Authored by Roland S Kabange
Abstract
Dangerous and unhealthy sanitation practices, attitudes, and beliefs significantly contribute to adverse public health outcomes in low-income peri-urban communities of developing countries. This research explores sanitation practices and attitudes of the Kotoko community in Kumasi (Ghana) through household survey triangulated by in-depth and key-informant interviews and transect walks. In 67 households lived 2,226 people with average household and family sizes of 33 and four respectively. The ‘sanitation facilities’ used in the research community were broadly grouped into community, private, and open (or inappropriate) defecation. The results showed that two-thirds of respondents reportedly defecated in the community pour-flush (PF) latrine, while 9% of respondents were open defecators, and the rest defecated in private (either own or neighbor’s). Among the two-thirds of respondents who used the community PF latrine, 56% (a larger majority men) were dissatisfied with its condition on grounds of poor maintenance and queuing, while 8% attributed the dissatisfaction to the distance of the facility from their homes (proximity concerns). These results also provided an initial indication for community sanitation improvement support. The majority (83%) of the open defecators were men and all were willing to participate in community sanitation projects. The research community sanitation expenditure was categorized into low (0 – Ghȼ4.9), medium (Ghȼ5.0 – Ghȼ9.9), and high (Ghȼ10.0 – Ghȼ14.9) payment bands and 61%, 29%, and 10% of respondents respectively paid within these bands – giving an average expenditure per capita per month as Ghȼ4.95 (USD3.01). There was no evidence to suggest that either willingness to pay and use a sanitation facility was age-sensitive, or willingness to participate in community sanitation projects was gender-sensitive in the research community when Pearson chi-square (χ2) non-parametric tests were conducted. Regular facility cleaning (15%) and pit emptying (15%) were significant reported operation and maintenance practices at the community facility. The research findings indicated potential overuse and poor maintenance of the community PF latrine, suggesting inadequate sanitation provision. There was however a high sense of community participation spirit in sanitation projects. Improved maintenance of the community PF latrine, and either the construction of an additional latrine or expansion of the existing one are recommended.Keywords: Sanitation practices and attitudes; Peri-urban; Latrine usage; Community latrine; Ghana
Introduction
Cairncross & Satterthwaite [1] contend that adequate sanitation would reduce the spread of diseases and lead to wider social, economic and environmental benefits. The global challenge of improved sanitation access is compounded by an existing gap between attitude, practice, and knowledge [2]. Dangerous practices, attitudes and beliefs, poverty, poor governance, extreme climate, and high population densities are found to increase the likelihood of negative public health outcomes [3]. A research on women sanitation practices in Kenya found that they defecated in plastic bags and threw them on streets because they did not want to be seen using sanitation facilities often [4]. The impact of unhygienic practices on the health of communities is devastating. The unhealthy open defecation practice, for instance, degenerates into deadly diseases such as tuberculosis, cholera, hepatitis, dysentery, typhoid and diarrhoea [5]. The author argues that Ghana is currently practicing nearly 100% open defecation in principle, as about 5.2 million Ghanaians (or 19% of total population) openly defecate [6], while collected and stored excreta and other waste are mostly improperly disposed, which technically, equates to open defecation. The repercussions of open defecation and inappropriate waste disposal are eutrophication of aquatic life, adverse health implications on Ghanaians, and environmental degradation. Water, sanitation, and hygiene (WASH) interventions in schools are however found to improve behavioural practices and enhance knowledge in developing and developed countries alike [2], but these intervention outcomes cannot be realized without adequate investment in the sanitation subsector.A South African study found that sanitation investment can lead to the adoption of safer and hygienic practices, with accrued benefits – morbidity and mortality reduction, life expectancy and general health improvement, and healthcare cost savings [7]. Unhygienic sanitation practices such as indiscriminate excreta, solid, and liquid waste disposal adversely affects individuals, families, and economies in terms of life quality, education, and development, promotes diseases and poor health [8]. Morgan [9] argues that poor health in turn places individuals and families in a cycle of poverty and lost income. Over 50 communicable diseases are associated with poor sanitation practices and attitudes, often resulting in millions of premature deaths annually, especially children [10]. Health education and promotion strategies to ensure households understand and practice healthy waste management to prevent diseases are therefore necessary [2]. Socio-cultural preferences, which are a function of sanitation practices and attitudes, play a significant role in sanitation facilities selection and usage [11], which lead to sanitation improvement and ultimately improved health. For instance, while it is expected that sanitation facilities users would prefer to sit rather than squat to defecate, recent research found that users in a predominantly Muslim community in Ghana preferred to sit in a specific direction (North-South) during defecation so as not to face Mecca nor give their back to it [12,13].
Research Aim and Objectives
There currently exist dangerous and unhealthy sanitation practices, attitudes, and beliefs in Ghana that significantly contribute to adverse public health outcomes. Adverse health outcomes in turn put individuals and families in a cycle of poverty, and increased healthcare cost to economies. This research aim is therefore to assess the sanitation practices and attitudes in the low-income high-density peri-urban Kotoko community to inform future sanitation interventions. Based on the research aim, the following under-listed objectives are therefore set to:• Determine the research community’s initial and current sanitation situations, including its history and initial prevalent common diseases;
• Determine the research community’s sanitation practices, attitudes, and beliefs; and
• Make recommendations to inform future sanitation improvement interventions.
Kumasi and the Research Community (Kotoko)
Kumasi is Ghana’s second largest city and capital of the most populous region (Ashanti). Kumasi’s population is roughly 1.6 million with a land area of 22,300 km2, residents are predominantly Christians (79%) and Muslims (16%), 1% belongs to other religious denominations, and 4% reported no religious affiliation [14]. English and languages of the Akan tradition are the main languages spoken in Kumasi. Four main streams (Daban, Sisa, Wiwa and Subin) flow through the city, which then join the Oda River downstream. Characteristic of Kumasi’s drainage system is a concrete drain superimposed on the Subin to avert flooding in the city. This concrete drain, however, has now been turned into a “solid and liquid waste super-highway” due to the dumping of all sorts of wastes in it. Figure 1 shows the map of Kumasi, the research community (Kotoko), other Sub-Metropolitan areas, and major roads.Kotoko is a multi-ethnic predominantly Muslim community in the Suame district and located close to the Kumasi City Centre (Kejetia). Households are built mainly from mud and bamboo, and roofed using old rusted corrugated iron sheets. The community is a heterogeneous one and composed of descendants of immigrants from northern Ghana. It is a high-density slum community characterized by inadequate infrastructure, land tenure challenges, and a mix of high- and low-income areas. Although predominantly poor, the socio-economic profile of the community is mixed (Figure 1).
Survey Methodology and Ethics
Three peri-urban communities (Kotoko, Akwatia Line, and Race Course) in Kumasi were preliminarily short-listed for the research based on the defining elements of a peri-urban community – infrastructure situation, population density, estimated level of community co-operation, and household income. Kotoko community in Suame (Kumasi) was finally selected for the research on the strength of the defining elements. Community meetings were held at the elders, unit committee, and community levels before the household survey to brief them on the research and gain the community’s informed-consent and willingness to participate. In compliance with Muslim tradition and norms, financial tokens were provided after the elders’ meeting and key-informant interview. Contact was established with key stakeholders (Kumasi Metropolitan Assembly (KMA), Kumasi Technical University (KsTU), and The University of Leeds) at the beginning of the household survey. Though there are currently no ethics standards for general research in Ghana, ethical approval was sought from The University of Leeds for the household survey. Appropriate permissions were also obtained from KMA and the community, and attempts were made to phrase questions in a culturally acceptable manner. A local translator was available throughout the fieldwork, as most community members had neither formal education nor common language [15].Sampling and questionnaire design
The questionnaire was designed, pre-tested, and customized to suit local circumstances. The pre-test was to identify and rectify flaws in the questionnaire design, unearth its positive features, determine interviews timelines, and any reviews required to make the questionnaire self-explanatory, accurate and reliable. The pretest commenced on a Sunday at 6 am, as it was the most convenient day and time to get household members at home. A total of ten randomly-selected respondents was interviewed in the pre-test. Due to hot temperatures of about 40 °C, the pre-test was limited to the morning session only. Sixty-seven respondents overall were interviewed in the household survey, one from each household. One household member (household head, family head or an adult) of at least 16 years was randomly identified and interviewed. The identified respondent was briefed on the interview process and requested to either complete the questionnaire if educated, or translation was done, and the respondent’s exact answers were written down. When a potential respondent refused to offer an interview, the next nearest adult member of the household was approached, and the process was repeated. To avoid interviewing households twice, a mark was left at the entrance of households interviewed before proceeding to the next. Completed questionnaire were reviewed at the end of each interview day to improve data collection quality. Three consecutive Sundays were used to complete the questionnaire administration. The household survey questionnaire consisted of six sections and provided information on socio-demographic and housing characteristics, water supply and excreta disposal, community participation in sanitation projects, existing sanitation provision, operation and maintenance, and sanitation expenditure.To gather qualitative data on the community, observation and unstructured interviews were additionally employed. Observation took the form of a transect walk to gather information on behaviour, environmental conditions, physical structures, water use patterns and practices, and defecation practices, attitudes, and beliefs. Unstructured in-depth interviews with two community elders were also conducted. The community history, experiences, and situations were documented and transcribed. The two interviews took place on two separate occasions in the elders’ homes and lasted about 30 minutes per interview. An interpreter service was provided who directly translated the informants’ perspectives as expressed in their own words. The gathered information was triangulated by two key-informants’ interviews where necessary to minimize bias, errors, and increase findings reliability. UNDP [16] and UN MDG [17] publications on household survey design were useful methodology material.
Result and Discussion
A family in this research referred to a person (or persons) who lived together in a structure (or part of it) and were catered for as a unit with the same house-keeping arrangement. A household, however, referred to single or multiple families who lived in a single compound structure. A worker was anyone who did any form of activity that directly or indirectly brought financial rewards to support the family. With a total of 67 households, the average household size was 33, and household sizes ranged from 3 – 113. These results were in sharp contrast to an average household membership of 4 – 6 people when sanitation attitudes and practices study was conducted in Kenya [2]. An earlier work in Kumasi (Ghana), however, found that over 55% of households lived in buildings with more than 10 people [18]. The average household size of 33 was comparable to MICS [19] data that found 29% and 28% of 6,302 sampled households in Ghana had sizes of 45 and 2-3 members respectively. The research community had 543 families with an average family size of four. Huge variations therefore existed in household and family sizes in the research community.Household survey and demographic data
The research community population distribution was skewed in favour of the adult category (summarized in Table 1). From a total of 2,226 inhabitants, children five years and under constituted the least proportion (15%) of the population, 57% were adults 18 years and above, and people between 5-8 years constituted 28% of the community population. A significant 42% of the community were workers. Most (66%) respondents were men, and 70% were household heads or family heads, 30% of whom were women. Mariwah & Drangert [20] argued that most often the heads of household were men, and most women expected husbands (or men) to discuss matters related to the household, which explained why more men than women were interviewed. On the contrary, however, a sanitation practices, attitudes, and knowledge research conducted in Western Kenya found that the majority (87.5%) of respondents were women aged between 21 and 30 [2]. The same research further explained that men opted for women to be interviewed because of gender roles. An interesting finding that linked age to sanitation facility choice showed that people were likely to opt for an improved sanitation facility as they grew older [21] (Table 1).
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