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Poor sanitation causes 30% of diarrheal deaths globally, and much of the world has struggled to finance top-down interventions. Sanitation marketing is a demand-led approach that uses a mixture of social and commercial marketing methods and direct sales to households. However, little is known about its impacts on household decision making. This mixed-methods study uses data from eight focus groups and 86,666 household surveys from participants in a five-year sanitation marketing program in Uganda. Logistic regression models identified 10 variables predicting attainment of improved (limited or basic) sanitation and four variables predicting female involvement in decision making. Triggering session attendance increased chances of reaching improved sanitation by 15–28%, depending on who attended, and by 19% if the household found the session motivational. Although women were engaged in decision-making conversations, they were not viewed as primary decision makers, even in female-headed households. Women were more likely to become involved in decision making if they had attended triggering sessions with men (+70%) or engaged with sales promoters alone (+74%) or with men (+78%). For both outcomes, joint activity engagement was more effective than male or female engagement alone. This work highlights two sanitation marketing activities as pathways to improving latrine coverage and women’s decision-making agency.