When alcohol is easier to access than toilets: water, sanitation and hygiene exclusion and infrastructural inequality in Nompumelelo, South Africa

Introduction

Globally, rapid urbanisation and the expansion of informal and peri-urban settlements continue to place significant pressure on basic service delivery systems, particularly water, sanitation and hygiene (WASH). In many low- and middle-income countries, these pressures are intensified by poverty, population growth and inadequate infrastructure, resulting in persistent inequalities in access to safe and reliable sanitation services (Baye, Wegayehu and Mulugeta, 2020; World Health Organization, 2019). Despite global commitments to Sustainable Development Goal 6 (SDG 6), which seeks to ensure universal access to water and sanitation, millions of people remain without safely managed sanitation services. These deficits are closely linked to broader development challenges, including health inequalities (SDG 3) and socio-economic disparities (SDG 10), which disproportionately affect marginalised communities (Nelson et al., 2021). In South Africa, these inequalities are are particularly evident in peri-urban and township settlements, where inadequate sanitation infrastructure, poor maintenance and uneven municipal service delivery continue to undermine public health outcomes (King and Shackleton, 2022; Zindi and Shava, 2022). The Eastern Cape province, in particular, reflects deep-seated structural inequalities, with many peri-urban communities experiencing limited access to functional sanitation facilities, unreliable water supply and overcrowded living conditions (Bazaanah and Mothapo, 2024). These challenges are not only infrastructural but are also shaped by broader socio-economic conditions, including poverty, unemployment and constrained access to social services.

Emerging literature increasingly shows that sanitation outcomes in such contexts are influenced not only by infrastructure deficits but also by social and environmental determinants of health, including behavioural environments, substance availability and community-level vulnerability (Ayelazuno and Tetteh, 2025; Neaemeka and Dikwa, 2025). However, while alcohol consumption has been associated with reduced attention to hygiene practices and increased household vulnerability, existing studies have largely examined alcohol misuse and WASH challenges as separate phenomena. Limited attention has been given to how sanitation exclusion and alcohol accessibility interact within peri-urban settlements characterised by structural deprivation and service delivery inequalities (Pillay et al., 2010b). Nompumelelo, a peri-urban settlement in South Africa, provides a relevant case study for examining these intersecting challenges due to its persistent sanitation deficits, socio-economic vulnerability and widespread alcohol accessibility outlets. The settlement reflects broader peri-urban realities where informal growth, inadequate infrastructure and limited municipal capacity converge to shape everyday living conditions (Pillay et al., 2010a).

Understanding how residents experience and interpret the relationship between alcohol accessibility and sanitation access in such a context is critical for advancing integrated public health and development responses. Guided by the Social Determinants of Health (SDH) framework (Commission on Social Determinants of Health, 2008; World Health Organization, 2010), this study sought to examine how residents of Nompumelelo experience and perceive the relationship between alcohol accessibility and sanitation access within the context of infrastructural inequality and service-delivery constraints. The study is guided by the following research questions: (1) How do residents perceive the relationship between alcohol accessibility and sanitation access? (2) What structural, socio-economic and governance factors contribute to WASH exclusion in the settlement? (3) How can these insights inform more equitable and integrated WASH interventions in peri-urban communities?

To address this gap, this study investigates how community members and key informants (KIs) perceive the relationship between alcohol accessibility and sanitation access in Nompumelelo within the broader context of socio-economic and infrastructural inequalities. It further identifies community-based and policy interventions that can contribute to more equitable and sustainable sanitation outcomes. By situating alcohol-related behavioural environments within broader structural WASH inequalities, the study contributes to a more nuanced understanding of sanitation challenges in peri-urban settlements and offers insights for integrated public health and infrastructure interventions.

Methodology

Study area

Nompumelelo peri-urban township located in Ward 15, East London, within the Buffalo City Metropolitan Municipality, Eastern Cape Province, South Africa. The area is predominantly isiXhosa-speaking and comprises of a mix of low to middle income households (Buku, 2014). The area is characterised by a combination of formal and informal settlements, high population density, limited green space and uneven access to basic municipal services, particularly water and sanitation infrastructure (Buku, 2014). Geographically, Nompumelelo is bounded by the N2 motorway to the north, Mdantsane township to the south, the Buffalo River to the east and Amalinda township. It is situated on the peripheries of East London (see Figure 1) and reflects typical peri-urban spatial and socio-economic conditions in South Africa's urban fringe areas (Buku, 2014). The township was purposively selected due to its relevance to the study objectives, particularly its representation of persistent WASH service delivery challenges in peri-urban settlements, including inadequate sanitation infrastructure and intermittent access to potable water (Munyai, 2023). Its socio-economic diversity and settlement complexity (Ndasana et al., 2022) make it suitable for examining how structural inequalities shape sanitation experiences and related behavioural environments.

Study design

This study employed a convergent mixed-methods case study design, integrating quantitative and qualitative approaches to examine WASH service challenges and the relationship between alcohol accessibility and sanitation practices in Nompumelelo. A convergent design was appropriate because it enabled quantitative and qualitative evidence to be collected concurrently, analysed separately and integrated during interpretation to provide a more comprehensive understanding of the alcohol-WASH nexus than either approach could achieve independently. Nompumelelo was purposively selected as an information-rich case because it is characterised by persistent sanitation service deficits, rapid peri-urban growth, socio-economic vulnerability and widespread alcohol accessibility (Muchaku and Zhou, 2025). These characteristics reflect the structural challenges experienced by many peri-urban settlements in South Africa, making the township an appropriate setting for investigating the interaction between alcohol accessibility and sanitation access.

The quantitative component employed a cross-sectional household survey to capture prevailing patterns of sanitation access and hygiene-related behaviours at a single point in time, while the qualitative component comprised key informant interviews to provide contextual insights into WASH service delivery, governance, and community experiences. The integration of findings from both components strengthened the validity and depth of the study by triangulating measurable patterns with contextual explanations.

Sampling methods

A mixed sampling strategy was used, combining purposive sampling for the qualitative strand and availability and willingness sampling for the quantitative strand. Recruitment was guided by data adequacy and thematic relevance rather than statistical representativeness, consistent with the exploratory and pilot nature of the study. Fifteen (15) KIs were purposively selected from a pool of 24 eligible participants identified in Nompumelelo. The KI sample comprised four municipal officials, two community leaders, four representatives from local non-governmental organisations (NGOs), two health professionals and three long-standing community members. Participants were selected based on their direct involvement in, or extensive knowledge of, WASH-related issues and community development processes. Eligibility criteria required participants to have at least two years of relevant experience or residence in the community, as well as demonstrated knowledge of water and sanitation challenges. Individuals who did not meet these criteria or were unavailable during data collection were excluded.

Survey sampling

The quantitative strand included 264 drawn from a total of 423 adult residents (aged 18 years and older) in Nompumelelo using availability and willingness sampling. Participants were recruited from households and public spaces within the community based on accessibility and their willingness to participate at the time of data collection. Eligibility criteria required participants to be permanent residents of Nompumelelo, aged 18 years or older and willing to provide informed consent. Non-residents and individuals under 18 years were excluded. The sample size of 264 was considered adequate for a cross-sectional descriptive analysis within a mixed-methods design aimed at examining prevailing WASH conditions and perceived behavioural and infrastructural challenges rather than making statistical generalisations. The adequacy of the sample was assessed using the finite population sample size formula at a 95% confidence level and 5% margin of error: n = N/(1 + N(e)^2)

Where N = 423 and e = 0.05:The minimum recommended sample size was therefore approximately 206 participants. Since 264 participants were included in the study, the sample exceeded the minimum requirement and was considered adequate for generating reliable quantitative findings and capturing community perspectives.

n=423/(1+423(0.05)^2)=423/(1+1.0575)=423/2.0575≈206

Ethical consideration

Ethical clearance for the study was obtained from the Inter-Faculty Human Research Ethics Committee (IFHREC) prior to data collection (Ethics Clearance Reference Number: ZHO002-24 Project). Before participation, all participants were provided with information regarding the purpose of the study, the voluntary nature of their involvement, and their rights as research participants. Participants were informed that they could withdraw from the study at any stage without penalty. Issues relating to confidentiality, anonymity, beneficence and informed consent were explained both verbally and in writing. Written informed consent was obtained from all participants before data collection commenced and all information provided was treated confidentially and used solely for research purposes. Detailed information relating to sensitive materials, such as photographs and other potentially identifiable data, has not been reported to protect participant privacy.

Data collection

Data were collected between February and June 2025 by the researchers and trained research assistants in Nompumelelo, Eastern Cape, South Africa. In line with the convergent mixed-methods design, interviews and questionnaires were administered concurrently in English and isiXhosa, depending on participants’ language preference. The qualitative component involved semi-structured face-to-face interviews with purposively selected KIs using an interview guide comprising open-ended questions on sanitation access, WASH service delivery, alcohol accessibility and hygiene practices. Interviews were audio-recorded with participants’ consent, lasted approximately 30–45 min and were subsequently translated and transcribed into English.

Data saturation was reached after 15 KIs, as no substantively new themes or perspectives emerged. The trustworthiness of the qualitative data was enhanced through the use of a semi-structured interview guide, audio recording and verbatim transcription, researcher familiarisation with the data, and systematic coding of transcripts. Credibility was further strengthened by triangulating qualitative findings with the quantitative survey results during data integration. The quantitative component utilised a structured questionnaire consisting predominantly of closed-ended and Likert-scale items, complemented by a limited number of open-ended questions to capture additional contextual insights. To enhance content validity and face validity, the questionnaire developed from the relevant WASH literature and reviewed by researchers with expertise in water, sanitation, and public health before data collection. A pilot study was conducted in a neighbouring peri-urban community to assess the clarity, relevance, and comprehensibility of the questionnaire, resulting in minor revisions to the wording and sequencing of several items prior to the main survey. The questionnaire comprised five sections covering (i) demographic characteristics; (ii) household access to water and sanitation services; (iii) perceptions of WASH infrastructure and service delivery; (iv) hygiene practices; and (v) perceived alcohol accessibility and its influence on sanitation.

Quantitative responses were recorded using descriptive statistics, including frequencies, percentages, and mean scores. Household survey responses were collected using five-point Likert-scale items ranging from 1 (strongly disagree) to 5 (strongly agree). For each assessment indicator, the household mean score was calculated by averaging the Likert responses of all survey participants. Corresponding key informant (KI) ratings were independently assessed using the same five-point scale, and the mean KI score was calculated for each indicator. To facilitate integrated interpretation, the household and KI mean scores were assigned equal weight and combined to produce a composite score out of 10. The composite score was then converted to a percentage using the formula (Composite score ÷ 10) × 100, with higher percentages indicating stronger perceived influence or agreement. These percentage scores were subsequently used to compare, rank, and interpret the relative importance of the identified alcohol-WASH themes.

Data analysis

The collection of data involved in-depth interviewing of 15 KIs using a semi-structured interview guide and by distributing matrix questionnaires to 264 community members. Qualitative data obtained from the key informant interviews (KIIs) were analyzed in the ATLAS ti.24 software which is specifically designed to manage large volumes of qualitative data (González-Prieto et al., 2023). Data analysis began after data collection and transcription, followed by importing the data files into ATLAS.ti 24, where coding and cross-linking allows themes to be identified and patterns to be analysed. The analysed data were then visualised in the form of a flowchart that illustrates the thematic relationships and conceptual frameworks that emerge from the qualitative data analysis. This flowchart's ability to support the rigorous management and analysis of qualitative data was helpful by enhancing the generation of informative insights with this assertion being supported by other researchers in the likes of Smit et al. (2021) and Muchaku and Magaiza (2024). The compiled matrix questionnaire-based data were analyzed and presented as matrix scores because of their robustness in boosting the dependable analysis of multi-sourced data (Winters, 2006). The conjunctive use of these two-software packages enabled rigorous and comprehensive analysis by enabling the integration of qualitative and quantitative data collected from the study area. This approach provided deeper insight into the challenges facing Nompumelelo and informed the development of evidence-based recommendations applicable to both the study community and other peri-urban settings. This case study provides a timely contribution to WASH scholarship by illuminating the socioeconomic, behavioural, and institutional factors that influence sanitation access and utilisation. In doing so, it offers valuable lessons for improving the sustainable delivery of WASH services in resource-constrained peri-urban communities across developing countries. This analysis attempts to do this by exploring the underlying factors that contribute to the relentless persistence of alcohol consumption's adverse effects on the provisioning of WASH services in peri-urban settings.

Results and discussion

This section presents findings on the relationship between alcohol consumption and sanitation practices in Nompumelelo, demonstrating how behavioural, socio-economic and environmental factors shape WASH outcomes in peri-urban settings. Data from KIIs were analysed using Braun and Clarke's six-step thematic analysis framework. An inductive coding approach was applied in ATLAS.ti, where verbatim transcripts were systematically coded to identify recurring patterns, relationships and meanings emerging from participants’ experiences (Naeem et al., 2023). Previous studies have largely examined alcohol consumption and WASH as separate public health issues, with limited attention to their intersection in informal settlements. This study addresses this gap by providing empirical evidence on how alcohol consumption influences sanitation and hygiene behaviours in South African informal settlements, thereby contributing to a more integrated understanding of alcohol-related WASH challenges.

Clarification of study population

Matrix scores of quotations reflecting lived experiences of alcohol use and sanitation practices

To enhance analytical rigour and transparency, selected verbatim quotations representing each theme were further evaluated using a matrix scoring system (see Table 1). Two researchers independently assessed the extent to which each quotation reflected participants lived experiences based on evidence from the key informant interviews, using a five-point scale where 1 indicated very low agreement and 5 indicated very high agreement. The scores assigned by the two researchers were averaged and converted into percentages to facilitate comparison across themes. Any scoring discrepancies were discussed and resolved through consensus to improve consistency and minimise subjective bias.

Table 1. Demographic characteristics of survey respondents (N = 264) .

Some demographic data were unavailable due to participant non-disclosure. Variables not collected during fieldwork could not be retrospectively generated and are acknowledged as a limitation of the study. The study comprised two participant groups; that is, a) survey respondents (n = 264) and (b) key informants (n = 15). Consequently, the demographic table reports the total sample size (N = 279), representing participants from both groups. The former comprised general adult residents of Nompumelelo, while the latter consisted of stakeholders purposively selected for their specialised knowledge of WASH and local community conditions. This approach aimed to capture a broad understanding of WASH challenges in the settlement by combining adult community perspectives with expert stakeholder insights.

To strengthen analytical rigour and facilitate the integration of qualitative and quantitative findings, a matrix scoring approach was applied to the thematic analysis (see Table 2). Following theme development, two researchers independently evaluated the degree to which each selected quotation reflected the underlying evidence generated from both key informant interviews and survey responses using a five-point scale (1 = very weak support; 5 = very strong support). Mean scores were computed separately for KIs and survey participants and subsequently combined to produce an overall thematic score. To enhance comparability across themes, composite scores were standardised as percentages of the maximum attainable score. Discrepancies between researchers were resolved through discussion and consensus, thereby improving consistency, reducing subjective interpretation and enhancing the trustworthiness of the findings.

Table 2. The dual challenge of alcohol consumption and sanitation practices.

KIs (n = 15) represent the average prominence scores assigned to each theme based on evidence from the 15 key informant interviews, while Survey (n = 15) represents the corresponding average scores derived from the household survey responses. Matrix scores were rated on a five-point scale (1 = very low prominence, 2 = low, 3 = moderate, 4 = high, and 5 = very high). The Average (%) represents the integrated prominence of each theme, calculated by combining the qualitative (KI) and quantitative (survey) matrix scores to facilitate comparison across themes. Italicised text denotes verbatim quotations from key informants.

Table 2 presents the matrix scores of selected verbatim quotations reflecting KIs’ lived experiences of alcohol use and sanitation practices. The highest scores were recorded for quotations associated with failure to maintain basic hygiene standards (76%), a culture of apathy towards health risks (75% and 74%), the use of flying toilets (74%), and alcohol-induced incontinence (73%). Quotations relating to overburdened sanitation infrastructure also received relatively high scores (72%). In contrast, lower scores were observed for quotations associated with budgetary constraints and prioritisation (44% and 53%). Overall, the matrix scores indicate moderate to high levels of agreement regarding the extent to which the selected quotations reflected KIs’ lived experiences.

Figure 2A shows the typical living conditions in Nompumelelo. The white and grey structure on the right side of the image (see Figure 2B) is the rear view of a poorly ventilated communal toilet and shower facility that, when operational, can be used by over 50 households. Due to lack of maintenance and inadequate sanitation facilities, the back of the toilet is contaminated with faecal matter and frequently used for open-air urination as some people resort to open defecation. The bucket hanging on the wall is used for manual flushing and bathing as running tap water is rarely available.

Alcohol-induced incontinence

A critical issue that emerged from the findings is the link between excessive alcohol consumption and compromised hygiene practices. Specifically, alcohol-induced incontinence was identified as a significant contributor to unsanitary conditions in the community (see Figure 1). Respondents highlighted that alcohol impairs decision-making, often leading individuals to lose control of their bodily functions, resulting in urination or defecation in public spaces. As shown in Figure 1, 80% of respondents reporting that excessive alcohol consumption is linked to unsafe hygiene practices, while 20% disagreed, arguing that alcohol has no direct impact on behavior. Although some respondents challenge this view (see Figures 1,2), research by Yuan et al. (2024) supports the argument that alcohol abuse impairs decision-making. This assertion is supported by Siddique et al. (2023) who assert that excessive alcohol consumption impairs cognitive function, decreasing compliance with safe sanitation practices and increasing the likelihood of open defecation and improper waste disposal. This challenge is particularly acute in peri-urban settlements such as Nompumelelo, where inadequate sanitation infrastructure is further aggravated by the misuse of limited facilities (Zhou and Shadreck, 2025).

Beyond environmental concerns, alcohol-induced incontinence has far-reaching social and public health implications (Yuan et al., 2024). One respondent recounted assisting friend who was incapacitated and disoriented after excessive drinking, illustrating the broader consequences of alcohol misuse. These incidents raise concerns about public health, human dignity and social cohesion, key priorities aligned with the SDGs (Amer and AlDajani, 2024). The loss of dignity associated with such events extends beyond the individual, affecting families and eroding social bonds (Siddique et al., 2023). Additionally, in communities where sanitation services are scarce, such behaviors heighten health risks and further degrade living conditions (Munyai, 2023). Addressing this issue requires a multi-faceted approach that integrates public health interventions with behavioral change strategies. Initiatives that promote responsible drinking while reinforcing community norms around hygiene and sanitation are essential. Lessons can be drawn from global programs that have successfully reduced substance abuse-related behaviors through targeted awareness campaigns and policy interventions. The take-home message from these programs is that community-tailored interventions can go a long way in enhancing our capacities to mitigate the dual burden of alcohol misuse and inadequate WASH services not only in Nompumelelo, but other peri-urban areas elsewhere.

Triggers the use of flying toilets

The widespread reliance on “flying toilets”, plastic bags or containers used for urination and defecation, within informal taverns and bars in the community emerged as a critical public health concern (Abdulhadi et al., 2024). Our findings indicate that this practice is particularly prevalent among heavy drinkers near alcohol consumption areas, where limited access to sanitation facilities exacerbates the problem. Open defecation and urination were especially common in these spaces, posing significant hygiene and environmental risks (see Table 1 and Figure 2B). While non-drinkers were not entirely exempt from engaging in open defecation, the behavior was notably more frequent among habitual alcohol consumers (see Figure 1). Respondents attributed this hazardous practice to impaired decision-making associated with excessive alcohol consumption, as confirmed by KIs (see Figure 1). Additionally, pollution of water sources and major public roads was often linked to these unsanitary behaviors, further compounding public health risks. Interviews with community members underscored the deeply entrenched nature of this issue, highlighting its intersection with systemic infrastructure deficiencies. Evidence suggests that targeted improvements in sanitation infrastructure near alcohol consumption zones promise to enhance the meaningful assimilation of behaviours that are potentially capable of safeguarding public health creating space for these harmful practices to be avoided.

Failure to maintain basic hygiene standards due to impaired judgement

The widespread accessibility of alcohol in Nompumelelo's peri-urban areas has significant implications for sanitation practices. Findings indicate that excessive alcohol consumption exacerbates poor sanitary conditions, as 68% of respondents reported that alcohol misuse impairs judgment regarding proper sanitation behaviors (see Figure 1). Intoxicated individuals often neglect basic hygiene, such as flushing toilets or using sanitation facilities responsibly, leading to the contamination of shared amenities. This negligence heightens public health risks, particularly in areas where sanitation infrastructure is already strained (see Figure 2B). Additionally, respondents highlighted those sanitary facilities at alcohol-serving venues, though intended for public use, often rely on users to maintain cleanliness. However, intoxication frequently leads to unhygienic conditions, making it difficult to sustain safe and sanitary environments. Given the prevalence of inadequate and poor sanitation facilities (see Figure 1) and water resources in peri-urban settlements like Nompumelelo (Pillay et al., 2010a; Munyai, 2023), the negative impact of alcohol-related unhygienic practices further compounds existing challenges. Addressing these sanitation concerns requires a multi-faceted approach that includes public health awareness campaigns, community-led interventions and improved infrastructure to mitigate the effects of alcohol misuse on shared sanitation services. Strengthening regulatory measures around alcohol accessibility in vulnerable communities, coupled with enhanced waste and water management strategies, is essential to ensuring that public health risks do not escalate further.

Budgetary constraints and prioritization on purchasing sanitary materials

A key finding from this study is that sanitation-related decisions in resource-constrained households are shaped by intersecting financial constraints, income insecurity and limited access to basic services in peri-urban contexts such as Nompumelelo. As one key informant representing health professionals aptly remarked, “The irony of human choices lies in the fact that beer is considered a daily necessity, while sanitation is often treated as an afterthought” (See Figure 1). Rather than reflecting individual “preferences,” these patterns highlight the structural conditions under which households must allocate scarce resources across competing essential needs, including hygiene materials and sanitation maintenance. Within this constrained environment, alcohol consumption is described by participants as one of several coping strategies for managing socioeconomic stress, consistent with existing literature on substance use in contexts of deprivation (D’Aquino and Callinan, 2024; Taylor et al., 2019; Zhou and Shadreck, 2025). However, these interpretations are derived from qualitative evidence and do not include household expenditure data; as such, they cannot substantiate claims of prioritisation or causal relationships between alcohol and sanitation spending. Instead, the findings point to an interaction between structural deprivation and coping practices that may be associated with delayed sanitation maintenance and increased reliance on unsafe alternatives. These dynamics are best understood through a socio-ecological lens, where individual behaviours are embedded within broader systems of poverty, service delivery constraints and infrastructural inequities that jointly shape health-related practices in marginalised communities.

Vandalism and abuse of WASH infrastructure

Although excessive alcohol consumption in this study was not perceived to be associated with physical violence, it emerged as a significant challenge to the sustainability of community sanitation and WASH infrastructure. Respondents frequently reported incidents where intoxicated individuals engaged in the vandalism or misuse of facilities, such as leaving taps running unattended, leading to considerable water wastage. This behaviour exacerbates the existing water crisis and places additional strain on aging and fragile infrastructure. Furthermore, the damage to public toilets and water points disrupts essential service delivery and hygiene management, heightening public health risks for the community (Heard, (2019). The misuse, overcrowding and frequent use of these facilities by intoxicated individuals further reduce accessibility, intensifying sanitation challenges (see Figure 1). These findings are in agreement with observations by Ballard et al. (2022) and by Keramati et al. (2023) that highlight the association between alcohol misuse and the deterioration of public infrastructure. Beyond the immediate physical damage, such behaviours reflect a deeper intersection between substance abuse and resource mismanagement. Scholars such as Patel (2024) argue that excessive alcohol consumption often leads to the irresponsible use of essential resources, undermining both environmental sustainability and community well-being.

Addressing these challenges requires a multifaceted approach. First, public awareness campaigns should emphasize the responsible use of communal WASH facilities while fostering a culture of accountability within the community. Second, targeted interventions for substance abuse prevention, particularly those incorporating behavioral change models, could help mitigate the root causes of alcohol misuse. Finally, collaborative efforts between local authorities, WASH service providers and community leaders are essential in safeguarding infrastructure, promoting sustainable sanitation practices and ensuring long-term service delivery. By integrating these strategies, communities can work towards enhancing WASH resilience and improving overall public health outcomes.

Overburdened sanitation infrastructure

This study highlights a significant pattern between alcohol consumption and sanitation practices in informal social spaces, particularly taverns. These establishments often operate without adequate planning, infrastructure, or plumbing, further straining already fragile sanitation systems. Community members emphasized that the high concentration of people in these spaces is associated with a) frequent blockages and overflows, b) unsustainable and unsanitary conditions, c) pollution and d) the deterioration of water sources, particularly in areas lacking proper sewage systems. These findings reinforce the existing infrastructural inadequacies in Nompumelelo, where rapid population growth continues to outpace service delivery (Pillay et al., 2010b). Prior research supports the notion that alcohol-related activities exacerbate sanitation challenges, particularly through the overuse and misuse of limited facilities (Agberotimi and Adekunle, 2024; Eberendu et al., 2024). Beyond direct sanitation concerns, improper waste disposal in and around drinking establishments worsens environmental degradation. Littering, discarded bottles and other waste materials frequently clog drainage systems, increasing the risk of flooding and water contamination, especially during heavy rain, eutrophication of fresh water sources from inappropriate disposal of nutrient-rich human waste and urine. These challenges underscore the need for integrated urban planning and waste management strategies that address both behavioral and infrastructural shortcomings. Addressing these issues requires a holistic approach that includes improved urban sanitation planning, community-led waste management initiatives and behavioral interventions that promote responsible waste disposal. Without such measures, the intersection of alcohol consumption and inadequate sanitation will continue to pose significant public health risks in peri-urban areas like Nompumelelo

Collective efficacy and structural disengagement in Nompumelelo

The findings reflect service-delivery fatigue, institutional distrust and erosion of collective efficacy resulting from sustained infrastructural neglect in Nompumelelo. Residents express clear dissatisfaction with deteriorating sanitation conditions; however, this is coupled with resignation shaped by repeated experiences of limited municipal responsiveness and constrained capacity to effect change. Over time, these conditions weaken expectations that collective action will yield meaningful improvements, thereby reducing coordinated community engagement in sanitation maintenance and advocacy. Within this context, alcohol use functions less as a primary cause of disengagement and more as a coping mechanism within a structurally constrained environment, where immediate relief is prioritised over long-term behavioural or environmental improvements. This dynamic interacts with poor sanitation conditions to increase the likelihood of unsafe hygiene practices, as illustrated by participant accounts linking excessive drinking to inappropriate use of sanitation facilities.

A key informant representing community leaders aptly stated, “People who drink may not share my views, but excessive drinking often results in the irresponsible use of sanitation facilities.”

These findings suggest that improving WASH outcomes requires interventions that address both material and relational dimensions of service delivery. In addition to upgrading sanitation infrastructure, municipalities must strengthen consistent service provision, enforce sanitation standards and visible responsiveness to community concerns to rebuild trust. Simultaneously, targeted public health and community engagement initiatives should be embedded within settings such as taverns, but their effectiveness will depend on parallel improvements in governance credibility. Strengthening collective efficacy therefore depends not only on behaviour change messaging, but on restoring confidence in institutional performance and sustained service delivery.

Policy implication

Improving peri-urban sanitation requires coordinated regulatory, infrastructural and behavioural interventions. Municipalities, supported by district health and water authorities, should establish formal community WASH committees to oversee local sanitation monitoring and maintenance. Municipal by-laws and licensing regulations should be enforced to require alcohol-serving establishments to provide adequate sanitation facilities, with compliance ensured through routine inspections by environmental health practitioners and penalties for non-compliance. Governments should prioritise investment in sewerage expansion, decentralised wastewater systems and communal sanitation facilities in peri-urban areas, aligned with Integrated Development Plans. At the same time, primary healthcare services, NGOs and community health workers should deliver substance abuse counselling, mental health support and prevention programmes, supported by community-led awareness campaigns involving ward councillors and traditional leaders. As a pilot study, these findings are exploratory and limited in scale. Future full-scale study should involve a larger, more representative sample across multiple peri-urban settlements, employ mixed-methods designs and include longitudinal data collection.

Study limitations

This study is limited by its cross-sectional design, which captures perceptions at a single point in time and therefore does not allow for causal inference. In addition, the use of non-probability sampling restricts the generalisability of findings beyond Nompumelelo settlement. The study also relies on self-reported data, which may be influenced by perception and recall bias, although this is appropriate for capturing lived WASH experiences. Finally, the context-specific focus on one peri-urban settlement limits direct transferability to other WASH settings with different infrastructural conditions.

Conclusion

This study advances understanding of the nuanced relationship between alcohol consumption and WASH challenges in peri-urban contexts, using Nompumelelo as an illustrative case. The findings suggest a perceived alcohol-WASH vulnerability cycle, in which participants described alcohol use and weak sanitation systems as interacting in ways that may reinforce unsafe sanitation practices. Participants perceived alcohol use as being associated with unsafe sanitation practices, increased strain on limited infrastructure, vandalism of WASH facilities and reduced adherence to hygiene norms. In turn, inadequate and poorly managed sanitation conditions normalise poor hygiene behaviours and weaken community capacity to demand or maintain improved services, thereby perpetuating structural vulnerability. The findings further suggest that this cycle may be sustained by governance and service delivery gaps, particularly weak enforcement of sanitation standards in alcohol-serving environments and limited integration of behavioural health considerations into local WASH planning. This study contributes to the limited empirical evidence on the relationship between alcohol consumption and WASH outcomes in informal settlements by integrating quantitative household survey findings with qualitative insights from key informants. In doing so, it extends current understanding of how behavioural, infrastructural and governance factors interact to influence sanitation and hygiene outcomes in vulnerable communities. Overall, the findings demonstrate that sanitation challenges in peri-urban settlements cannot be effectively addressed through infrastructure provision alone.

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Footnotes

Edited by: Samson Femi Agberotimi, University of Ibadan, Nigeria

Reviewed by: Rotimi Oguntayo, University of Monterrey, Mexico

Joshua Ogunsemi, Redeemer’s University, Nigeria