10.7)	234 (89.3)		7 (2.7)	255 (97.3)

Association between attitude level and sociodemographic characteristics among internally displaced persons in Somalia

The analysis revealed a significant association between attitude levels and age groups (p < 0.001). Participants aged 25–34 demonstrated a notably higher proportion of negative attitudes toward WASH compared to older age groups. Marital status also exhibited a significant association with attitudes (p = 0.004), with married participants showing a higher prevalence of negative attitudes compared to participants in other marital categories. Educational attainment was strongly associated with attitude levels (p < 0.001); participants with no formal education exhibited predominantly negative attitudes towards WASH. Additionally, a strong association was found between occupation and attitude (p < 0.001), indicating that unemployed participants were more likely to hold negative attitudes compared to their employed counterparts. The analysis also revealed a significant association between the number of family members in the household and attitudes (p < 0.001); participants from smaller households (fewer than five members) were more inclined to possess negative attitudes compared to those from larger households. The duration of residency in the Internally Displaced Persons camp was significantly associated with attitudes (p < 0.001), with those who had been in the camp for less than six months exhibiting markedly higher negative attitudes compared to longer-term residents. Access to healthcare services also demonstrated a strong association with attitudes (p < 0.001); participants without access to healthcare were more likely to hold negative attitudes toward WASH practices compared to those with access. Understanding the factors influencing negative attitudes, particularly among younger and less educated individuals, can inform the development of targeted behavior change campaigns. Interventions could focus on fostering more positive attitudes towards WASH through community engagement and education, especially in settings where access to information is limited (Table 2).

Association between practice level and sociodemographic characteristics among internally displaced persons in Somalia

The study found a significant association between the level of education and WASH practices, indicating that participants with tertiary education exhibited notably poorer WASH practices compared to their counterparts with higher levels of education (P < 0.000). Additionally, employment status was significantly associated with WASH practices; unemployed participants demonstrated significantly poorer WASH practices than those who were employed (P < 0.001). The number of family members per household showed significant results, revealing that households with more than five members had poorer WASH practices compared to those with fewer than five members (P < 0.001). The duration of stay within the IDP camp was also significantly associated with WASH practices, as those who lived in the camp for less than six months exhibited poor WASH practices (P < 0.001). Finally, individuals who had access to health services demonstrated better WASH practices than those who did not (P < 0.001). These findings emphasize the importance of integrating WASH practice education into employment programs and ensuring that educational resources are accessible to all households, especially larger ones. Moreover, sustained outreach programs for longer-term residents could improve practices while prioritizing new arrivals with tailored, accessible interventions. By addressing these sociodemographic factors, interventions could lead to more effective adoption of WASH practices within the community. (See Table 2)

Discussion

Strengths and limitations

This study uses a cross-sectional design and a sufficiently large sample size calculated with statistical precision, enhancing the statistical power and generalizability of the findings to IDP populations in Mogadishu and Baidoa. The use of a multistage random sampling technique ensures a representative sample, which enhances the applicability of the results to the broader IDP population. The use of validated, pre-tested questionnaires and contextually derived cut-off points for KAP scores further strengthens the reliability of the results. However, the cross-sectional design limits causal inference, and self-reported data may introduce social desirability bias. Additionally, while the sample was drawn from highly populated IDP camps in Mogadishu and Baidoa, the findings may not be generalizable to all IDP populations in Somalia due to regional variations in displacement conditions and accessibility constraints.

Our study findings indicate that a significant proportion of participants demonstrated inadequate knowledge regarding water, sanitation, and hygiene (WASH) practices, which is concerning in refugee and internally displaced persons (IDP) situations due to the heightened risk of waterborne diseases from crowding and limited WASH services. This finding is corroborated by studies conducted in India, which reported similar knowledge deficiencies [7]. and indicated that inadequate WASH knowledge can exacerbate health conditions while increasing the financial burden on already strained health facilities [29]. Our results align with those from India [30], Bangladesh [31], Nepal [22, 32], Zimbabwe [33], and Ethiopia [7]. A study in Zimbabwe highlighted that over 60% of refugees lacked basic knowledge about hygiene practices, which correlates with our findings of inadequate WASH knowledge [34]. Similarly, research in South Africa found that knowledge gaps concerning sanitation directly led to increased morbidity rates from waterborne diseases, aligning with our concerns regarding health outcomes in the studied populations [35]. Importantly, poor WASH knowledge contributes to poor health conditions among the IDPs and also increases the expenditure burden on health facilities that already have limited resources in these settings. Therefore, health education and intervention programs should be emphasized to rectify these knowledge gaps, particularly in the vulnerable groups.

Our study also indicates that there were negative attitudes among participants toward water, sanitation, and hygiene. This negative attitude, stemming from cultural beliefs, misinformation, and inadequate former sanitation efforts, hinders health-promoting activities, fuels the continuous transmission of waterborne diseases, and saps community engagement in hygiene behaviors [36]. Similar findings have been reported in studies from Nepal [37] and Zambia [38], where negative perceptions towards WASH led to poor health outcomes. These negative attitudes need to be addressed, as they can significantly reduce the effectiveness of WASH programs. Previous research indicates that more successful changes would be found in programs that involve community participation and account for local perceptions about water and hygiene, which aligns with our findings [39, 40].

Our study also found that poor WASH practices were prevalent among participants, primarily due to inadequate access to clean water and sanitation facilities, insufficient hygiene promotion, and the influence of misinformation and cultural practices that contribute to the spread of diseases such as cholera. This agrees with the findings from studies conducted in India [30]. and Ethiopia [7], which stresses that full WASH programs addressing both infrastructure and behavior modification are urgently needed. Research in India has indicated that inadequate sanitation facilities contributed to cholera outbreaks in similar population contexts [30]. Furthermore, a study in Ethiopia highlighted that poor hygiene practices were directly linked to water scarcity and misinformation surrounding sanitation, resonating with our results and concerns of recurrent cholera outbreaks [7]. Targeted hygiene education and information about health consequences from waterborne diseases may potentially enhance practices within the community.

Our study also found that levels of knowledge, attitude, and practice were significantly related to demographic variables such as age group, marital status, educational level, occupation, number of family members, time spent in the Internally Displaced Persons camp, and availability of health services. This agrees with related studies done in Nigeria [41], Cameroon [42], South Sudan [43], Uganda [44], and Kenya [45].

Participants aged 25–34 exhibited poorer knowledge of WASH compared to older groups. This finding aligns with previous research indicating that younger adults often prioritize immediate concerns over broader health issues such as WASH. A study in Kenya found that younger individuals often lack adequate exposure to health education and may not engage as thoroughly with community health initiatives [46]. Moreover, younger adults may be less aware of the long-term effects of poor sanitation and hygiene practices due to a lack of life experience or access to informative resources [47]. Divorced participants demonstrated poorer WASH knowledge, possibly due to social isolation or lack of family support networks that facilitate information sharing. Studies in refugee settings indicate that married individuals often benefit from spousal communication on health matters, whereas divorced or separated individuals may face exclusion from community-based WASH programs [48]. Similar findings were reported in Kenya IDP camps, where single-parent households had lower health literacy due to competing survival priorities [49]. Surprisingly, respondents with tertiary education had lower WASH knowledge than those with primary or secondary education. This could be attributed to a mismatch between formal education and practical WASH training. Highly educated individuals may rely on theoretical knowledge rather than context-specific hygiene practices relevant to camp settings [50]. Unemployment was strongly associated with poor WASH knowledge, consistent with studies in refugee camps in South Sudan [51]. Employed individuals likely have greater access to workplace WASH training and peer networks that reinforce hygiene practices. Unemployment may also lead to psychological stress, reducing engagement in health education.

Participants from larger households (≥ 5 members) demonstrated lower WASH knowledge, likely due to overcrowding and difficulty disseminating information effectively. Smaller households allow better retention of hygiene messages, as seen in studies from Bangladesh [52]. Overcrowding also increases disease transmission risks, further complicating WASH compliance [53]. New arrivals (< 6 months) had significantly lower WASH knowledge than long-term residents, aligning with findings from Iraq [54]. Longer stays increase exposure to camp-based hygiene programs and peer learning. Conversely, the lack of exposure to WASH education among newer arrivals could lead to significantly poorer knowledge levels. Participants without healthcare access had poorer WASH knowledge, consistent with studies in Nigeria [55].

Younger adults (25–34 years) demonstrated more negative attitudes toward WASH compared to older age groups. This can be attributed to the possibility that younger individuals may lack comprehensive education or awareness regarding hygiene practices, especially if they grew up in environments with limited exposure to health education programs. Similar findings were reported in South Sudan, where younger internally displaced persons (IDPs) exhibited poorer hygiene compliance due to competing survival priorities [56]. Married individuals showed more negative attitudes, possibly because married individuals may prioritize immediate family needs (e.g., food, shelter) over perceived “non-urgent” WASH practices. A study in Syrian refugee camps in Jordan found that married women faced barriers in accessing latrines due to safety concerns, reinforcing negative attitudes [57].

Participants without formal education had significantly poorer WASH-related attitudes, consistent with findings from Ghana and Uganda [58, 59]. Education enhances health literacy, enabling individuals to understand disease transmission and preventive measures. Unemployed participants were more likely to hold negative attitudes, likely due to financial constraints limiting their ability to afford hygiene products (e.g., soap, clean water containers). A study in South Africa found that unemployment reduced access to WASH resources, exacerbating poor hygiene practices [60]. The analysis found that participants from smaller households were more inclined to exhibit negative attitudes towards WASH. This may be linked to the social dynamics and resource distribution within the family. Smaller households may have fewer collective resources for investing in health education and WASH facilities, leading to a lower prioritization of these issues, as observed in studies from India [61]. Newer camp residents (< 6 months) had poorer attitudes, likely due to inadequate exposure to WASH programs. Research in Bangladesh found that refugees in the first six months had significantly poorer sanitation practices than long-term residents [62]. Longer-term residents may have adapted to camp conditions or received more hygiene education. Studies have shown that prolonged residence can lead to improved adaptation and compliance with WASH practices as individuals become more accustomed to their environment [63]. The strong association between lack of healthcare access and negative attitudes is critical, as healthcare systems are often the backbone of health education. Research has consistently shown that individuals with limited or no access to healthcare exhibit poorer health behaviors. A study in Ghana showed that inadequate access to healthcare directly impacts understanding of WASH-related health risks and fosters negative attitudes [58]. A similar study in Congo found that communities far from health centers had 40% lower handwashing rates [64].

The study revealed that participants with tertiary education exhibited notably poorer WASH practices compared to those with higher education degrees. This counterintuitive finding may reflect a disconnect between formal educational attainment and practical knowledge concerning hygiene practices. A study by Shrestha et al. (2018) highlighted those higher educational levels do not necessarily translate to better knowledge or practices in WASH, as individuals may lack specific training in public health practices despite academic accomplishments [65]. Additionally, tertiary education might be associated with a greater reliance on technological solutions rather than grassroots sanitary practices. The association between unemployment and suboptimal WASH practices aligns with the findings of Nahimana et al. (2017), who noted that economic instability often compromises access to basic hygiene resources, thus exacerbating health risks [66]. Unemployed individuals often have limited financial resources, which affects their ability to purchase hygiene products or maintain sanitation facilities, leading to poorer WASH practices overall.

The findings indicate that households with more than five members exhibited poorer WASH practices. Larger households may experience overcrowding, which limits the ability to maintain sanitary conditions effectively. According to a study by Muniyapillai et al. (2022), larger family sizes can strain water and sanitation facilities, hindering proper hygiene practices [67]. Households with more members may also reflect broader socioeconomic challenges, where resources are spread thin, and prioritizing WASH may not be feasible, thereby increasing the risk of communicable diseases. The poorer WASH practices observed among individuals residing in IDP camps for less than six months could be attributed to the lack of adequate acclimatization to new environments and the potential unavailability of continuous education regarding WASH practices. A relevant study by Schweitzer R, et al. (2022) in 21 refugee camps and settlements in Bangladesh, Kenya, Uganda, South Sudan, and Zimbabwe highlighted those individuals in temporary shelters often faced challenges in adapting to new living conditions, exacerbating their WASH practices due to inadequate infrastructure and insufficient awareness campaigns [68].

Recognizing these factors influencing WASH knowledge and practices may lead to targeted interventions. The educational programs may need to be tailored by age and educational level so that messages appeal appropriately to various population segments. Understanding the role of access to health care will also indicate how the health systems can support WASH education and outreach so that Internally Displaced Persons camp populations are not only aware of safe practices but can practice them.

Conclusion

Our study found that poor knowledge, negative attitudes, and inadequate practices regarding water, sanitation, and hygiene (WASH) among Internally Displaced Persons (IDPs) in Somalia significantly hinder their overall health and well-being. We observed that a large proportion of IDPs lacked proper understanding of hygiene practices, exhibited unfavorable attitudes towards sanitation, and engaged in unsafe practices, which correlated with higher incidences of waterborne diseases and other health issues. Our study also demonstrated that factors such as age group, marital status, level of education, occupation, family size, duration of stay in the IDP camp, and access to healthcare services were significantly associated with individuals’ levels of knowledge, attitudes, and practices related to WASH. However, gaps remain in understanding how cultural beliefs and local infrastructure limitations influence WASH behaviors, which warrant further investigation. Addressing these issues is critical for improving the living conditions and health outcomes of the IDP population.

To improve WASH practices among IDPs, we recommend the following strategies. First, developing targeted health promotion strategies that focus on educational campaigns to enhance knowledge of WASH practices, specifically tailored for younger populations and individuals with lower levels of education, is essential. Second, investing in the development and improvement of WASH facilities within IDP camps to ensure the availability of clean water and adequate sanitation is crucial. Third, implementing community engagement programs designed to shift attitudes towards hygiene practices can foster a culture that values and prioritizes cleanliness and health. Lastly, organizing regular training sessions and workshops can enhance knowledge and promote positive attitudes toward hygiene practices among community members.

Appendix 1. Knowledge, attitudes, and practices (KAP) questionnaire for water, sanitation, and hygiene (WASH) assessment

Knowledge questions

1. Do you know the importance of clean drinking water for health? Yes/No 2. Are you aware of the potential health risks associated with contaminated water? Yes/No 3. Do you know that proper sanitation practices can help prevent the spread of diseases? Yes/No 4. Are you familiar with the proper way to store drinking water to prevent contamination? Yes/No 5. Do you understand the importance of handwashing in preventing the spread of germs? Yes/No 6. Are you knowledgeable about the impact of poor hygiene on personal health? Yes/No 7. Do you know the symptoms of waterborne diseases caused by contaminated water? Yes/No 8. Are you familiar with the benefits of maintaining proper sanitation facilities in communities? Yes/No 9. Do you know how to identify sources of clean water in emergencies? Yes/No 10. Are you aware of the importance of clean water for cooking and food preparation? Yes/No

Attitude Questions

1. Do you believe that access to clean drinking water is a basic human right? Yes/No 2. Do you think that proper sanitation facilities should be accessible to everyone? Yes/No 3. Do you value the importance of practicing good hygiene for overall health and well-being? Yes/No 4. Do you support initiatives that aim to improve water, sanitation, and hygiene conditions in communities? Yes/No 5. Do you feel a personal responsibility to maintain clean water sources in your community? Yes/No 6. Do you believe that investing in sanitation infrastructure is essential for community development? Yes/No 7. Do you think that education on hygiene practices should be a priority in communities? Yes/No 8. Do you believe that everyone should have access to clean water, regardless of their circumstances? Yes/No 9. Do you see the connection between proper sanitation practices and reduced disease transmission? Yes/No 10. Do you think that governments should prioritize funding for water and sanitation projects in communities? Yes/No

Practice Questions

1. Do you always wash your hands with soap and water before handling food? Yes/No 2. Do you use clean water for cooking and drinking purposes only? Yes/No 3. Do you segregate waste and dispose of it properly in designated bins? Yes/No 4. Do you make an effort to maintain cleanliness in toilet facilities? Yes/No 5. Do you regularly clean and disinfect water storage containers? Yes/No 6. Do you avoid defecating in open areas and use proper toilet facilities? Yes/No 7. Do you seek medical attention promptly if you experience symptoms of waterborne illnesses? Yes/No 8. Do you participate in community clean-up activities to maintain hygiene standards? Yes/No 9. Do you encourage others in your community to adopt good hygiene practices? Yes/No 10. Do you believe that your hygiene practices contribute to the overall health of your community? Yes/No

Author contributions

A.A.T. conceptualized and designed the study, analyzed the data, interpreted the results, and drafted the manuscript. M.A.D., A.A.S. and M.M.O oversaw the data collection. Y.S.A.H. and M.A.M. performed the statistical analyses. G.D., L.H.J., O.A.F. and A.Y.O. revised the manuscript and approved the final version for submission. All authors read and approved the final manuscript.

Funding

This research did not receive any funding for the publication of this article.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. All reasonable measures will be taken to ensure compliance with data protection regulations.

Declarations

Ethical approval and consent to participate

This study was conducted by the Declaration of Helsinki and was approved by the Institutional Review Board (IRB) of the National Institute of Health, Mogadishu, Somalia [NIH/IRB/10/APR/2024]. Written informed consent was provided by the participants before the collection; they were assured regarding the purpose of the study and the processes, risks, and benefits it entailed. Participation was entirely voluntary, allowing individuals the freedom to withdraw from the study at any time without facing any negative repercussions. The confidentiality and privacy of participants’ information were rigorously maintained; all collected data were anonymized, securely stored, and accessible solely to authorized researchers.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.