Three key hygiene practices of safe disposal of feces, hand washing with soap at critical times, and the treatment and storage of drinking water are the most effective ways of reducing diarrheal disease. The objective of this study was to determine the community awareness and practice on sanitation, hygiene and water use and to estimate the prevalence of diarrhea in the community.
The study has demonstrated that three quarters of the respondents regularly treat their drinking water and straining against cloth and boiling are the common ones. This result was higher to other studies that an estimated 33% of the households in these countries report treating their drinking water at home and boiling were the most dominant water treatment method (21%).  Other study also reported that household water treatment was practiced by 34%  and 18.3%  of the respondents and Chlorination was a major (20%) method of HWT . This higher practice of water treatment could be mainly due to their higher level of knowledge on the methods and on the disease burden compared to the other study groups.
This study showed that the community has high level of good comprehensive knowledge and practice of on sanitation, hygiene and water treatment options. This result was high compared to other studies that the overall mean knowledge of adults in terms of water safety, sanitation and hygiene was 78.1% . And in another study good knowledge and practice on WASH were observed in 42.2% and 49.2% of the respondents, respectively . This high level of knowledge and practice in the city could be mainly due to the continuous input of the Ministry of Health and the Eritrean Government in improving the life standards of the community in general and the proper utilization and usage of latrines and sanitation through the community lead total sanitation programs of increasing awareness and triggering processes.
Based on the trained investigators practical observation of the communities during data collection, most of them had functional toilets and about one tenth use neighbor’s toilet if they lack toilet. This result was similar (88.6%)  and higher (71%) to other studies . This higher utilization of latrines in the community reflects the works done by the environmental health program of Ministry of Health in construction and proper utilization of latrines in the community to end open defecation in the country.
During the spot observation by the investigators, feces were observed in the living area in only 5.7% of the households. This result was lower to other study from Ethiopia which reported 11.4% of the households practiced open-field defecation . This lower practice of open defecation in the community reveals their awareness and the increased utilization of latrines that enhances the motive to end open defecation in Eritrea to achieve the sustainable development goals.
This study indicates that about half of households claimed they wash their hands after defecating and most of them use water and soap. Similarly, peri-urban Ethiopian study showed that hand washing after using the toilet was practiced by 67% of households. And, 48% wash their hands with soap and water . Despite these results and even though almost all self-reported that regular hand washing is very important, but during practical observation the narrative changes. Mothers’ hands were not clean in 22.7% of them and only 22.9% of the households had soap at the toilet during the investigators visit, which is better than similar Ethiopian study (14.98%) . This shows that the practice of hand washing with soap after defecation is questionable. And that actual practice of proper hand washing in the community seems lower to the self-reported practice and could be some of the reasons for the higher prevalence of diarrhea in the households.
This study depicted two third % of the households wash the water storage containers used for drinking water on weekly basis and majority with water and OMO (detergent). This practice was higher to other study where 46% of households clean their water tanks . This further mirrors the higher awareness of the community on household water treatment techniques.
The trained investigators observation was crucial in assessing the gap on maintaining water safety, and personal sanitation and hygiene. And despite the communities’ relatively better knowledge about waterborne fecal-oral disease, the results showed discrepancies on actual practice. Absence of garbage container, unclean mother’s hand, absence of soap at toilet, uncovered food and feces in the living area were the noted indicators of actual sanitation and hygiene practices in the community. Hence, empowering the community to increase their practice through behavior change and sustaining the current results would be crucial.
Though the majority of participants are satisfied with the quantity and quality of water supplied; bad taste, poor quality and water turbidity were reported as major problem by one-third of them. Therefore, it is essential to introduce household piped water method or the household water treatment options should be enhanced.
The prevalence of diarrhea in the community in the last six months and in children less than five years age was 13%% and 10.1% respectively. This was similar to other study that the two-week prevalence of diarrhea in children under 5 years of age was 13.6% . And lower to other study that 19.1% households experience diarrhea symptoms in the last six months . This lower prevalence in diarrhea in the community could be mainly due to that they had higher knowledge on the association between sanitation, hygiene and diarrhea and also higher percent of the community were using water treatment techniques in their house. The introduction of Rota virus vaccine could have also an impact on the lower prevalence of diarrhea in children less than five years in the community.
Based on the results of this research, the administrative area in the city showed significant association with their comprehensive practice, prevalence of diarrhea, distance to municipality water source and hand washing practice. Other studies showed that statistically significant differences were observed on the levels of knowledge and education .
Strength and limitation of the study
The self-reported practices of the respondents were verified by practical observation of the investigators, which increases the validity of the respondents. This research tries to answer all aspects (sanitation, hygiene and water use) which can cause diarrhea to increase the strength of the study. Further studies with larger sample size that includes the urban and rural communities from different zoba’s and different ethnicities are necessary to have different responses
The study was no without limitations. It was conducted in one city which the results can’t be used to generalize to the whole country. Since there was no similar study conducted before in the country, it was difficult to associate the results with national previous studies.