Effect of demographic disparities on the use of the JMP ladders for water, sanitation, and hygiene services in Bishoftu Town, Ethiopia

Reducing inequalities in all its forms is one of the key principles of the Sustainable Development Goal (SDG). However, the 2030 SDG Agenda has been a real challenge in addressing inequalities in Water, Sanitation, and Hygiene (WASH) services. There is a disparity in the use of WASH services in Ethiopia. Therefore, this study aimed to identify demographic factors affecting the use of Joint Monitoring Program (JMP) ladders for WASH services. In this study, a total of 5350 households were included. Households having heads with vocational education levels were 2.9 times higher in use of basic drinking-water services ((Adjusted Odds Ratio (AOR) = 2.9 with 95% CI 1.6–5.1) than household having heads who could not read and write. Besides, households living in urban areas were 21.7 times more likely to use basic drinking-water services (AOR = 21.7 with 95% CI 16–30) than in rural parts. Further, households with merchants’ heads were 2.1 times higher to use basic sanitation services (AOR = 2.1 with 95% CI 1.5, 3.1) than households with farmers’ heads. Moreover, households having higher monthly income per head were 2.9 times higher in utilizing basic sanitation services (AOR = 2.9 with 95% CI 2.32–3.58) than the poorest households. Similarly, households with female heads were 1.5 times higher in using the JMP ladder for basic hygiene services (AOR = 1.5 with 95% CI 1.24–1.71) than households with male heads. Additionally, respondents who live in urban areas had 2.8 times higher use of basic hygiene services (AOR = 2.8 with 95% CI 2.26–3.54) than those in rural areas. Many demographic factors that influence the use of the JMP ladders for water, sanitation, and hygiene services were identified. The use of surface water, open defecation practice, unimproved sanitation, and no hygiene services were positively associated with illiteracy. The findings suggest that state authorities should initiate firm WASH policies and strategies to achieve the SDG 6 and 10. Additionally, the government should apply effective WASH interventions that consider demographic disparities.

factors on the use of JMP ladders for water, sanitation, and hygiene service. In addition, the study can provide an important evidence and baseline for policy makers as well as initiating and strengthen the JMP ladders for WASH services through better planning, monitoring, and designing of effective interventions.

Study area
Bishoftu town is located in central Ethiopia in the East Shewa Zone of Oromia National Regional State at a distance of 44 km from the capital Addis Ababa [25]. According to the Bishoftu town administration report, the city is clustered into nine urban Kebeles and five rural Kebeles. The town's population was estimated to be 171,227 [25].
The latitude and longitude of the BishoftuvTown are 8.734650 and 39.008533, respectively. The elevation of the city is 1920 meter above sea level. Also, it is located at the Global Positioning System (GPS) coordinates of 8° 44′ 4.74″ North and 39° 0′ 30.726″ East.
https:// www. count rycoo rdina te. com/ city-bisho ftu-ethio pia/. The Town is characterized by a cluster of volcanic crater lakes and popular spiritual sites that are found in and around it. It is surrounded by eight crater lakes namely: HoraArsadi, Babogaya, Bishoftu, Kuriftu, Chalalaka, Kilole, Green, and Balbala Lake. In the Town, the wet season is mostly cloudy, the dry season is partly cloudy, and it is warm year round. It has a mean annual temperature of 27 °C and a mean annual rainfall of 746.6 mm (ml) [26]. The Bishoftu Town Water Supply and Sewerage Service/Water Utility sector has the mandate to deliver water supply and sewerage services to the town. According to the unpublished current report of the Bishoftu Town water supply and sewerage office, there are 30 Boreholes that are the source of water to the Town with actual water production of 26,000 cubic meters per day. Further, the Town's daily water consumption and liquid waste generation in liters per capita per day are 801 L and 80 L, respectively (see Fig. 1).

Study design
A community-based cross-sectional study was conducted from January to February 2022.

Inclusion criteria
All residents aged 18 and above years old and who lived at least 6 months were included in this study. However, participants who had mental and severe illnesses were excluded.

Sample size determination
The sample size was calculated using the standard equation for determining the minimum sample size required for the study. This equation used a 95% confidence interval, 5% degree of accuracy, 1.5 design effect, and 0.2 estimated target population proportion. In addition, a 10% non-response rate was considered. The following formula was used to calculate the sample size. n = 4 * r * (1−r) * deff (RME * r)2 * pbRR , Where: Predicted value of indicator (in target/base population) or ratio (r) = 0.2, Design effect (deff) = 1.5, Relative margin of error at 95% confidence (RME) = 0.05, Proportion of target (pb) = 0.03, Average household size (AveSize) = 5, Household response (or completion) rate (RR) = 0.9 and Standard error (SE): (r*RME)/2. Finally, adding 10% for a non-response rate, the final sample was equal to 5350.

Sampling procedure
In this study, Bishoftu town was stratified by gender and Kebele administration, and the samples were selected in two stages. The sampling frame was used from the Central Statistics Agency's latest Population and Housing pre-census 2019 Enumeration Area. Firstly, 214 Enumeration Areas were selected by the Ethiopian Central Statistics Agency using proportional probability sampling. According to the sampling frame, the Enumeration Area (EA) size was the number of residential households in the EA. Secondly, each EA was delineated using Q-field software. Then, a new listing was collected for each EA. Each new listing was divided by 25 to obtain a sampling interval, and a constant of 25 households was selected from each EA. At first, one household was determined using a lottery method and continuous by adding the sampling interval to get the required 25 households from each selected EA.
Similarly, according to the JMP sampling method for drinking-water quality [2], a fixed number of 5 households per EA were taken to take water samples. The selected and interviewed 25 households were divided by 5 to obtain a sampling interval. One household was determined using a lottery method and continuous by adding the sampling interval to get the required five drinking-water samples from each selected EA. Accordingly, five drinking-water samples were taken from the 25 selected households or each EA, resulting in 1070.

Data collection method
Data collectors were identified based on professional capability and technical experience in collecting the required data using Open Data Kit (ODK) software. Forty-eight health professionals with Bachelor of Science with extensive experience in similar data collection practices were hired. In addition, eight Masters' degree holders acted as supervisors were assigned. Five days of training were provided to data collectors and supervisors. After written consent was obtained from each study participant, data was collected from heads of households through face-to-face interviews using a structured questionnaire.
Additionally, data collectors fulfilled the observational parts of the questionnaire. Drinking-water samples were collected directly from households' water storage and were tested bacteriologically and chemically. Heat-sterilized bottles of 250 milliliter (ml) capacity for bacteriology and 1000 ml plastic bottles for chemical properties of drinking water were used to collect the drinking-water samples. The sampling method was adapted from the WHO guidelines for drinking-water quality [27]. The bottles were delivered to the laboratory within 6 h and kept in the refrigerator at four °C until analysis.

Data analysis
First, data were checked for completeness and transferred into Stata 16 for analysis. Based on the JMP ladders for WASH definitions, variables were constructed. Data analysis was conducted using binary logistic regression and multivariable logistic regression. In all analyses, a P-value less than 0.05 was considered statistically significant.

Bacteriological and chemical analysis
Bacteriological analysis and enumeration of Escherichia coli, Total Coliform, and Fecal coliform bacteria were conducted using membrane filtration method according to the United States Food and Drug Administration [28]. Additionally, according to the United States America Environmental Protection Authority (USEPA) guideline, Ion-Selective Electrode (ISE) was used to determine fluoride levels [29]. Furthermore, nitrate concentration was determined by the Ultraviolet spectrophotometer screening method according to the American Public Health Association/American Water Works Association/Water Environment Federation (1998) Standard methods for the examination of water and wastewater [30].

Ethical considerations
The Ethical approval was obtained from the Ethiopian Public Health Institute scientific and ethical review board with EPHI-IRB-358-2021 reference number. Written consent was obtained from the participants. Those who did not wish to participate in the study were not forced to participate. The information provided by the respondents was treated unanimously and was never shared outside.

Drinking-water quality
According to WHO drinking water guideline 2004, water samples with < 1 Colony Forming Unit (CFU)/100 ml for indicator bacteria were considered uncontaminated, and samples with ≥ 1 CFU/100 ml were contaminated [27]. Additionally, drinking-water samples with ≤ 1.5 milligram (mg)/liter and ≤ 50 mg/liter concentration of fluoride and nitrate values were considered to be free from contamination, and samples with > 1.5 mg/liter and > 50 mg/liter concentration values of fluoride and nitrate were supposed to be contaminated, respectively.

Service level Definition
Drinking-water service ladders Safely managed Drinking-Water from an improved source accessible on-premises, available when needed, and free from fecal and priority chemical contamination (fluoride and nitrate). Basic Drinking water from an improved source, provided collection time is not more than 30 min for a round trip, including queuing. Limited Drinking water from an improved source, collection time exceeds 30 min for a round trip, including queuing. Unimproved Drinking water from an unprotected dug well or unprotected spring. Surface water Drinking water directly from a river, dam, lake, pond, stream, or irrigation canal. Sanitation service ladders Safely managed Use improved facilities that are not shared with other households and where excreta are safely disposed of in situ or removed and treated offsite. Basic Use of improved facilities that are not shared with other households.

Sociodemographic characteristics of respondents and ladders for drinking-water services
A total of 5350 households participated in this study, with a response rate of 99%. In the study, 60.7% of respondents were female. Above half (51.5%) of respondents were found to have an education level between one to twelve grades. Additionally, 18% of respondents could not read and write. Above three-fourths of respondents, 4135 (78.23%), had less than four family sizes. In this study, households' safely managed drinking-water services utilization was 4.9%. Using safely managed drinking-water services was higher (6%) among respondents with vocational educational levels. However, using surface water was higher (0.7%) among respondents who could not read and write. In this study, female respondents had higher (85.6%) utilization of basic drinking water service ladders. Utilizing surface water was higher (0.4%) among male respondents. Additionally, using safely managed and basic drinking-water services was higher among respondents with low family sizes (Table 1).

Sociodemographic characteristics of respondents and ladders for sanitation services
Only 10.2% of the households used safely managed sanitation services in this study. Utilizing safely managed sanitation services was higher (13.8%) among respondents with a vocational educational level. In addition, using basic sanitation services was higher (21.9%) among respondents with a university academic level. However, using unimproved and open defecation sanitation services was higher among respondents with no reading and writing ability. In this study, female respondents had higher utilization of safely managed (11.3%) and limited (59.6%) sanitation services. However, utilizing unimproved sanitation services (10.8%) and open defecation practice (5.6%) was higher among male respondents. Using open defecation was higher (6.7%) among respondents aged greater than or equal to 44 years old. On the other hand, safely managed and basic sanitation services were higher among the high-income respondents. However, utilizing unimproved and open defecation was higher among the poorest respondents (Table 2).

Sociodemographic characteristics of respondents and ladders for hygiene services
In this study, households' utilization of basic hygiene services was very low (19.4%). The use of basic hygiene services was higher (35.5%) among respondents with university-level education. However, utilizing limited hygiene services was higher (45%) among households having heads who could read and write. No hygiene service was higher (52%) among households having heads who could not read and write. Additionally, using basic hygiene services was higher (21.4%) among female respondents.
On the other hand, the limited and no hygiene services were higher among households having male heads. Utilizing basic hygiene services was higher (49%) among households having a high income. Further, the limited and no hygiene services were higher among the low-income households (Table 3).

Demographic factors associated with basic water, basic sanitation, and basic hygiene services
In the binary logistic regression analysis, seven (7) explanatory variables like sex, marital status, occupation, educational level, income, family size, and residence type of respondents were significantly associated (p-value < 0.05) with JMP ladders for basic drinking-water, basic sanitation, and basic hygiene services. However, only four (4) predictor variables, including marital status, occupation, educational level, and residence type of respondents, were significantly associated in the multivariable analysis (P-value < 0.05) with basic drinking-water services. Similarly, five (5) explanatory variables-including marital status, occupation, education level, income, and family size, were significantly associated in the multivariable analysis (p-value < 0.05) with the JMP ladder for basic sanitation services. Furthermore, all the seven (7) variables were significantly associated in the multivariable analysis (P-value < 0.02) with the JMP ladder for hygiene services (Table 4).

Discussion
Addressing all forms of inequality is one of the key pillars of the Sustainable Development Goal. However, the 2030 SDG Agenda facing a real challenge in addressing inequalities towards the JMP ladders for WASH services. Because, equal access to WASH services remains one of the biggest challenges facing countries, particularly low-income countries like Ethiopia. Additionally, the lack of detailed information on the role of demographic factors in water, sanitation, and hygiene services is another problem. Hence, assessing WASH services and associated demographic factors is essential to enhance public health. In this study, households' utilization of safely managed drinking-water and safely managed sanitation services were very low compared to global estimation [31]. Additionally, only a few households used basic sanitation and basic hygiene services. This indicates that the study area seems not on track to achieve SDG targets for safely managed drinking-water, safely managed sanitation, and basic hygiene services by 2030. The current findings revealed that households having married heads were 0.71 times less likely to use the JMP ladders for basic drinking-water services (AOR = 0.71 with 95% CI 0.5-1.0) than households headed by single.  Moreover, households with merchants' heads were 4.2 times more likely to use basic drinking-water services (AOR = 4.2 with 95% CI 2.4-7.4) than households with farmers' heads. This could be due to economic differences. Furthermore, households having heads with higher educational levels had higher utilization of basic drinking-water services than households having illiterate heads. Mainly, vocational education levels were 2.9 times higher to use basic drinking-water services (AOR = 2.9 with 95% CI 1.6-5.1) than in households with heads who could not read and write. Besides, households with heads who had university education levels were 2.2 times more likely to use basic drinking-water services (AOR = 2.2 with 95% CI 1.7-2.9) than households with heads who could not read and write. This indicated that academic level was a determinant factor for basic drinking-water services. In addition, households living in urban areas were 21.7 times more likely to use basic drinking-water services (AOR = 21.7 with 95% CI 16-30) than those living in rural parts. This finding was consistent with the WHO data [32].
Additionally, this study showed that marital status was significantly associated with the JMP ladder for basic sanitation services. Particularly, households having married heads were 2.5 times higher to use basic sanitation services (AOR = 2.5 with 95% CI 2.0-3.1) than households headed by single. Moreover, in the current study, the type of occupation was significantly associated with basic sanitation services. Specifically, households with retired heads were 2.16 times more likely to use the JMP ladder for basic sanitation services (AOR = 2.16 with 95% CI 1.55-3.02) than households having farmer's heads. Having better knowledge among retired respondents could be the main reason. Further, households with merchants' heads were 2.1 times more likely to use basic sanitation services (AOR = 2.1 with 95% CI 1.5, 3.1) than households with farmers' heads. This could be a result of income and knowledge differences. Besides, households having heads with grade (1-12) education levels were 2.8 times higher to use basic sanitation services (AOR = 2.8 with 95% CI 2.1-6.0) than households having heads with no ability to read and write. This indicated that level of education had a direct correlation with using basic sanitation services. This finding was supported by many studies [33][34][35]. Further, households having a monthly income greater than or equal to 8583.8 Birr or greater than or equal to 167 USD per head were 2.9 times higher to use basic sanitation services (AOR = 2.9 with 95% CI 2.32-3.58) than the poorest households. This result was supported by a study conducted in 2022 [36]. Also, households with a family size of four and above were 2.22 times more likely to use basic sanitation services (AOR = 2.22 with 95% CI 1.91-2.57) than those with less than four families.
Similarly, households with female heads were 1.5 times higher in using the JMP ladder for basic hygiene services (AOR = 1.5 with 95% CI 1.24-1.71) than households with male heads. This result was supported by [37]. This indicated that female household heads had a higher sense of responsibility and concern about their health and families than male household heads. However, this result needs further research. This study revealed that households having merchant's heads were 1.8 times more likely to use basic hygiene services (AOR = 1.8 with 95% CI 1.12-2.91) than farmer-headed households. Income differences and knowing about the advantage of basic hygiene services could be the main reasons.
Moreover, households with heads with grade (1-12) academic levels were 3.8 times more likely to use basic hygiene services (AOR = 3.8 with 95% CI 2.76-5.22) than households with heads with no ability to read and write. This indicated that education level was also a determinant factor for basic hygiene services. Moreover, households having monthly income greater than or equal to 8583.8 Birr or greater than or equal to 167 USD per head were 3.0 times more likely to use basic hygiene services (AOR = 3.0 with 95% CI 2.4-3.73) than the poorest households. As expected, fulfilling basic hygiene services requires money. In this study, households having a family size of four and above had 1.5 times higher to use basic hygiene services (AOR = 1.5with 95% CI 1.24-1.76) than those who had less than four. Additionally, respondents who live in urban areas had 2.8 times higher use of basic hygiene services (AOR = 2.8 with 95% CI 2.26-3.54) than those in rural areas. This finding was supported by a study done in 2022 [38].
In this study, using surface water was higher among households having heads with no abilities for reading and writing. This could be due to a lack of knowledge on waterborne diseases and economic factors. Moreover, this study revealed that utilizing surface water was higher among male respondents. This could be due to the difference in work type, as most male work depends on the field.
Additionally, safely managed and basic sanitation services were higher among high-income households. However, utilizing unimproved and open defecation was higher among the poorest households. This revealed that the income of households had a significant influence on using the higher JMP ladders. The current study revealed that, having no hygiene service was higher among households having heads with no ability to read and write. This showed that illiterate heads of households lacked understanding of and consequences of hygiene-related diseases. Despite this study providing significant information regarding the effect of demographic disparities on the use of the JMP ladders for water, sanitation, and hygiene services, a lack of previous related studies conducted on this particular topic, being a cross-sectional study that reports only associations between demographic and JMP ladders for WASH services of the study participants were the limitations of this study.

Conclusion
This study provides scientific information that might be used for informed decision on the effect of demographic disparities towards the New JMP ladders for WASH services. Many core determinant factors that influence the use of the JMP ladders for basic drinking-water, sanitation, and hygiene services were identified. Many households had low utilization of safely managed drinking-water, sanitation, and basic hygiene services. Households' utilization of basic sanitation and basic hygiene services was low. The use of surface water, open defecation practice, unimproved sanitation, and no hygiene services were positively associated with illiteracy. Level of income and education were identified as core detainments for the use of safely managed and basic sanitation services. Therefore, the researchers suggest that the households take practical actions to improve access to safely managed drinking water, sanitation, and basic hygiene services. Moreover, the government should apply effective WASH interventions that consider demographic disparities. Additionally, the findings suggest that state authorities should initiate firm WASH policies and strategies to achieve the SDG 6 and 10.