Factors Influencing Sanitation Conditions

Published Date: 26 Feb 2018

ABSTRACT

This thesis examines the socio-cultural and demographic factors influencing sanitation conditions, identifies the presence of Escherichia coli in household drinking water samples and investigates prevalence of diarrhoea among infants. It is based on questionnaire interviews of 120 household heads and 77 caretakers of young children below the age of 5years, direct observation of clues of household sanitation practice as well as analyses of household water samples in six surrounding communities in Bogoso. Data collected was analysed using SPSS and the Pearson Product Moment Correlation Value(R) technique. The findings revealed that the sanitation condition of households improved with high educational attainment and ageing household heads. On the contrary, sanitation deteriorated with overcrowding in the household. Furthermore, in houses where the religion of the head of household was Traditional, sanitation was superior to those of a Christian head and this household also had better sanitary conditions than that with a Moslem head of household. Water quality analysis, indicated that 27 samples out of the 30 representing 90% tested negative for E. Coli bacteria whilst 17(56.7%) samples had acceptable levels of total Escherichia coli. Finally, it was found out that diarrhoea among infants were highly prevalent since 47 (61.04%) out of the 77 child minders admitted their wards had a bout with infant diarrhoea. Massive infrastructural development, supported by behavioural change education focussing on proper usage of sanitary facilities is urgently needed in these communities to reduce the incidence of public health diseases. Intensive health education could also prove vital and such programs must target young heads of household, households with large family size and households whose heads are Christians and Moslems.

CHAPTER ONE

INTRODUCTION

BACKGROUND TO THE STUDY

Efforts to assuage poverty cannot be complete if access to good water and sanitation systems are not part. In 2000, 189 nations adopted the United Nations Millennium Declaration, and from that, the Millennium Development Goals were made. Goal 4, which aims at reducing child mortality by two thirds for children under five, is the focus of this study. Clean water and sanitation considerably lessen water- linked diseases which kill thousands of children every day (United Nations, 2006). According to the World Health Organization (2004), 1.1 billion people lacked access to an enhanced water supply in 2002, and 2.3 billion people got poorly from diseases caused by unhygienic water. Each year 1.8 million people pass away from diarrhoea diseases, and 90% of these deaths are of children under five years (WHO, 2004).

Ghana Water and Sewerage Corporation (GWSC) had traditionally been the major stakeholder in the provision of safe water and sanitation facilities. Since the 1960's the GWSC has focussed chiefly on urban areas at the peril of rural areas and thus, rural communities in the Wassa West District are no exception. According to the Ghana 2003 Core Welfare Indicators Questionnaire (CWIQ II) Survey Report (GSS, 2005), roughly 78% of all households in the Tamale Metropolis, 97 percent in Accra, 86% in Kumasi and 94% in Sekondi-Takoradi own pipe-borne water. Once more, the report show that a few households do not own any toilet facilities and depend on the bush for their toilet needs, that is 2.1%, 7.3%, and 5% for Accra, Kumasi, and Sekondi-Takoradi correspondingly. Access to safe sanitation, improved water and improved waste disposal systems is more of an urban than rural occurrence. In the rural poor households, only 9.2% have safe sanitation, 21.1% use improved waste disposal method and 63.0% have access to improved water. The major diseases prevalent in Ghana are malaria, yellow fever, schistosomiasis (bilharzias), typhoid and diarrhea. Diarrhea is of precise concern since it has been recognized as the second most universal disease treated at clinics and one of the major contributors to infant mortality (UNICEF, 2004). The infant mortality rate currently stands at about 55 deaths per 1,000 live births (CIA, 2006).

The Wassa West District of Ghana has seen an improvement in water and sanitation facilities during the last decade. Most of the development projects in the district are sponsored by the mining companies, individuals and some non-governmental organisations (NGO's). Between 2002 and 2008, Goldfields Tarkwa Mine constructed 118 new hand dug wells (77 of which were fitted with hand pumps) and refurbished 48 wells in poor condition. Also, a total of 44 modern style public water closets, were constructed in their catchment areas. The company also donated 19 large refuse collection containers to the District Assembly and built 6 new nurses quarters. The Tarkwa Mine has so far spent 10.5million US dollars of which 26% went into health, water and sanitation projects, 24% into agricultural development, 31% into formal education and the remaining went into other projects like roads and community centre construction ( GGL, 2008). Golden Star Resources (consist of Bogoso/Prestea Mine and Wassa Mine at Damang) also established the community development department in 2005 and has since invested 800 thousand US dollars. Their projects include 22 Acqua-Privy toilets, 10 hand dug wells (all fitted with hand pumps) and supplied potable water to villages with their tanker trucks (BGL, 2007). Other development partners complimenting the efforts of the central government include NGO's WACAM, Care International and Friends of the Nation (FON). WACAM is an environmentally based NGO which monitors water pollution by large scale mining companies. They have sponsored about 10 hand dug wells for villages in the district. Care International sponsors hygiene and reproductive health programmes in schools and on radio. They have also donated a couple of motor bicycles to public health workers in the district who travel to villages.

The aims of all these projects were to improve hygiene and sanitation so as to reduce disease transmission. Despite efforts by the development partners, water supply and sanitation related diseases are highly prevalent in the district. Data obtained from the Public and Environmental Health Department of the Ministry of Health (M.O.H., 2008) showed that the top ten most prevalent diseases in the district include malaria, acute respiratory infections, skin diseases and diarrhoea. The others are acute eye infection, rheumatism, dental carries, hypertension, pregnancy related complications and home/occupational accidents. A lot more illnesses occur but on a lower scale and these include intestinal worms, coughs and typhoid fever. A complete data on the top ten diseases prevalent in the district is attached as Appendix D but below is a selection of the illnesses that directly result from bad water and sanitation practices.

The number of malaria cases decreased from 350 in 2006 to 300 cases per 1000 population in 2008. Despite the decrease, the values involved are still quite high. The incidence of diarrhoea among infants and acute respiratory infection remained 30 and 60 cases per 1,000 populations respectively. This can be attributed to several reasons, including population boom, lack of uninterrupted services and inadequate functioning facilities. In fact, according to the World Health Organization (WHO, 2004), an estimated 90% of all incidence of diarrhoea among infants can be blamed on inadequate sanitation and unclean water. For example, in a study of 11 countries in Sub-Saharan Africa, only between 35-80% of water systems were operational in the rural areas (Sutton, 2004). Another survey in South Africa recognized that over 70% of the boreholes in the Eastern Cape were not working (Mackintosh and Colvin, 2003). Further examples of sanitation systems in bad condition have also been acknowledged in rural Ghana, where nearly 40% of latrines put up due to the support of a sanitation program were uncompleted or not used (Rodgers et al., 2007). The author had a personal communication with the District Environmental Officer and he estimated that, approximately there are 224 public toilets, 560 hand dug wells, 1,255 public standpipes and 3 well managed waste disposal sites in the district. According to the 2006 projection, the population of the district is expected to reach 295,753 by the end of the year 2009 (WWDA, 2006).

Development partners in the past have concentrated their efforts on facilities provision only. They have not looked well at the possible causes of the persistence of disease transmission despite the effort they are making. Relationships between household's socio cultural demographic factors and people's behaviour with respect to the practice of hygiene could prove an essential lead to the solution of the problem. The fact is, merely providing a water closet does not guarantee that it could be adopted by the people and used well to reduce disease transmission. Epidemiological investigations have revealed that even in dearth supply of latrines, diarrhoeal morbidity can be reduced with the implementation of improved hygiene behaviours (IRC, 2001: Morgan, 1990). Access to waste disposal systems, their regular, consistent and hygienic use and adoption of other hygienic behavioural practices that block the transmission of diseases are the most important factors. In quite a lot of studies from different countries, the advancement of personal and domestic hygiene accounted for a decline in diarrhoeal morbidity (Henry and Rahim, 1990). The World Bank, (2003) identifies the demographic characteristics of the household including education of members, occupation, size and composition as influencing the willingness of the household to use an improved water supply and sanitation system. Education, especially for females results in well spaced child birth, greater ability of parents to give better health care which in turn contribute to reduced mortality rates among children under 5years (Grant, 1995). In a study into water resource scarcity in coastal Ghana, Hunter (2004) identified a valid association between household size, the presence of young children and the gender of the household head. It was noted that, female heads were less likely to collect water in larger households. Furthermore, increasing number of young children present increased the odds of female head/spouse being the household water collector. Cultural issues play active part in hygiene and sanitation behaviour especially among members of rural communities. For example, women are hardly seen urinating in public due to a perceived shame in the act but men can be left alone if found doing it. Also, the act of defecation publicly is generally unacceptable except when infants and young children are involved. The reason is that the faeces from young people are allegedly free from pathogens and less offensive (Drangert, 2004). Ismail's (1999) work on nutritional assessment in Africa, detected that peoples demographic features, socioeconomic and access to basic social services such as food, water and electricity correlate significantly to their health and nutrition status. Specifically, factors such as age, gender, township status and ethnicity, which are basic to demography, can play a role in the quality of life especially of the elderly.

This research assessed people's practice of personal hygiene in Bogoso and surrounding villages. It also identified the common bacteria present in household stored water sources. Furthermore, the research identified the relationships between some socio-cultural demographic factors of households and the sanitation practice of its members.

THE PROBLEM STATEMENT

The Wassa West District in the Western Region is home to six large scale mining companies and hundreds of small scale and illegal mining units. Towns and villages in the district have been affected by mining, forestry and agricultural activities for over 120 years (BGL EIS, 2005). Because of this development, the local environment has been subjected to varying degrees of degradation. For example, water quality analysis carried out in 1989 by the former Canadian Bogoso Resources (CBR) showed that water samples had Total coliform bacteria in excess of 16 colonies per 100ml (BGL EIS,2005). Most of the water and sanitation programs executed in the district exerted little positive impact and thus, diarrhoeal diseases are still very high in the towns and villages (See Appendix D on page 80).

However, in order to solve any problem it is important to appreciate the issues that contribute to it; after all, identifying the problem in itself is said to be a solution in disguise. Numerous health impact research have evidently recognized that the upgrading of water supply and sanitation alone is generally required but not adequate to attain broad health effects if personal and domestic hygiene are not given equivalent prominence (Scherlenlieb, 2003). The troubles of scarce water and safe sanitation provisions in developing countries have previously been dealt with by researchers for quite some time. However, until recent times they were mostly considered as technical and/or economic problems. Even rural water and sanitation issues are repeatedly dealt with from an entirely engineering point of view, with only a simple reference to social or demographic aspects.

Therefore, relatively not much is proven how the socio-cultural demographic influences impinge on hygiene behaviour which in turn influences the transmission of diseases. The relationship between household socio cultural factors and the sanitation conditions of households in the Wassa West District especially the Bogoso Rural Council area has not been systematically documented or there is inadequate research that investigates such relationship.

THE RESEARCH QUESTIONS

The following research questions were posed to help address the objectives;

1. Why are the several sanitation intervention projects failing to achieve desired results?
2. Why is the prevalence of malaria and diarrhea diseases so high in the district?
3. What types of common bacteria are prevalent in the stored drinking water of households?

OBJECTIVES

The main aim of this research was to investigate people's awareness and practice of personal hygiene, access to quality water and sanitation and the possible causes of diarrhoeal diseases and suggest ways to reduce the incidence of diseases in the community. The specific objectives were;

1. To assess the quality of stored household drinking water
2. To establish the extent to which sanitation behaviour is affected by household socio-cultural demographic factors like age and education level of the head.
3. To investigate the occurrence of diarrhoea among young children (0-59 months old) in the households.
4. To identify and recommend good intervention methods to eliminate or reduce the outbreak of diseases and improve sanitation.

HYPOTHESIS

In addition to the above objectives, the following hypotheses were tested;

1. Occurrence of infant diarrhoea in the household is independent on the educational attainment of child caretakers.
2. There is no relationship between households' background factors and the sanitation conditions of the household.

CHAPTER TWO

LITERATURE REVIEW

In this chapter, various literature related to the subject matter of study are reviewed. Areas covered are sanitation, hygiene, water quality and diarrhoeal diseases. Theories and models the study contributed to include USAID's Sanitation Improvement Framework, the "F diagram" by Wagner and Lanois and the theory of Social learning.

SANITATION

Until recently, policies of many countries have focused on access to latrines by households as a principal indicator of sanitation coverage, although of late there has been a change and an expansion in understanding the term sanitation. Sanitation can best be defined as the way of collecting and disposing of excreta and community liquid waste in a germ-free way so as not to risk the health of persons or the community as a whole (WEDC, 1998).

Ideally, sanitation should end in the seclusion or destruction of pathogenic material and, hence, a breach in the transmission pathway. The transmission pathways are well known and are potted and simplified in the "F diagram" (Wagner and Lanois 1958) shown below by figure 3.1. The more paths that can be blocked, the more useful a health and sanitation intervention program will be.

It may be mentioned that the health impact indicators of sanitation programmes are not easy to define and measure, particularly in the short run. Therefore, it seems more reasonable to look at sanitation as a package of services and actions which taken together can have some bearing on the health of a person and health status in a community.

According to IRC (2001:0), issues that need to be addressed when assessing sanitation would include:

• How complete the sanitation programme is in addressing major risks for transmitting sanitation-related diseases;
• Whether the sanitation programme adopted a demand driven approach, through greater people's participation, or supply driven approach, through heavy subsidy;
• Whether it allows adjustment to people's varying needs and payment;
• If the programme leads to measurably improved practices by the majority of men and women, boys and girls;
• If it is environmentally friendly. That is; if it does not increase or create new environmental hazards (IRC, 2001)

Sanitation is a key determinant of both fairness in society and society's ability to maintain itself. If the sanitation challenges described above cannot be met, we will not be able to provide for the needs of the present generation without hindering that of future generations. Thus, sanitation approaches must be resource minded, not waste minded.

HYGIENE

Hygiene is the discipline of health and its safeguarding (Dorland, 1997). Health is the capacity to function efficiently within one's surroundings. Our health as individuals depends on the healthfulness of our environment. A healthful environment, devoid of risky substances allows the individual to attain complete physical, emotional and social potential. Hygiene is articulated in the efforts of an individual to safeguard, sustain and enhance health status (Anderson and Langton, 1961).

Measures of hygiene are vital in the fight against diarrhoeal diseases, the major fatal disease of the young in developing countries (Hamburg, 1987). The most successful interventions against diarrhoeal diseases are those that break off the transmission of contagious agents at home. Personal and domestic hygiene can be enhanced with such trouble-free actions like ordinary use of water in adequate quantity for hand washing, bathing, laundering and cleaning of cooking and eating utensils; regular washing and change of clothes; eating healthy and clean foods and appropriate disposal of solid and liquid waste.

Diarrheal Dise ases

Diarrhoea can be defined in absolute or relative terms based on either the rate of recurrence of bowel movements or the constancy (or looseness) of stools (Kendall, 1996). Absolute diarrhoea is having more bowel movements than normal. Relative diarrhoea is defined based on the consistency of stool. Thus, an individual who develops looser stools than usual has diarrhoea even though the stools may be within the range of normal with respect to consistency.

According to the United States Centre for Disease Control and Prevention (CDC, 2006), with diarrhoea, stools typically are looser whether or not the frequency of bowel movements is increased. This looseness of stool which can vary all the way from slightly soft to watery is caused by increased water in the stool. Increased amounts of water in stool can occur if the stomach and/or small intestine produce too much fluid, the distal small intestine and colon do not soak up enough water, or the undigested, liquid food passes too quickly through the small intestine and colon for them to take out enough water. Of course, more than one of these anomalous processes may occur at the same time. For example, some viruses, bacteria and parasites cause increased discharge of fluid, either by invading and inflaming the lining of the small intestine (inflammation stimulates the lining to secrete fluid) or by producing toxins (chemicals) that also fire up the lining to secrete fluid but without causing inflammation. Swelling of the small intestine and/or colon from bacteria or from ileitis/colitis can increase the haste with which food passes through the intestines, reducing the time that is available for absorbing water. Conditions of the colon such as collagenous colitis can also impede the capacity of the colon to soak up water.

Escherichia coli O157:H7 is probably the most dreaded bacteria today among parents of young children. The name of the bacteria refers to the chemical compounds found on the bacterium's surface. Cattle are the main sources of E. coli O157:H7, but these bacteria also can be found in other domestic and wild mammals. E. coli O157:H7 became a household word in 1993 when it was recognized as the cause of four deaths and more than 600 cases of bloody diarrhoea among children under 5years in North-western United States (US EPA, 1996). The Northwest epidemic was traced to undercooked hamburgers served in a fast food restaurant. Other sources of outbreaks have included raw milk, unpasteurized apple juice, raw sprouts, raw spinach, and contaminated water. Most strains of E. coli bacteria are not dangerous however, this particular strain attaches itself to the intestinal wall and then releases a toxin that causes severe abdominal cramps, bloody diarrhoea and vomiting that lasts a week or longer. In small children and the elderly, the disease can advance to kidney failure. The good news is that E. coli O157:H7 is easily destroyed by cooking to 160F throughout.

Reducing diarrhoea morbidity with USAID's Framework

To attain noteworthy improvement in reducing the number of deaths attributed to diarrhoea, its fundamental causes must be addressed. It is approximated that 90% of all cases of diarrhoea can be attributed to three major causes: insufficient sanitation, inadequate hygiene, and contaminated water (WHO 1997). According to USAID, for further progress to be made in the fight against diarrhoea, the concentration will need to include prevention, especially in child health programs. The first method, case management of diarrhoea, has been tremendously successful in recent years in reducing child mortality. The primary process of achieving effect has been through the initiation and operation of oral rehydration therapy; i.e. the dispensation of oral rehydration solution and sustained feeding (both solid and fluid, including breast milk).

In addition, health experts have emphasized the need for caretakers to become aware of the danger signs early in children under their care and to obtain suitable, appropriate care to avoid severe dehydration and death. The second approach, increasing host resistance to diarrhoea, has also had some victory with the enhancement of a child's nutritional status and vaccination against measles, a familiar cause of diarrhoea. The third element is prevention through hygiene improvement. Although the health care system has dealt comprehensively with the symptoms of diarrhoea, it has done insufficiently to bring down the overall incidence of the disease. Despite a drop in deaths owing to diarrhoea, morbidity or the health burden due to diarrhoea has not decreased, because health experts are treating the symptoms but not addressing the causes. Thus, diarrhoea's drain on the health system, its effects on household finances and education, and its additional burden on mothers has not been mitigated. Programs in several countries have confirmed that interventions can and do reduce diarrhoea morbidity. A critical constituent of successful prevention efforts is an effective monitoring and appraisal strategy.

In order to reduce transmission of faecal-oral diseases at the household level, for example, an expert group of epidemiologist and water supply and sanitation specialist concluded that three interventions would be crucial. These are:

• Safer disposal of human excreta, particularly of babies and people with diarrhoea.
• Hand washing after defecation and handling babies' faeces and before feeding, eating and preparing food, and;
• Maintaining drinking water free from faecal contamination in the home and at the source (WHO, 1993).

Studies on hand washing, as reported in Boot and Cairncross (1993), confirm that it is not only the act of hand washing, but also how well hands are washed that make a difference. To prevent diarrhoea, its causes must first be fully tacit. According to the USAID's hygiene improvement framework, a thorough approach to diarrhoea at the national level must tackle the three key elements of any triumphant program to fight disease. These are; contact with the necessary hardware or technologies, encouragement of healthy behaviours, and assistance for long-term sustainability. The concept is explained by figure 3.3 below;

The first part, water supply systems, addresses mutually the issue of water quality and water quantity, which reduces the risk of contamination of food and drink. Similarly, ensuring access to water supply systems can greatly ease the time women spend collecting water, allowing more time to care for young children and more time for income generating activities. The third element, household technologies and materials, refers to the increased accessibility to such hygiene supplies as soap (or local substitutes), chlorine, filters, water storage containers that have restricted necks and are covered, and potties for small children. The second element of the hardware component, toilet facilities, involves providing facilities to dispose off human excreta in ways that safeguard the environment and public health, characteristically in the form of numerous kinds of latrines, septic tanks, and water-borne toilets. Sanitation reporting is important because faecal contamination can spread from one household to another, especially in closely populated areas.

WATER QUALITY STANDARDS AND GUIDELINES

Water quality is defined in terms of the chemical, physical, and biological constituents in water. The word "standards" is used to refer to legally enforceable threshold values for the water parameters analyzed, while "guidelines" refer to threshold values that are recommended and do not have any regulatory status. This study employs the world health organization (WHO) and the Ghana standards board (GSB) "standards" and "guidelines" in determining the quality of water.

Water Quality Requirements for Drinking Water – Ghana Standards

The Ghana Standards for drinking water (GS 175-Part 1:1998) indicate the required physical, chemical, microbial and radiological properties of drinking water. The standards are adapted from the World Health Organizations Guidelines for Drinking Water Quality, Second Edition, Volume 1, 1993, but also incorporate national standards that are specific to the country's environment.

Physical Requirements

The Ghana Standards set the maximum turbidity of drinking water at 5 NTU. Other physical requirements pertain to temperature, odour, taste and colour. Temperature, odour and taste are generally not to be "objectionable", while the maximum threshold values for colour are given quantitatively as True Colour Units (TCU) or Hazen units. The Ghana Standards specify 5 TCU or 5 Hazen units for colour after filtration. The requirements for pH values set by the Ghana Standards for drinking water is 6.5 to 8.5 (GS 175-Part1:1998).

Microbial Requirements

The Ghana Standards specify that E.coli or thermotolerant bacteria and total coliform bacteria should not be detected in a 100ml sample of drinking water (0 CFU/100ml). The Ghana Standards also specify that drinking water should be free of human enteroviruses.

WHO Drinking Water Guidelines

Physical Requirements

Although no health-based guideline is given by WHO (2006) for turbidity in drinking water, it is recommended that the median turbidity should ideally be below 0.1 NTU for effective disinfection.

Microbial Requirements

Like the Ghana Standards, no E.coli or thermotolerant bacteria should be detected in a 100 ml sample of drinking water.

Water Related Diseases

Every year, water-related diseases claim the lives of 3.4 million people, the greater part of whom are children (Dufour et. al, 2003). Water-related diseases can be grouped into four categories ( Bradley, 1977) based on the path of transmission:

• waterborne diseases,
• water-washed diseases,
• water-based diseases,
• insect vector-related diseases.

Waterborne diseases are caused by the ingestion of water contaminated by human or animal faeces or urine containing pathogenic bacteria or viruses. These include cholera, typhoid, amoebic and bacillary dysentery and other diarrhoeal diseases. Water washed diseases are caused by poor personal hygiene and skin or eye contact with contaminated water. These include scabies, trachoma and flea, lice and tick-borne diseases. Water-based diseases are caused by parasites found in intermediate organisms living in contaminated water. These include dracunculiasis, schistosomiasis and other helminths. Water related diseases are caused by insect vectors, especially mosquitoes that breed in water. They include dengue, filariasis, malaria, onchocerciasis, trypanosomiasis and yellow fever.

The Theory of Social Learning

Learning is any relatively permanent change in behaviour that can be attributed to experience (Coon, 1989). According to the social learning theory, behavioural processes are directly acquired by the continually dynamic interplay between the individual and its social environment (Mc Connell, 1982). For example, children learn what to do at home by observing what happens when their siblings talk back to their parents or throw rubbish into the household compound.

The learning process occurs through reinforcement and punishment. Reinforcement refers to any event that increases chances that a response will occur again (Coon, 1989). Reinforcement and punishment can be learned through education where the person can read about what happens to people as a result of actions they make. The elementary unit of society is the household and this can be defined as a residential group of persons who live under the same roof and eat out of the same pot (Friedman, 1992). Social learning is necessary for the household in acquiring the skills pertinent to the maintenance of health promoting behaviour. Most of our daily activities are learned in the household. Individuals begin to learn behaviour patterns from childhood by observing especially the parents and later on their siblings.

The environment is understood as comprising the whole set of natural or biophysical and man-made or socio-cultural systems, in which man and other organisms live, work or interact (Ocran, 1999). The environment is human life's supporting system from which food, air and shelter are derived to sustain human life. Humans interact with the physical and man-made environment and this interaction creates a complex, finely balanced set of structures and processes, which evolve over the history of a people. These structures and processes determine the culture of the society, their social behaviour, beliefs and superstition about health and diseases. Social relationships seem to protect individuals against behavioural disorders and they facilitate health promoting behaviour (Barlow and Durand, 1995; House et al, 1988). Cultural systems shape peoples' motivation so that they want to act in ways that the system needs them to act (Agbola, 1993). To function as adults, children must learn the cultural beliefs and behaviour patterns of their society and must construct an understanding of social rules and gradually come to experience cultural beliefs and values on their own (Maccoby, 1980, 1992; Sapir, 1947)

CHAPTER SUMMARY

Sanitation is the provision of facilities that help in keeping waste materials safely without the risk of contamination. Hygiene is the art of healthy living and the maintenance of this healthy state. Diarrhoea can be defined in absolute or relative terms based on either the frequency of bowel movements or the consistency (looseness) of stools. Sanitation and hygiene are partner factors in health promotion in a community.

Behavioural changes can be achieved through learning that usually starts from the household in one's childhood and continues through formal education. The role of parents in the learning process in the household and especially of women is critical. Any attempt to provide hygiene improvement intervention must be holistic. The holistic view requires knowledge about the three key factors that interact to create the environmental problem, namely, the economic, the ecological and the socio-cultural systems. This is important for the attainment of sustainable development.

CHAPTER THREE

METHODOLOGY

The study was undertaken to examine issues in rural water supply such as sanitation conditions, hygiene and the incidence of some hygiene related diseases. It was to determine the extent to which bacteria have contaminated households' water and to identify the types of bacteria present if any. This chapter describes the area of study, the sample and sampling technique, the instruments for data collection, data collection and data analysis procedures.

THE WASSA WEST DISTRICT

The Wassa West District is located in the South Western part of the Western Region of Ghana. It is located between latitude 4o – 50? and 5o – 40? N, and longitude 1o 10W and 2o 10W. It has a total land area of 2,354km2. The district capital is Tarkwa and it is about 90km from the Regional Capital Sekondi – Takoradi. The population of the District is 232, 669 (2000 population and housing census). The District falls within the forest-dissected plateau of Ghana. Pre-Cambrian rocks of Birimian and Tarkwaian formations underline the forest – dissected plateau. The relief is generally undulating with few scarps rising between 150m and 300m above sea level (WWDA, 2006).

The Bogoso Community

The case study community, Bogoso, is about 35km from the district capital with an estimated population of 8,659 people (2006 projection, WWDA) representing 3.95% of the population of the district. The population density is 96.27 persons per km2. Male to female ratio is 100:97. Traditional authority is exercised by a paramount chief who is supported by two divisional chiefs (Adontehene and Benkumhene).

The dominant tribe is the Wassa tribe who constitute about 43% of the population. Other tribes include Asante, Ewe, Ga, Kokomba, and Brongs among others. Bogoso forms part of the Birimian and Tarkwaian geological formations. Economically, the Birimian rocks are regarded as the most important formations due to its mineral potentials. It accounts for the existence of many gold mining companies operating in the town. Soils in Bogoso are the forest oxysols formed from Tarkwaian and Birimian rocks, suitable for cultivation of food and tree crops. The vegetation of Bogoso is the Equatorial Rain Forest type with moist semi – deciduous forest. This yields various tree species including Odum, Mahogany, Wawa, and Utile to the Ghana Timber Industry. Climatically, the community lies within the south-western equatorial zone and is marked by double maximum rainfall starting from March to September. It has an annual mean rainfall of 187.83mm and a uniform temperature ranging between 26oC in August and 30oC in March. Relative humidity is generally high throughout the year between 70% - 80% in the dry season and 75% - 80% in the wet season.

DATA COLLECTION METHODS

The aim of this study was to gain knowledge into the extent to which households' drinking water has been bacteriologically contaminated and to identify factors that have contributed to the pollution. Three methods were combined to study the problem so that the strengths of each method could overcome the deficiencies of single method studies (Sarantakos, 1998). Interview schedule was developed for household heads and caretakers of children below 5 years as well as an observational guide. Slight changes were made to the questions for the heads and that for the child miners. It covered general sanitation and hygiene behavioural issues. Copies of questionnaire for household heads, caretakers and the observational guide are attached as Appendices A, B and C. The general sub-topics were; household characteristics, waste disposal methods, water use behaviour, water storage, occurrence of diseases in households, presence of sanitation facilities, hygiene practice and health education attendance.

Two research assistants who spoke the local languages of the study area and had secondary school education were trained to administer the interview schedule and the observational guide. Personal interviews were conducted at the respondents' home in the dialect of the respondents. The interview method was chosen because of the high illiteracy rate among the respondents. Direct observation of sanitation practices was undertaken to help the researcher capture at first hand, the sanitation behaviour of the people. The observation involved looking out for physical clues of sanitation practices as well as water storage conditions.

Due to the cost and the tremendously large and scattered population of the Bogoso community, multi-stage cluster sampling was employed in the administration of the interview guide. First, the study area was divided into six cluster communities (indicated with red spots on the map). At the second stage, some houses were identified at random within each cluster. Out of these houses, a household was sampled and given household identification numbers in the third stage followed by individuals within these households in the final stage. A total of 120 household heads and 77 caretakers of children below 5 years responded. The review of secondary data helped in obtaining information that has been documented about water, sanitation and health in the region and elsewhere. Review of secondary data also provided criteria for analysing the water as well as standards of bacteria and their concentrations.

Data Analysis

Field notes, interviews and all other information were collated, edited and coded. The information was tabulated and frequency tables obtained using the SPSS software. The data was then analyzed to extract meaning and understanding using Pearson Product Moment Correlation Values. Scatter plots were obtained for continuous data and cross tables were used for categorical data to determine the relationship between the variables.

WATER QUALITY SAMPLING

The number of samples tested by the author of this study was limited to the 3 months time available and the main aim was to sample as many households as possible. Water samples were collected between June 2007 and August 2007 from stored water sources of 30 households in the target communities for analysis. Physical observation of the stored drinking water revealed that some containers had no covers and most households collect water from the containers by dipping cups and bottles into it. The number of water samples collected for analysis was not equal to the number of respondents because of time, resources and financial burden. Water samples were collected in sterilized 500ml Whirl-Pak® bags with sodium thiosulfate tablet. They were transported in ice packs and cooler bags to ensure low temperatures (2-8ºC) were maintained at all times. This was done to preserve the integrity of the samples since bacteria reaction cannot progress at that temperature. If any excess reaction is not stopped, the results of the analysis may be affected. Analysis of the water samples began within 4 to 6 hours of collection at the Environmental Quality Department of Golden Star Bogoso/Prestea Mine. When testing within 4 to 6 hours was not possible, the samples were transferred to a refrigerator and tested within 24 hours. Distilled, bottled or boiled water was used to meet sterile water requirements.

Studies done by Obiri-Danso et al (2003) indicated that all samples of bottled water tested were free of microbial contamination (0 CFU/100ml for both E.coli and total coliforms), which implies that using bottled water as sterile water could not have been a major source of error for the tests conducted in this study. Blanks were consistently run of this water and (with one day's exception on distilled water that was obtained from St Augustine's School labs and potentially contaminated by the collection container) came out blank. Where the household used bagged sachet water, these samples were transported in their original sachet-packs. Water samples were only transferred to the Whirl-Pak® bags at the testing lab, so that the sodium thiosulphate tablet contained in the Whirl-Pak® bags would neutralize any chlorine in the sachet water. The sodium thiosulfate tablet contained in one bag is capable of neutralizing 500ml of a chlorinated water sample (HACH, 1999). The neutralization by sodium thiosulfate ensured that no residual chlorine would interfere with the microbial analysis.

Membrane Filtration Method (MF) using mColiBlue24®

In the Membrane Filtration (MF) method, water of a known volume (usually 100ml) is passed through a sterile filter paper with 0.45 microns pore diameter. These pores are small enough to filter out bacteria. The filter paper is then transferred to a Petri dish which contains a pad saturated with medium. For this study, mColiBlue24® broth (ready-to-use broth sold in plastic ampoules) was the media for coliform growth. mColiBlue24® is a nutritive membrane-filtration media that simultaneously detects total coliforms and E. coli within 24 hours. The media is lactose based and contains inhibitors to selectively inhibit growth of non-coliform cells (HACH, 2003). Total coliforms are "highlighted" by non selective dye, 2,3,5-Triphenyltetrazoliumchloride (TTC), which produces red colonies. E.coli, on the other hand, is "highlighted" through the action of ?-D-glucuronidase enzyme and/or 5-bromo-4-chloro-3-indolyl-?-glucoronide (BCIG or X-Glu). Red and blue colonies combined are total coliforms while blue colonies alone are E. coli. The media is provided in 2ml ready-to-use ampoules, which have a shelf life of one year when stored under temperature conditions between 2-8 ºC. The detection limit (or sensitivity) is one CFU coliform bacteria or E. coli per 100ml of sample (HACH, 1999).

The Petri dish is incubated at 35ºC ± 0.5ºC for 24 hours, during which coliforms, if present, multiply and grow in size, and can thus be identified and counted. Visible coliforms form since dye present in the media causes the coliforms to appear coloured. For drinking water, the counts are reported as coliforms forming units per 100ml of water (CFU/100ml). Where necessary, various dilutions were applied to obtain coliform counts within a given range. Colonies that entirely cover the plate grid, causing it to be red or pink in color, are recorded as "too numerous to count" (TNTC).

Sterilization

Before testing the water samples, all the Petri dishes, pipette tips, and measuring cylinders were sterilized by being boiled in water for 10 to 15 minutes and left to cool at ambient temperature before use. Isopropylene was used to clean all working surfaces as well as the outer wrap of sachet-water packets. The forceps were flame sterilized (by candle flame) before every use. The Millipore stainless steel, portable filtration unit was sterilized by soaking the wick attached to its lower plate with methanol, igniting the methanol and immediately capping the filtration unit. The methanol ignition produces formaldehyde, which sterilizes the unit. The unit was left closed for 15 minutes for effective sterilization to take place.

Preparation of Petri Dishes

To prepare the Petri dish, a sterile absorbent pad was placed in a Petri dish (with labelled base plate) using flame sterilized forceps. In some cases, disposable Petri dishes, bought with absorbent pads were used. Otherwise, recyclable Petri dishes made of stainless steel were used. The mColiBlue24® medium was added evenly on to the absorbent pad after inverting it two to three times to mix it. Excess liquid was poured off.

Preparing Sample Dilution

For water samples that were suspected to have high counts of total coliform and E.coli counts above the 20 to 80 range, mainly the surface water sources, dilutions of 1:10 and 1:100 were used. For the 1:10 dilutions, a sample of 10ml was pipetted using the automatic pipette and this was placed in a graduated cylinder that contained 90ml of sterilized (bottled or boiled) water. Similarly for the 1:100 dilutions, 1ml of the sample was pipetted into 99ml sterile water.

Filtration

Using sterile forceps, a sterile membrane filter paper was placed in the filtration unit over the porous plate of the receptacle with the grid side up. Well mixed samples of 100ml were then filtered under a partial vacuum. After filtration, sterilized water in the squeeze bottle was used to rinse the interior surface of the funnel 3 times with 20 to 30 ml water. The rinsing ensured that coliform that could have been stuck on the sides of the vessel would be washed onto the filter paper. The membrane filter was then removed using sterile forceps and placed, with the grid side up, on the prepared Petri dish by applying a slight "rolling motion". The sample was then incubated for 24 hours at a temperature of 35ºC ± 0.5 ºC, upside-down (inverted with the base side up) to prevent steam(bubbles) from forming on the filter thus making it difficult to read the samples.

Sterile water was also run through the filtration unit, before each sample, as a blank to make sure there was no contamination. If blank samples contained coliforms, as they did on several occasions, the corresponding tests were repeated. In some cases, where coliforms in the samples were much larger than those in the blanks, instead of repeating the test, the actual coliform count was taken to be the difference between the coliforms in the sample and those in the blank. While it may have been ideal to also ran blanks between dilutions, because of time constraints not all tests done on sample dilutions were preceded by blanks. In all cases however, the lowest dilutions were first tested and the filter unit always sterilized after testing a given series of dilutions, of the same sample. A magnifying glass was used to determine colony counts on the filter papers. All waste material generated from the tests were soaked in disinfectant bleach, and allowed to stand for 30 minutes to 24 hours before they were disposed off.

Interpretation of Results

Red and blue colonies combined indicated that the sample had total coliforms, while blue colonies indicated E.coli. The absence of red or blue colonies indicated that the sample contained no total coliforms or E.coli. The coliform density was directly given by the number of coliforms counted based on the formula,

Where: N = the number of colonies counted;

V = the sample volume in ml.

In cases where no colonies were observed, the coliform colonies were reported as 0 CFU/100ml.

Averaging Counts

For duplicate tests that were carried out on samples with varying dilutions, the average values of colonies counted were obtained after multiplying the counts with appropriate dilution factors. 57% of the samples tested (17/30) were also run as duplicates. Where duplicated samples were taken with some results being TNTC, only the average of the countable colonies was obtained. In cases where the "blanks" that preceded samples being tested had more coliforms than samples run subsequently, the colony counts in samples associated to those blanks were disregarded (spoiled samples). Nevertheless, when blanks tested had colonies, but the sample test that followed had none, the corresponding sample was taken to have 0 CFU/100ml.

Testing Apparatus

• Incubator capable of operating at 35ºC ±0.5 ºC;
• Vacuum pump;
• Millipore membrane filtration stainless steel funnel unit and flask;
• Pre-sterilized 45 mm filter papers of 0.45?m pore diameter;
• Petri dishes of 50 mm with or without absorbent pads (with base plate labelled);
• Pre-sterilized absorbent pads (for Petri dishes without absorbent pads);
• Lab supplies: Graduated cylinders, stainless steel forceps and disposable pipette tips,
• 2 squeeze bottles, one for sterilized water and the other methanol;
• Automatic pipette and magnifying glass (3X and 10X);
• Candles and lighters for flame sterilization;
• Boiling equipment (pots, stove or burner);
• Stop watch and bleach disinfectant.

Reagents

• Methanol for flame sterilization,
• isopropylene for sterilization of working surface,
• mColiBlue24® pre-packed culture medium
• and sterilized water (distilled or bottled water).

CHAPTER FOUR

RESULTS AND DISCUSSION

This chapter discusses the socio-cultural profile of the respondents to throw more light on the relationship between variables such as age of head of household, educational attainment, family size, and religious affiliation of the head, the sanitation conditions and the occurrence of diarrhoeal diseases in the households.

HOUSEHOLD CHARACTERISTICS

The risk of diseases like diarrhoea heightens when people continuously drink or use water obtained from unprotected wells and live in poor housing conditions (Isely, 1985). Therefore, the type of dwelling and certain household conditions can affect the health of the members of the household. The household conditions considered in this study include wall construction, floor construction, roof construction and the presence or absence of children below the age of 5years and their caretakers.

Wall Construction

Out of the 120 sample size, 52 respondents representing 43.33% used mud; 38 respondents representing 31.67% used cement; 18 respondents representing 15% used stones; 10 respondents representing 8.33% used raffia and 2 respondents representing 1.67 used a combination of building materials. This is illustrated by figure 4.1 below;

Roof Construction

Materials used by respondents for roof construction are shown by fig. 4.3. A total of 68 people out of the 120 sample size, representing 56.67% used corrugated sheets; 38 people representing 31.67% used straw; 8 people representing 6.67% used cement; 4 people representing 3.33% used other and 2 people representing 1.67% used mud.

From the above data it is obvious that the walls of most houses in the Bogoso area are built with mud and earth is the most used material for floor construction. Earth is easily attacked by erosion and therefore during the rainy season, it may crumble and washed along with the runoff especially during heavy downpour. The eroded materials are transported as sediments into the streams, hence contaminating it. The usage of the contaminated water without proper treatment increases the incidence of water-borne diseases. Besides the use of straw, corrugated sheets are the most used material for roofing in the community. The use of straw for roofing may also create sanitation problems. Straw may provide breeding place for insects such as tsetseflies, cockroaches, and mosquitoes. These insects may attack the dwellers of a household leading to all forms diseases. Thus the increase in the cost of frequent health care aggravates the poverty situation in the area. In as much as majority of the people use earth others appreciate the use of modern materials such as cement and tiles. This need to be vigorously encouraged to reduce the incidence of health problems.

SOCIO-CULTURAL CHARACTERISTICS OF THE SAMPLED HOUSEHOLDS

Socio-cultural characteristics of a household determine the models for learners (Robine et al, 1999). The socio-cultural characteristics that were considered as relevant to the objectives of this study were gender, age, marital status, occupation, educational attainment and the religious affiliation of the heads of the households and the caretakers of children below 5years in the households.

Sex of Heads of Households and Caretakers of Children below five years of Age

The head of household is the person around whom the household is organized. The caretaker of a child is the one who provides the essential needs of the child such as healthcare and training the child. It is usually the mother who spends a lot of time with the child. Fathers give more confidence to the child and the more supportive of the mother the father tends to be; the mature the child will become (Mc Connell, 1982). The head of the household is expected, in our society, to fend for the whole household.

Culturally and naturally, males are the head of the household and therefore command much authority and respect. Consequently; children adhere to the instructions of their fathers. This is a good platform for the father to instil proper sanitation and hygiene practices into the children. This reinforces the statement that Charity begins at home. Per our culture, mothers do spend a lot of time with their children and are responsible for their nursing and nurturing. It is therefore not surprising that the female caretakers dominate that of the males.

In every community, there are learning systems by which local knowledge is adapted to new information and transmitted through dialogue and participation. Women are mostly the controllers in local learning systems regarding water, health and sanitation (Roark, 1980, Amsyari et al, 1978). However, in the Bogoso community, males determine roles in the household and this ultimately defines the learning process in the household. This situation does not auger well for the informal learning of good hygiene behaviour in the household since women who have the knowledge, are not taking the decisions on the rewards and punishment systems in the household. Kendie (2002) notes that the low status accorded women in the households in the sampled community promotes poor environmental hygiene and the resulting burden of disease is borne more by the women and children than their male counterparts. Much of the informal learning about water and sanitation takes place through interpersonal contacts between women (Wijk-Sijbesma, 1985:1); so where women do not have time to meet in these informal meetings, they do not learn much to impart to their children and dependants.

Marital Status of the head and the caretaker of children in the households

The traditional ideal of the family in the Wassa West district is large families. Status and prestige of the family group are measured in size: the more numerous, the higher the status.

Household Size

The average size of the households sampled for this study as shown by table 4.3 is 5.79 which is slightly above the national average of 5.55people (Ghana, 2000b). This indicates that a lot of pressure is exerted on water and sanitation facilities across the nation. This also implies that there would be poor sanitation and hygiene practices in the Bogoso community which is detrimental to the health of the people.

Age of Head and caretakers of children below five years in the households.

The age of marriage is crucial in determining fertility behaviour. Marriage for women in most societies, including the Wassa West District, takes place soon after puberty, usually between 15 and 20 years. Early age of marriage for women in traditional societies contributes to high fertility, as almost the entire child bearing period of the woman from puberty to menopause is available for utilisation (Nukunya, 1992).

The mean age of head of household in the Bogoso community is 46.67 years and that for the caretakers of children below 5years is 38.64years. The average age of male head of household for Ghana is 44years (Ghana, 2000b). The average family size of 6 (approximately), means there is a drain on the economic resources of the household and the household's life will revolve very much around the task of meeting the basic needs of food, healthcare , water and clothing (Awortwi, 1999).

Religion of Head of Household

Religion affords an unusually effective vehicle for change in attitude and behaviour because of its ability to link what people say and do with what they think (Zanden, 1990). Because religion shapes peoples beliefs and attitudes, the religious affiliation of the heads of household were obtained.

With Muslims their doctrine requires that they pray five times each day and before each time of the prayer, they perform ablution which is the cleansing of their bodies. This enables them to physically wash off dirt from their bodies thus improving their health conditions and promoting hygiene. The traditionalists also have some health promoting beliefs. For example, it's a taboo to pick food from the ground or enter a shrine with your shoes on. It is evident then that religion plays a vital role in inculcating sanitation and hygienic practices into individuals.

SOCIOECONOMIC CHARACTERISTICS OF RESPONDENTS

Socioeconomic characteristics of a family affect the family's participation in community development issues (Hausknet, 1962) and health inequalities are systematically associated with economic status (Wagstaff, 2000). Research by Hausknet (1962) indicates that low economic status, as measured by income, education and occupation has a negative correlation with rates of participation in community organizations. As such, low economic status populations feel powerless to change processes that affect them and therefore separate themselves from active community roles. In addition, such groups have little time and resources to partake in such outside activities that do not directly provide livelihoods. This isolation of some level of the population will affect the extent of learning that takes place in the community as well as the rate at which new knowledge that are disseminated at health education meetings is learned in the community. In this subsection, occupation and formal education levels of sampled households are discussed.

Education attainment of head of household and caretaker of children below 5years

It was observed in the sampled district that the women were always engaged in petty trading and subsistence farming when they were not doing anything at home. There would also be little time and resources for the formal education of children from such households. Formal education will let them become more aware of the health benefits of improved water supply and sanitation and more likely to use improved services if they were available (World Bank, 1993)

For the purpose of this study, the definition of a literate is someone with at least 6years of formal education, which is up to class six in Ghana's education system. This study found that 65% and 76.6% of heads of household and caretakers of children below the age of 5years respectively in the Bogoso community had no formal education as compared to the national ratio of 31.8% (Ghana, 2000). The heads of household in the sampled communities are less educated than their counterparts in Ghana generally. This may mean that they are not equipped with knowledge to make informed decisions about health promoting behaviour. According to Taylor (1995: 72-73) health behaviours are learned in one's most powerful learning environment, which is the home, and from one's most powerful models, the parents. The sort of behaviour the parents exhibit in the household therefore has a significant effect on the sanitation conditions that prevails in the household.

Occupation of household heads

Out of the 120 persons sampled, 48 heads of the households representing 40% are farmers; and the rest of them are artisans, traders, miners, teachers, housewife and unemployed respectively. The predominant occupation of heads of household is mining followed by farming. Most of these miners are engaged in small scale mining popularly called "Galamsey" with a few in the legal mining companies. The percentage of the population engaged in farming is less than the national average. In Ghana, 54.3% of workers are involved in agricultural activity and 70.1% of rural economic activity is in agriculture (Ghana, 2000:31) as compared to the 40% for the Bogoso community. The agricultural activity the respondents are engaged in is subsistence and this normally does not fetch much money.

SANITATION CONDITIONS OF THE SAMPLED HOUSES

In this section, the researcher examines the availability of sanitation facilities such as toilets, rubbish dumps and the sanitation conditions of the sampled households. The relevance is due to the fact that the values associated with a household like the availability of adequate waste and excreta disposal facilities and their hygienic use are an integral part of primary health care (Mc Junkin, 1983).

Toilet facilities

The majority of households in the Bogoso community have no household toilets. The distribution of household toilets is shown by figure 4.9. From the figure, at least 80% of sampled households did not have household toilet.

The unavailability of household toilets and places of convenience would automatically provide the inhabitants of the community the opportunity to ease themselves in bushes which is the most widely used spot as the study found out, along river banks or even into polythene bags and litter the environment with it. This is a great source of pollution to the environment. Their water source could easily be polluted leading to increase in water borne- diseases in the community. The distribution of places of convenience for households is given in the table 4.5 below.

In the Bogoso community and its surrounding villages, 35% of the population had no toilet facility and use the bush as compared to the national average of 20% (Ghana, 2000:51). The higher incidence of the bush as place of convenience in the wet season has serious consequences for the health of the people. Dense vegetation and often wet bushes will not encourage people to go deep into the bush to ease themselves and faeces are found closer to human habitats. In times of heavy downpour, runoff water may wash faeces into nearby water bodies to cause contamination. Also, 25% used the manual bucket latrine and in most cases, the facility was situated a few meters from the household. The method of disposal of the contents in these buckets is a big problem. Usually, the buckets are emptied into nearby bushes creating the same problem as those who ease themselves in the bush. Others dispose into pits created for that purpose somewhere outside the village. It seems safe for them but infiltration and deep percolation can still transport bacteria even into underground water sources.

DISPOSAL OF RUBBISH AND DISTANCE OF HOUSEHOLD DUMP TO HOUSE

Out of the 120 sample size, 56 people representing 47% dispose their waste at the damp site; 35 people representing 29% dispose off their waste anywhere whilst 17 people representing 14% burn their waste; 9 people representing 8% bury theirs and the remaining 3 representing 3% leave their waste to compost. It is therefore not surprising to notice the seasonal emergence of communicable diseases such as cholera, diarrhoea and malaria in these communities.

Distance of household dump from house

Household dumps which are all close to the houses, are exposed to rodents, vermin and vultures and also provide breeding grounds for flies and mo