3.1. Access to Environmental Services

Access to environmental services in this study is; people being able to have sufficient safe drinking water, sanitation and good hygiene services which are necessities for human health and survival. In the absence of these essential services could result in disease prevalence among people, which is a thread to their very existence.

Water supply, sanitation and hygiene are essential services needed for human development, health and survival. An increasing challenge is for the world to provide these environmental services to the growing population. The world projections indicate that two-third of its population will suffer water and sanitation stress by 2025 despite 95% and 80% coverage levels for water and sanitation respectively. (UN HABITATE, 2006), Estimates  indicate that about 2.5 billion people lack improve sanitation facilities and 780 million people still use unsafe water sources in the developing world.  In sub-Saharan Africa, estimates show that almost half a billion will require water and sanitation services in the next 25 years added to the urban population. Inadequate access to safe water and sanitation services coupled with poor hygiene practices kills, sickens thousands of children every day, leads to impoverishment, and diminishes opportunities for thousands more. Ghana is projected to reach 85% coverage for water and sanitation services by 2015 WHO/UNICEF (2008). The provision of these necessities by nations especially the developing, is critical to meeting the Millennium Development Goal (MDG) targets set by the United Nations (UN) .Poor sanitation, water and hygiene have many other serious repercussions. Children and particularly girls are denied their right to education because greater part of their time is spent in search for water. Poor farmers and wage earners are less productive due to illness, health systems are overwhelmed and national economies suffer. Without water, sanitation and hygiene sustainable development is impossible.

3.2. Rapid Urbanization and Access to Environmental Services

Urbanisation, simply defined, is the shift from a rural to urban society, and involves an increase in the number of peoples in urban area during a particular year. Urbanisation is the outcome of social, economic and political developments that leads to urban concentration and growth of large cities, changes in land use and transformation from rural to metropolitan pattern of organisation and governance. Urbanisation- as both a social phenomenon and a physical transformation is one of the powerful irreversible and visible anthropogenic forces on earth. Many of the most important and significant changes associated with the impact of globalisation are taken place in urban areas. More than half the world population approximately 3.3 billion people are estimated to live in urban areas (UN, 2004a, UN, 2004b, UNCHS, 2002, HABITATE, Kraas, 2002). According to some projections over 60% of the world, population will live in cities by 2030. The current average of urbanisation is 0.8%, but this rate varies widely from about 1.6% for all African countries to 0.3% for all highly industrialised countries. More than 50% future population is likely to be concentrated in cities and mainly in developing countries (Bronger 2004,  Kraas2003). Rapid growth of population and its concentration in urban areas have significant implications for the long-term outlook on humanity. Burdened with many of the problems associated with growth, urban areas are increasingly subject to dramatic crisis, especially true in poor countries where economic and financial crisis together with fast and unbalanced growth of urban areas, have created fragmented spaces with spatial segregations’ that aggravates the social exclusion characteristics of those societies. (Beall 2002, Coy and poehler 2002,Priez 2002). The aforementioned problems play an important role in the interactions between urban areas and global environment change. These interactions create a diversity of impacts that can be grouped into two broad categories: those originating in urban areas that have negative effect on global environmental change that have negative effect on urban areas.

A large number of people without adequate provision for safe drinking water and sanitation live in urban areas. WHO and UNICEF report that global water supply coverage in urban areas has remained unchanged since 1990, at 95%. This implies that many governments and water supply providers are managing to keep up with urban growth. But this is now threatened by rapid urbanisation over 2005 to 2015.Global access to sanitation and hygiene in urban areas is, however projected to increase coverage from 80% in 2004 to only 82% by 2015.In many developing countries however, the urban water supply and sanitation situation is far worse. In urban sub-Sahara Africa for example, as many as 50% of the population do not presently have adequate water supplies while 60% lack adequate sanitation and hygiene practices, WHO and UNICEF (2008).It is estimated that almost half a billion persons who require water and sanitation services will be added to urban population in the sub-Saharan African (SSA) countries within the next 25 years. There is a need for urgent measures to improve and extend provision in urban areas, for as new as well as existing households, if outbreaks of diarrhoea become a more regular and frequent occurrences in the continent.

The critical need for improving access to safe drinking water, hygiene, and sanitation services has been recognised by all levels of international development strategies, yet support and financing remain proportionally low. The United Nations Millennium Declaration Codified the Millennium Development Goals (MDG,s) confirmed the central role of water, hygiene and sanitation in sustainable development and towards poverty alleviation(W.H.O Website).However, many countries do not allocate sufficient funds in this sector. It is estimated that halving the proportion of people without access to safe water supply services would cost an estimated 1.8 million USD per year while halving the proportion of people without access to sanitation and hygiene would cost an estimated 11.3 billion USD annually(WHO website).These figures show the critical need to increase in this sector.

The joint monitoring programme for water supply, sanitation and hygiene estimates 1.1 billion people live without access to environmental services such as improved water ,hygiene and sanitation facilities while over half of the developing world population representing 2-6 billion people lack access to improved sanitation WHO and UNICEF (2004).Water ,sanitation and hygiene(WSH) have important social and economic benefits with implications for environmental cleanliness, health, poverty reduction and gender equity. One of the most important benefits of WSH is by providing barriers to transmission from the environment to the human body of diarrhoeal disease which is responsible for an estimated 21% of fatalities of under-five in developing countries 2-5 million deaths per year (Kosek etal 2003).Many debilitating or even fatal illnesses are spread by contamination of the water supply with human faecal matter containing disease-causing viruses, bacteria and parasites. Unfortunately, over one-third of the world’s population nearly 2.5 million have inadequate access to sanitation and over 1 billion people do not have access to enough safe water. This conditions combine with poor hygiene are largely responsible for the fact that 50% of the world’s population suffers delitaling diarrhoea diseases at any given time. Of those affected three million die each year over all polluted water affects the health of 1.2 billion people every year and contribute to the death of 15 million every year. (UNEP Global Environment outlook report 2000)

Disease and mortality are not the only consequences of polluted and scare water.Less attention are paid to the fact that women and children bear much of the cost of dirty water and water shortages. Children are more likely to become ill and women have to look after them. Women and girls carry out most water collection and many spent long hours during so. Time spent in collecting water could be spent on more productive activity such as food production or especially the care children education. As a result, there is a high  opportunity cost to lack of  access to environmental services(clean water).When people are sick they and their care givers cannot carry out other tasks(So there are opportunity costs there as well).

3.3. Relationship between Access to Environmental Services and Health

Access to environmental services is an integral part of health, development and poverty reduction strategies; Basic sanitation is the series of actions taken within the human ecosystem to improve water supply services and wastewater and excreta disposal, solid waste management, household hygiene and industrial waste. During the implementation of reforms under the Poverty Reduction Strategy Papers (PRSP’s) framework, governments in sub-Saharan Africa (SSA) has devoted increasing resources to water and sanitation interventions. However, many households in the sub-region still do not have access to safe drinking water and improved sanitation.

According to the 2006 Human Development Report, only 55% of house-holds in the Sub-Sahara Africa have access to safe water, and 36% of the households have access to improved sanitation (UNDP, 2006) policy makers and researchers are increasingly concerned with the effects of such poor household environmental conditions, particularly those on human development outcomes such as health, education and poverty. On the health front, lack of access to water and sanitation is associated with increasing incidences of waterborne diseases-particularly diarrhoea. According to the World Health Organisation (WHO), diarrhoea accounts for about 4% of the total global burden of disease, and worst still, the burden is unevenly distributed- the annual Disability Adjusted Life Years (DALY’s) lost due to diarrhoea is five times higher in children aged 5 years and below compared to the rest of the population. There are other obvious indicators that poor sanitation services are the roots of mosquitoes breading ground which causes serious malaria infections worldwide and mostly in developing countries giving rise to untold deaths recorded WHO( 2006).

A number of studies have examined the effects of water and sanitation investment in developing countries on health status, poverty and other human development outcomes. Examples of empirical studies in the recent past include Lee et al (1997), Newman et al (2002), Abou Ali (2003) and Gamper-Rabindram et al (2009) provide recent review on the effects of environmental conditions on specific illnesses, notably diarrhoea, The main focus for most of the above studies is on the effect of access to environmental services on three heath outcomes- disease prevalence, child mortality and malnutrition. Evidence from developed countries, particularly the United State (US) shows major health benefits from improved access to environmental services and infrastructure. Cutler and Miller (2005) using historical data to study the adoption of water treatment by US cities, find that the provision of access to environmental services was a key to the observed declines in child mortality.

Although a few studies find no impact on access to environmental services, the majority find strong and significant effects. The study by Lee at el (1997), based on survey data from Bangladesh and Philippines is among the few that find no effect of water on child survival and nutrition. On the contrary, Jalan and Ravillion (2003), based on data from India and using two measures of health status- diarrhoea, prevalence and length of reported illness- find out that having access to improved environmental services in household is associated with a 21.3% reduction in the prevalence of diarrhoea among rural households. Furthermore, the author finds that piped water and toilet facilities are associated with 29.4% reduction in the length of illness. Galiani et al (2005) also finds strong effects of water and argue that having water connections and improved hygiene is associated with a 6.7% reduction in child mortality. On the other hand, Gamper- Rahbindran et atal (2009), using panel data and quintile regression approach find that the impact of access to environmental services on infant mortality differs by socioeconomic status, expanding pipe water benefits most children residing in areas with very high rate of child mortality.

Read Part 1: Access to Clean Environment in the North

Apart from water and sanitation infrastructure, individual behaviour, point-of-use water treatment, and childcare have been identified as important for reducing diarrhoea prevalence. (Lucy etal, 2004). Point-of- use water treatment is another behavioural strategy considered important for diarrhoea reduction between 20 -30%. Due to the problems establishing causal treatment effects, experimental studies that control for unobserved heterogeneity have been used to study the impact of water and sanitation infrastructure on diarrhoea incidence (clasen et al, 2004and Newman et al, 2002). Newman et al using the match comparison design of beneficiaries and non-beneficiaries of water projects and applying the difference-in-differences method, the authors find that water supply investments were associated with a 42% drop in child mortality rates.

 Due to Sub-Sahara Africa’s large water borne disease burden, a number of studies have investigated that impact of access to environmental services investment on children health in the sub-region (Quick et al, 2002, Fuentes et al, 2006a, 2006b). Using the Demographic and Health Survey (DHS) database, find that water and sanitation infrastructure has significant impact on child health. Specifically, having an improved sanitation source, especially a flush toilet is associated with 30% reduction in child mortality. With water, the distances and associated travel times can affect the quality and volume of water collected. Finally, we examine the various models relating to the access to environmental services and the prevalence of diarrhoeal diseases and this model include (i) the socioeconomic approach (ii) the Econometric approach (iii) Household Environmental conditions.

The socio-economic model captures information on household demographics (ie age, sex, marital status and position within the household), socioeconomic characteristics (educational attainment, household consumption and access to communication facilities such as bicycle and mobile phones) these are key in determining the level of vulnerability and exposure to diarrhoea and other related diseases, for instance where the household educational level is low especially the principal homemaker there is a high degree of the household been vulnerable to the diarrhoea disease.

The Econometric approach model estimates the relationship between the prevalence of diarrhoea and access to improved water and sanitation, including background variables such as household consumption, education and location variables. Some variables in such relationship may not be exogenous. For example, piped water may only be available in affluent areas and indicators of household welfare status may be endogenous to the diarrhoea regression. Related, while the lack of improved water or sanitation source may lead to diarrhoea illness, it is also conceivable that exposure to diarrhoea may force household to adopt particular preventive measures such as investing in either improved water or sanitation sources leading to concerns of simultaneity bias. Given the possibility of such environment, comparing the effect of access to water or access to particular facilities or to factors that affect the child’s location. If the factors that influence a child’s household characteristics also directly affect the child health, then any observed differences in diarrhoea prevalence between households with water and sanitation facilities and those without may be partly explained by unobserved differences between children rather than the access to improved water and sanitation.

A household environmental condition captures the atmosphere faced by the child; we consider a number of variables related to the housing condition of a child. This included whether the household has a separate room/facility for kitchen apart from partially signalling the welfare status of the household, most of the above variables indicate the level of cleanliness one should expert in a dwelling. With regard to access to drinking water, the following sources were considered; piped water, boreholes, protected springs, for toilet facility used, we consider flush toilets, private covered ventilated improved pit (VIP) latrines.

3.4. Access to Environmental Services and Diarrhoea Prevalence.

Lack of safe water, basic sanitation and hygiene may account for as much as 88% of the disease burden due to diarrhoea. Studies have shown that hygiene improvement interventions such as improved water, sanitation and hygiene have resulted in a 30-50% reduction in the burden of diarrhoeal diseases. The Bellagio Child Survival Study Group also includes water/sanitation/hygiene as one of the top ten proven preventive interventions for deaths of under- six. WHO Global Burden of Diseases (GBD) (2002)

The USAID’s Environmental Health Project (EHP) was launched in June 1999 and had one overriding objective- to reduce mortality and morbidity associated with infectious disease of major public health importance by improving environmental conditions or reducing exposure to disease agents. A decision was made early on in EHP to develop a rigorous health-centred programmatic framework. What emerged was the Hygiene Improvement Framework (HIF), a comprehensive approach to diarrhoea prevention through water supply, sanitation and hygiene interventions. The HI F is a comprehensive approach to prevent childhood diarrhoea through a focus on improving key hygiene behaviours, especially ensuring safe drinking water, proper hand hygiene and effective use of sanitation. WHO Global Burden of Disease (GBD) (2002).

The intent of the HIF is to include inputs and activities required to achieve these critical behaviours through a combination of: (1) Improving water and sanitation (2) Promoting proper hygiene and (3) Strengthening the enabling environment to ensure the sustainability of hygiene improvement activities. In examining the implementation of hygiene improvement programs in child health, water supply and sanitation (WS&S) and other areas are essential. EHP found that programs that are using all the HIP components can achieve significant results. For example, integrated hygiene promotion into water supply and sanitation intervention resulted in a decrease in diarrhoea prevalence by as much as two-thirds and an improvement i hygiene behaviours for hand washing alone by 70-80% the SAFE study in Bangladesh.

3.5. Causes of Diarrhoea

The prevailing environmental condition and logistics available in the setting; educational level of the parents and or caretakers are the major factors to be considered. Complains of diarrhoea should not be taken lightly. A whole lot of factors can cause diarrhoea especially in children, causes could be bacterial, viral etc, and since fluid loss occurs quickly in children, this could be fatal.

3.5.1. Contaminated food/ water

Breast- feeding, especially if this is the only source of nutrition, has been shown to protect children against the development of diarrhoea in Africa.(Huttly et al, 1987; Mocketal, 1995) as elsewhere in the developing world. In contrast, foods given for complementary feeding probably contribute to diarrhoea in infants (Barrell etal, 1979). One should not loose sight of contamination as the main cause of diarrhoea.

3.5.2. Early introduction of milk formula or solid food

The early introduction of milk formula or solid food is often consider increasing exposure to enter pathogens, and has been associated with increased rate of acute diarrhoea in infants (Barrell et al). Millet flour, cooking water, empty serving bowls and even simmering gruel were all found to be contaminated with Ecoli,colony counts of this and other organisms increased steadily with storage at room temperature(Rowland etal, 1978)

3.5.3. Personal hygiene

Methods of food handling and storage, source and use of safe water and personal hygiene all contribute to the potential risk of developing acute diarrhoea. Ponds, rivers, standing water and unprotected springs tend to be more contaminated than protected spring’s source of drinking water and have been significantly, associated with increased risk of diarrhoea in a number of studies.

Two more studies have found an increased risk of diarrhoea associated with the consumption of maize-based weaning foods. However, in one of the studies, this association was only significant in children living in rural communities (Ekanem et al, 1999). There is an increased risk of diarrhoea in household lacking the habit of frequently washing hands with soap. Storage of food in proximity to house defecation. Playing in the soil is a major risk factor; hence mother can limit contamination from soil practises and pathogens during sitting, crawling periods etc by providing children with walking chairs and seeing personally to and taken interest in their food preparation and personal hygiene.

3.5.4. Lack of maternal education and care

There is a trend toward lower maternal educational status among cases which shows that maternal ignorance of proper caretaker hygiene were significantly associated with diarrhoeal diseases and showed that household having inferior hygiene practise including improper disposal of children faeces, absence of toilet paper, solid or liquid waste disposal within the living compound constitute a major risk factors. Habitual teaching of hand washing with soap and using running water is ideal.

Weaker association with diarrhoea includes presence of flies in the latrines area and visible stool around the latrines. Logistic regression demonstrated that the improper means of faecal and solid waste disposal was found to be associated with the prevalence of diarrhoea (Child Health Research special Report, 1998).

   3.6.Interventions to Diarrhoea Prevention

Diarrhoea can be prevented by pursuing multi sectoral efforts by:

  • Improving access to clean water and safe sanitation.
  • Promoting hygiene education about how infectious spread.
  • Exclusive breast-feeding
  • Improve weaning practises
  • Immunizing all children
  • Using latrines.
  • Keep food and water clean.
  • Washing hands with soap before touching food.
  • Sanitary disposal of stools.

(All these are measures to reduce the number of cases with diarrhoea)

Key measure to treat diarrhoea include

  • Continue feeding
  • Consulting health workers if there are signs of dehydration
  • Giving more fluids than usual including Oral Rehydration salts solution to prevent dehydration.

3.7. Conclusion

In conclusion, lack of access to environmental services is the dominant causes of diarrhoea prevalence among children across the entire globe ranging from developed countries to developing countries. It contributes to an estimated 4billion cases of diarrhoea annually and to a death toll of 2.2million among children under age five WHO(2000a).This issue has necessitated the call for countries to half the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015(MDG7). This literature provides the unfolding events cutting across previous and current interventions and studies to reduce the incidence of diarrhoea across the globe and specifically in the developing world.    


                                   DATA ANALYSIS AND PRESENTATION

4.1. Introduction

This chapter seeks to analyse and discuss the findings of the research in line with the objectives of the study. It seeks to examine how access to environmental services, availability and access to water, sanitation services and household hygiene behaviours and how these variables affect diarrhoea prevalence among children under age six in Pwalugu community.

4.2. Socio-Economic and Demographic Characteristics of Respondents

4.2.1. Age Distribution

This comprises of age distribution of respondents, marital status, level of education of respondents, household water supply source, access to environmental and sanitation facilities among the forty ( 40) sampled principal homemakers. The survey reveal that out of forty (40) sampled principal homemakers, 57.5%, 37.5% and 5% constitutes the age ranges between 15-29, 30-45 and 46-60 respectively.

The table below shows the age distributions of the 40 sampled respondents.

Table 1 Age Distribution of Respondents

Age Frequency Percentage
15-29 23 57.5
35-45 15 37.5
46-60 2 5
Total 40 100

    Source:  Field Survey, 2012

Based on the responses from the forty(40) sampled respondents, the survey reveals that twenty-three (23)of respondents fall within the age range of 15-29, representing 57.5%,fifteen (15) respondents fall within the age group of 30-45 representing 37.5% whiles two (2) respondents are within the age group of 46-60 representing 5%. This shows that majority of the principal homemaker’s falls within the age range of 15-29 years. This implies that majority of the homemakers do not possess much knowledge and experience in childcare.

4.2.2. Marital Status of Respondents

The survey conducted revealed that thirty-three (33) out of forty (40) sampled respondents are married, five (5) being single and two (2) divorced representing 82.5%, 12.5%, and 5% respectively. The table below illustrates the marital status distribution.

Table 2Marital Status of Respondents                                                                                  

Status Frequency Percentage
Married 33 82.5
Single 5 12.5
Divorced 2 5
Total 40 100
Source:  Field Survey, 2012 4.2.3. Number of Children, under age six (6), Diarrhoea Prevalence Rate among Children under age six (6) The study revealed that out of the total number of forty (40) household visited, a total number of one hundred and fourteen (114) children were found among all respondents. Out of the figure, Eighty- five (85) children were found to be under age six (6) and out of this, sixty-nine (69) children were found to have been infected with Diarrhoea over the past two weeks.  This represents 81.2% of the children under age six
  4.2.4. Religious Status of the Respondents
The religious classification 40 principal homemaker can be categorised into Christianity, Islam and Traditional. Christianity constitute twenty-nine (29) representing 72.5%, Islam constitutes six (6) representing 15% whiles five (5) principal homemakers been traditionalist represents 12.5%.   The table below shows the religious distribution of the sampled principal homemakers. Table 3 Religious Distribution of Respondents Religious denominations Frequency Percentage Christianity 29 72.5 Islam 6 15 Traditional 5 12.5 Total 40 100 Source: Field Survey, 2012
  4.2.5. Educational Status of Respondents   The educational status among the sampled 40 principal homemakers can be categorised into No formal (45%), Basic (47.5%), Secondary (2.5%), and Tertiary (5%). The research revealed that about 92.5% of the principal homemakers have little or no education which negatively affect hygiene behaviour of the community and hence diarrhoea prevalence among children under six. The table below illustrates the educational status of the homemakers. Table 4 Educational Status of Respondents Level of education Frequency Percentage No formal 18 45 Basic 19 47.5 Secondary 1 2.5 Tertiary 2 5 Total 40 100 Source: Field Survey,2012

4.2.6. Occupational Distribution of Respondents

The survey revealed that of occupations such as commerce, services, artisan, agriculture and unemployed, majority of the people are engaged in farming activities.  The table below illustrates the occupational distribution of respondents in Pwalugu.

Table 5 Occupational Distribution of Respondents

Occupation Frequency Percentage
Commerce 9 22.5
Services 2 5
Artisan 7 17.5
Farming 12 30
Unemployed 10 25
Total 40 100

Source: Field Survey, 2012

4.2.7. Income Distribution of Respondents
The survey revealed that about 97.5% of the people in Pwalugu earn below GHC500.00 monthly while 2.5% earn GHC500 and above. The table below shows the income distribution of the respondents.

Table 6 Income Distribution of Respondents

Monthly income Frequency Percentage
Below GHc100 16 40
GHc101-GHc200 12 30
GHc201-GHc300 8 20
GHc301-GHc499.9 3 7.5
GHc 500+ 1 2.5
Total 40 100

Source: Field Survey, 2012

It can be seen that majority of the respondents earn low incomes probably because they are engaged in subsistence farming mostly backyard farming.

4.2.8. Wealth Index Classification
The wealth index helps in determining and classifying the household possession of respondents. Benneh etal (1993), classified wealth into groups (low, medium, high) using a weighted score based on household ownership of durable consumer commodities.

4.2.9. Wealth Classification

Based on the weights and categorisation of indices by Benneh etal (1993),the study applied this to ascertain the relationship between household wealth and diarrhoea prevalence among household with children under age six. The results indicated that 60% of the respondents fall within the low wealth class, 22.5% in the medium class and only 17.5% fall within the high wealth class. The table below depicts the wealth classification of respondents in Pwalugu. This explains why the people are low-income earners.

Figure 2 Wealth Classification of Respondents

Source: Field Survey, 2012

4.2.10. Wealth index and Diarrhoea Prevalence

The study revealed that diarrhoea prevalence among children under six from households with low wealth index and thus poor is higher (about 58%) than those in both medium (23%) and high (19%) wealth classes. The table below shows the relationship between wealth index and diarrhoea prevalence in Pwalugu as reflected in the responses. It indicates that the wealth status of the people relate inversely with the incidence of diarrhoea among children under six.

Table 7  Shows the Relationship between Wealth Index and Diarrhoea Prevalence

Diarrhoea prevalence among infants under six in households
Wealth weight index 1 Children 2 Children2 3 Children3 Total Total Children
Low wealth 11 11 10 20 3 9 24 40
Medium wealth 4 4 3 6 2 6 9 16
High wealth 2 2 4 8 1 3 7 13
Total 17 17 17 34 6 18 40 69

Source: Field Survey, 2012

4.2.11. Education and Diarrhoea Prevalence

The education status of the principal homemakers has an influence on the rate of diarrhoea among their children under age six. The study revealed that a principal homemakers who had a basic education at all, have a high rate (about 91% of total) of diarrhoea infection among their children under six. The table below shows the cross tabulation between educational status and prevalence of diarrhoea infection among their children.

Table 8 Educational level of Principal homemaker’s and Diarrhoea infection among Children under age six

  Diarrhoea infection among children under six years
Educational level 1 Children 2 Children2 3 Children3 Total Total Children
No formal 8 8 7 14 3 9 18 31
Basic 9 9 7 14 3 9 19 32
Secondary 0 0 1 2 0 0 1 32
Tertiary 0 0 2 4 0 0 2 4
Total 17 17 17 34 6 18 40 69

Source: Field Survey, 2012

In an interview with EHP’s and Nurses in the community, it was revealed that the educational level of infant mothers plays a significant role in child care and hygiene practises, implying that little or no formal education will have an adverse effect on the prevalence of diarrhoea in the community.

4.3. Sources of Water Available
The survey revealed that the sources of water available in Pwalugu are wells, boreholes, rivers and dugouts. The majority of the people as revealed from the respondents preferred water from boreholes but this is in acute supply in the community. 30% of the respondents enjoy borehole water and the remaining 70% rely on other sources of water such as river, streams, and dugouts among others, which are unreliable for consumption.Below is a plate showing a source of water used by some of the people.

Plate 1: Children accessing water from a dug-out


Sources: Field Survey, 2012

4.3.1. Access to and Availability of Water Supply    
Access to potable water is critical in determining the health status of the people. According to the EHP’s there is inadequate potable water supply in Pwalugu and this compels community members to resort to other sources such as dug-outs, wells, streams, rivers among others which are contaminated with faecal matter, bacteria and impurities and this exposes the people especially children to Diarrhoea and other waterborne diseases.

The survey revealed that majority of the respondents (87.5%) used water less than 225 litres, which does not depict good hygiene and sanitation behaviours. This could be attributed to the scarcity of potable water and the time and distance spent/covered in search for potable water. This make the people reduce the quantity of water used.

4.4. Access to Sanitation Services
Sanitation is important in promoting the health status of people. The sanitation situation in Pwalugu is however very poor as majority of the people practice open defecation.Inadequacy of toilet facilities in Pwalugu was seen to adversely affect diarrhoea incidence among people especially children under age six. The study revealed that only 5% have access pit latrine, which is the only service available. The remaining 95% resort to open defecation. The table below shows households with access to sanitation services

Table 9 Shows the Availability and Access to Sanitation Services

Sanitation Facility Frequency Percentage
Pit latrine 2 5
Open defecation 38 95
Total 40 100

Source: Field Survey, 2012

Waste disposal in Pwalugu is largely (about 62.5%) by open dumping. As waste is disposed closed to the surroundings, it creates an enabling environment for the transmission of diseases such diarrhoea and cholera. The plate below shows open disposal of waste in Pwalugu near a house.

Plate 2: Children practicing open defecation

Source: Field Survey, 2012

4.5. Hygiene Behaviours

Hygiene behaviours are paramount in determining the incidence of diarrhoea among children.
Hand washing after defecation, prior to cooking and cleaning of children after defecating are sound environmental practises that could help reduce diarrhoea infection among children. An interview conducted with EHP reveals that majority of community members do not practice good hygiene behaviours which consequently results to diarrhoea infection mostly among children because of their vulnerability. Hand washing before cooking is key in preventing food contamination. The survey revealed that only 2.5% of respondents wash their hands with soap prior to cooking that is not sound hygiene behaviour and this possibly lead to diarrhoea infection among households. The table below illustrate the household hygiene behaviours of the people as obtained from the respondents.

Table 10 Shows Household Hygiene Behaviours of Respondents

Activity Frequency Percentage
After defecating 21 52.5
Prior to cooking 1 2.5
After eating 3 7.5
Before prayer 15 37.5
Total 40 100

Source: Field Survey, 2012

4.6. Impact Of Environmental Services on Prevalence of Diarrhoea among Children under six (6) years of age
Based on the responses obtained from key informants (the Magazia, opinion leaders and youth leaders), CHN’s, the EHP and the principal homemakers, it was revealed that there is inadequate environmental services in Pwalugu. This exposes the people especially children to diarrhoea and other related diseases. It was revealed that adequate provision of environmental services is salient in the reduction of diarrhoea infection among the people especially children under age of six.

4.6.1. Diarrhoea Prevalence among Children under six
According to a survey conducted on the incidence of diarrhoea cases and titled, “Integrated Management of Childhood Illnesses (IMCI)” by DHMT from 2008 to May 2012 on  diarrhoea cases reported and treated at the community clinic it was revealed that the number of childhood diarrhoea cases still persist in Pwalugu. The survey revealed that the prevalence rate of Diarrhoea among children less than six in Pwalugu is about 81.2% as shown in table (11). This means over 81% of all children less than six are infected with Diarrhoea over two (2) weeks.This is attributed to lack of environmental services such as potable water, bad sanitation and hygiene behaviours.

Table 11 Shows the Incidence of Diarrhoea Prevalence in the Community amongChildrenunder age six

Incidence of diarrhoea prevalence in the community
Wealth index Frequency Number of Children Children under six Children with diarrhoea
Low class 24 75 60 56
Medium class 9 25 15 10
High class 7 14 10 3
Total 40 114 85 69

Source; Field survey, 2012

4.6.2. Sources of Water and Diarrhoea Prevalence in Children under age six
The source of water used by household determines the extent of diarrhoea infection among people. This means that households that use water from contaminated sources are prone to infection than those who use reliable sources (Boreholes in the case of Pwalugu). The study revealed that 30% of the respondents use water from boreholes with infection of  21 children representing 30.4% of the total number of children infected whiles the remaining 70% use water from rivers, dugouts, streams among others that are contaminated with 48 children representing 69.6% of the 69 children infected over the past two weeks.

The table below is a cross tabulation between a households’ source of water and diarrhoea prevalence among children under age six in those households.

Table 12 Cross tabulation between Source of Water and Diarrhoea prevalence

Source of water 1 Children 2 Children2 3 Children3 Total Total children
Well 5 5 3 6 1 3 9 14
Borehole 5 5 5 10 2 6 12 21
Streams/springs 0 0 1 2 0 0 3
Dugout 1 1 6 12 1 3 8 21
Rivers 6 6 2 4 2 6 10 16
Total 17 17 17 34 6 18 40 69

Source: Field Survey, 2012.

4.6.3. Sanitation service and Diarrhoea Prevalence in Children under age six
A good practice of sanitation depends on access to toilet facilities by households. The study revealed that majority of households does not have toilet facility and therefore practice open defecation. The table below shows the relationship between household that have access to pit latrine and those who do not have and the prevalence of diarrhoea among children under six of such households.

Table 13 A cross-tabulation between access to Sanitation Facilities and DiarrhoeaPrevalence

Children under six infected
Facility 1 Children 2 Children2 3 Children3 Total Total Children
Pit latrine 0 0 1 2 1 3 2 5
Open defecation 17 17 16 32 5 15 38 64
Total 17 17 17 34 6 18 40 69

Source: Field Survey, 2012  

From the table, the infection among children from households that practice open defecation is about 93% while those from households that have access to pit latrines is about 7% only.

This shows that infection rate is high among households without access to sanitation services relative to households with access to sanitation services.

4.6.4. Hygiene Behaviour and Prevalence of Diarrhoea in Children under age six
Hygiene practices are essential in determining the health standard of any society. Hands washing with soap, after defecating, prior to cooking, after cooking and after prayers are fundamental hygiene practises that could help prevent infection. It was however observed that some of the respondents do not wash their hands prior to cooking which could result in food contamination and as they consumed the contaminated food, it could result in diarrhoea infection. This explained why diarrhoea prevalence is high in the community. The table below is a cross tabulation of hygiene practices and diarrhoea prevalence among children less than six in the households.

Table 14 Shows the Hygiene Behaviour and Diarrhoea Prevalence among childrenunder six among respondent households

Children below six with diarrhoea
Source 1 Children 2 Children2 3 Children3 Total Total children
After defecating 9 9 9 18 2 6 20 31
Prior to cooking 1 1 1 2 0 0 2 3
After eating 2 2 0 0 1 2 3 4
Before prayer 5 5 7 14 3 6 15 25
Total 17 17 17 34 6 12 40 69

Source: Field Survey, 2012

From the table 14 above, it can be seen that only 5% of the homemakers wash their hands with soap before cooking, 50% after defecating, 37.5% before prayer and 7.5% after eating. Considering the number of child infections (about 57% of the total child infections) of homemakers who claimed to wash their hands with soap do not practice this or possibly do not wash properly.
Again, the study also considered the mode of waste disposal of respondents against diarrhoea prevalence and the result was that the prevalence was high (about 62.3%) among households that practice open dumping of waste close to their surroundings as a against 37.7%  among households that burn waste. The table below shows the picture clearly.
Table 15 Shows the Relationship between Disposal habits and Diarrhoea infection inhouseholds

Children under age six infected
Method of waste disposal 1 Children 2 Children 3 Children2 Total Total Children
Open dumping 11 11 10 20 4 12 25 43
Burning 6 6 7 14 2 6 15 26
Total 17 17 17 34 6 18 40 69

Source: Field Survey, 2012

The study reveals that households that practice bad sanitation behaviours such as  failure to wash before cooking, improper washing of hands with soap after defecation and open dumping of waste near their homes experiences a high incidence of diarrhoea infection among their infants below six



This chapter is divided into three sections; summary of the major findings, conclusions and recommendations.

5.1. Summary of Major Findings
5.1.1. Access to and Availability of Water

The people of Pwalugu source water mainly from borehole, wells, streams and rivers. There is one borehole, which is the only source of potable drinking water, and this is insufficient for the entire population of about 3,971 people. This borehole often dries up during the dry season due to the pressure on it. People travel about 2km in search for water, and this takes away the time that could have been used for other beneficial economic activities. The other sources such as rivers, wells and streams are the most assessed by the people and these are usually contaminated due to the sanitation and hygiene behaviours of the people. This results in increases in water-related diseases including diarrhoea.

5.1.2 Sanitation and Hygiene Behaviours
Sanitation in Pwalugu is not encouraging since majority (95% of the people) practice open defecation and indiscriminate waste disposal near their surroundings.

Hygiene behaviours such as washing of hands with soap after defecation, prior to cooking, after eating, after praying and after cleaning a child who defecates among the people, revealed that the people do not properly practice or at worst do not practice these habits at all. The incidence of diarrhoea among children under six of homemakers could be attributed to these.

5.1.3. Wealth Classification and Diarrhoea Prevalence

The wealth status of the people relate inversely with the incidence of diarrhoea among children under six. The study revealed that homemakers in the low wealth class had 58% of diarrhoea infection among their children under six, 23% among the medium class and 19% in the high class. Improvement in the wealth status of the people has the chance of reducing diarrhoea infection.

5.1.4. Education and Diarrhoea Prevalence

Ninety one percent (91%) of the principal homemakers had little formal education (i. e up to basic) and this negatively affected diarrhoea infection among children.
A cross tabulation between level of educational attainment and diarrhoea prevalence among principal homemakers children under six, it was clear that principal homemakers who had little or no education had high rate of diarrhoea infection among their children. This is attributable to the little knowledge they had in sanitation and hygiene behaviour.

5.2. Conclusion

Diarrhoea infection among children under age six in Pwalugu is largely attributed to the inadequate access to environmental services such as water, sanitation and hygiene services, which are crucial in reducing the prevalence of diseases in Pwalugu and the country at large.

Ghana’s aim of reaching MDG seven (7) which is reducing by half the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015 is in danger if many communities in northern Ghana especially the deprived ones still lack access to environmental services especially potable drinking water where the community understudy is of no exception. This is among the causes of high prevalence of diarrhoea among children under age six. The high incidence of diarrhoea is not strange because more than 90% of the community members access their water from contaminated sources.
The community is lacking behind in terms of the provision of environmental services such as boreholes, public toilets, and public refuse dumps. All these service provisions are necessary if Ghana is to achieve MDG goal 7.It is our firm believe that when the above recommendations is  given proper attention, it would help in reducing or complete eradication of diarrhoea among children under six and other killer diseases such as cholera and measles.

5.3. Recommendations

Diarrhoea disease is the second largest killer of children below six years and accounts for approximately 15% of under six child mortality WHO (2006). In developing countries, diarrhoea is responsible for 17% of all deaths of children under six UN (2006).
In the case of Ghana, Baffoe-Bonnie etal (1998) in “Review of diarrhoea diseases cases admitted to the busy referral hospital in Ghana” indicate that children under six years of age make up 84% of all child admissions and 56.5% of them being infants below one year.
In the upper east region, diarrhoea is ranked fourth among the top ten diseases and according to the Pwalugu clinic, the disease is ranked fourth.

Considering the results of the study which show a high prevalence rate of diarrhoea, the following are recommendations which when implemented would help reduce the prevalence of diarrhoea infection among children under six in Pwalugu and Ghana at large.

  • “Charity, they say, begins at home”. The people of Pwalugu (especially principal homemakers) should ensure good hygiene practices such as washing hands thoroughly with soap and clean water after defecation, before cooking, after cleaning children when they defecate since these are the major causes of diarrhoea infection among the people especially vulnerable children under six
  • In addition, the people of Pwalugu should also practice proper disposal of waste and avoid littering of their surrounding with faecal matter and other solid waste.
  • The people should also do well to treat contaminated water through filtration and boiling before consumption.
  •  The Talensi-Nabdam District Assembly should include in their medium to long-term plan, pragmatic efforts in providing the community and other such communities like Pwalugu with boreholes or pipes, toilet facilities and refusal disposal containers.
  • The DHMT who aim at preventing disease outbreak should intensify health education campaigns on control of diseases such as diarrhoea, cholera among others. This is expected to improve upon the healthcare awareness level of the people in the district and particularly the people of Pwalugu.
  • The government through the MOE at the district level should provide the people of Pwalugu with educational facilities and intensify campaign on the need for formal education, which could help improve upon the level of literacy of the people.


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