Pervasive Exposure to Fecal Contamination in Low-Income Neighborhoods in Accra, Ghana Público

Abstract

BACKGROUND: Globally, diarrhea contributes to about 800,000 fatalities in children under five each year, and is a primary cause of mortality in developing countries. Rapid urbanization in low-income countries has led to a growing sanitation crisis. A need exists for more effective WASH interventions in low-resource urban environments that can minimize the transmission of feces and reduce the rate of diarrheal illnesses. Effective interventions require evidence-based research that highlights risk behaviors and perceptions of fecal contamination risk in people's daily lives.

METHODS: This study examines the context of fecal contamination during daily activities among residents in low resource urban settings of Accra, Ghana. Qualitative data were collected through 16 focus group discussions to understand the daily behaviors that place people at risk of fecal contamination. Data were collected and analyzed using a grounded theory approach to develop a conceptual framework of the context of fecal contamination in low-income neighborhoods of Accra. MaxQDA10 software was used for data analysis.

RESULTS: Results show that latrine use is low in these neighborhoods leading to a range of alternative methods of fecal disposal (e.g. take aways, chamber pots, hawker's containers, and open defecation) that contribute to fecal contamination throughout neighborhoods. Feces were further spread through refuse dumping, poor refuse collection systems, recreational activities, and occupational tasks of residents. Fecal contamination also occurred between public and private domains contributing to pervasive fecal contamination throughout the study neighborhoods.

DISCUSSION: This study is unique in describing in detail the range of fecal disposal methods used by residents in their daily lives, and how feces are transmitted between public and private domains throughout low-resource urban neighborhoods. The context of fecal disposal and contamination throughout neighborhoods suggests that people may be frequently exposed to feces through regular daily activities, which may lead to a high frequency of fecal transmission overtime.

CONCLUSION: These pathways of fecal contamination underscore the pervasiveness of risk for fecal contamination throughout low-income urban neighborhoods, suggesting the need for multi-pronged interventions that target multiple pathways of feces transmission.

Table of Contents

TABLE OF CONTENTS

I. INTRODUCTION…….………………………………….….…………..……..…….….…1

A. Causes and Mitigation Factors of Diarrhea…………..….…………………………………..……2

B. Significance of Study………………………………….………………………………………..………….….3

II. LITERATURE REVIEW ………………….……………….…………………….…….….4

A. Risk of Exposure to Diarrheal Diseases………….…………………………….…….…….……...4

B. Transmission of Enteric Pathogens………………………………………………..…………..……….5

C. Urbanization and Sanitation……………………………………………………….….…………...………6

D. Risk of Fecal Contamination due to Infrastructure ………....………….……………..…….8

i. Sanitation Systems……………………………..……..………………………………….……………..…….8

ii. Water Infrastructure…………………………….……………………...………………………….………….9

iii. Access to Water Sources………………………….………………………………………………….……10

iv. Access to Latrines………………………………….……………………..……………………………....…11

E. Behavioral Risk of Fecal Contamination…………………….…………….……..……………..…11

i. Public vs. Private Domains…………………………...………………….…..………..………………..11

ii. Public Vs. Private Latrines………………………………………………………………..……………….12

iii. Blocked Drains………………………………………………………………………………………..…………13

iv. External Contexts Affect Behavior and Exposure…………………...……..……….……..14

F. Risk of Exposure to Fecal contamination due to daily activities.….............……14

i. Education and Children's Exposure to Fecal Contamination……..………………..….…15

ii. Household activities affecting contamination…………………………….…….…….…………15

iii. Water Storage and Hygiene in the Home….……………………………………..…….……….16

iv. Behavior Change Interventions………………….…………………..………..……..……….…….16
III. METHODS……………………………………............................….....………….19
A. Study Design…………………………………………..……………………………………….…………..……19
B. Study Sites………………..…………………………………………………………….…………………………19
C. Table 1………………………………………………………..………………………………………………………20
D. Key Informant Interviews & Transect walks…….…………………..…………….……………21
E. Focus Group Discussions……..…………………………………………………….…………..…….…..22
F. Data Analysis….....……………....………………….….....……………………….………………………23

CONCEPTUAL FRAMEWORK (Figure 1) ……………………….………..…….…......25

IV. RESULTS……………………………………………….........……………................26
A. Latrine Use….………………………………….………………………………………………………………….26
i. Private Latrines….………………………………………………………………….……..……….…………..26
ii. Public Latrines….…………………………………………………………...…………..……….…….………28
B. Transmission of Feces ….………………………………….………………..……………..…………....30
i. Fecal Disposal Methods ….………………………………….…………………………..……………….…31
ii. Feces in the Environment….……………………………………………………….……..……..….…..35
iii. Refuse Disposal....………………………………….…....…...……………...….…….....……………39
iv. Choked Drains….………………………………….……..……………………………….………..……...…42
C. Pervasiveness of Fecal contamination ....…………...…………………………….….....…...45

V. DISCUSSION/CONCLUSION ………………………………………………...….……49
A. Overview ….………………………………….……..……….………………..………………………………..49
B. Latrine Use….………………………………….……..……….…………………………..……..…….……..49
C. Fecal Disposal Methods….…………………………………..……………………….……..…….…..…50
D. Pervasiveness of Fecal Contamination in Daily Activities…….…….………………..….51
E. Fecal Transmission into the Household…….……..……….……………………………..…..….53
F. Study Limitations….………………………………….……..……….……………………………………..…54
G. Conclusion ………………………………….……..……….…………………………………………….………54

V I. PUBLIC HEALTH IMPLICATIONS/ FUTURE RESEARCH ………....……...….55

V II. REFERENCES ……………………………………………………………...……………57

VIII. APPENDIX…………………………………………………………………………..….63
A.Appendix A: Protocol and Focus Group Guides ………………………………………….……. 63
B. Appendix B: Codebook…………………………………………………………………………………….…77

C. Appendix C: IRB approval letter…………………………………………………………………………85

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Palabra Clave	Ghana Sanitation Grounded theory Urban health Water Feces Fecal contamination Qualitative analysis fecal transmission WASH Fecal disposal Open Defecation Drains
Committee Chair / Thesis Advisor	Hennink, Monique, Emory University
Committee Members	Moe, Christine L, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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