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

Introduction Despite sustained investments by the South African government, municipalities, and development partners to achieve Sustainable Development Goal 6 (SDG 6), access to safe water, sanitation, and hygiene (WASH) services remains inadequate in many peri-urban communities. While alcohol misuse has been widely studied as a public health concern, its implications for WASH behaviours and sanitation outcomes remain poorly understood. This study investigated the paradox of alcohol being more accessible than sanitation facilities in Nompumelelo, South Africa, and examined how alcohol misuse influences WASH practices and sanitation-related behaviours. Methods A convergent mixed-methods design was employed, integrating questionnaire surveys with 264 adult residents drawn from a sampling universe of 423 and in-depth interviews with 15 purposively selected key informants. Quantitative data were analysed using descriptive statistics, qualitative data were analysed thematically in ATLAS.ti, and findings were integrated through matrix scoring to identify convergent patterns across the two datasets. Results The integrated analysis identified a strong association between alcohol misuse and compromised sanitation behaviours. Alcohol misuse was most strongly linked to failure to maintain basic hygiene standards (76%), a culture of apathy towards sanitation-related health risks (75%), increased use of flying toilets (74%), alcohol-induced incontinence (73%), and overburdened sanitation infrastructure (72%). Qualitative evidence further revealed that these behaviours were reinforced by inadequate sanitation infrastructure, poor waste management, and limited access to safe WASH services, illustrating how alcohol-related practices interact with structural inequalities to exacerbate sanitation risks and undermine community health. Conclusion The findings demonstrate that sanitation challenges in peri-urban communities cannot be addressed through infrastructure investments alone. Effective progress towards SDG 6 requires integrated interventions that simultaneously strengthen WASH service delivery, address alcohol-related social vulnerabilities, promote sustained behaviour change, and enhance multisectoral collaboration between public health, municipal, and community stakeholders. By explicitly linking alcohol misuse with WASH outcomes, this study extends current understanding of the social determinants of sanitation and provides evidence to inform more holistic and context-responsive WASH policies and interventions.