Spatial distribution and determinants of unimproved sanitation facilities among households in Somalia: Using Somalia integrated household budget survey (SIHBS 2022).

BACKGROUND: Access to adequate sanitation remains a critical public health challenge in Somalia, where a large portion of the population relies on unimproved facilities due to persistent conflict, climate shocks, and political instability. This reliance contributes to a high burden of waterborne diseases. This study aimed to assess the spatial distribution of unimproved sanitation and identify its individual and community-level determinants using recent national data to inform targeted interventions.

METHODS: This study is a secondary analysis of the 2022 Somalia Integrated Household Budget Survey (SIHBS), which included 7,212 households. The primary outcome was the use of unimproved sanitation facilities, categorized according to the WHO/UNICEF Joint Monitoring Programme (JMP) definitions. We employed a multilevel logistic regression model to identify individual and community-level determinants associated with unimproved sanitation. To analyze the spatial patterns of unimproved sanitation, we used Global Moran's I for spatial autocorrelation and the Getis-Ord Gi* statistic for hotspot analysis.

RESULTS: Overall, 36.87% of Somali households use unimproved sanitation facilities. There are significant disparities across residence types, with the highest prevalence among nomadic populations (83.28%), followed by rural (51.10%) and urban (23.88%) residents. The multilevel analysis revealed that households in permanent/formal housing (AOR: 3.42) and those with IDP status (AOR: 3.18) had significantly higher odds of using unimproved sanitation. At the community level, urban residence was paradoxically associated with higher odds of unimproved sanitation (AOR: 7.99) compared to rural areas, while nomadic populations had significantly lower odds (AOR: 0.04), likely reflecting a high prevalence of open defecation not captured as a "facility." Spatial analysis identified significant hotspots of unimproved sanitation in the Hiraan (90.65%) and Bay (80.39%) regions, and cold spots in Banadir (5.37%) and Lower Shabelle (3.70%).

CONCLUSION: The findings highlight deep inequalities in sanitation access across Somalia, driven by geographic location, socioeconomic status, and population group. The high prevalence of unimproved sanitation, especially among nomadic, rural, and displaced populations, calls for urgent, geographically-targeted interventions. A multi-pronged approach is necessary, focusing on the specific needs of different communities and addressing the underlying structural and individual-level drivers of poor sanitation to advance public health and sustainable development goals in the region.