Reducing Childhood Diarrhoea Morbidity in the Tamale Metropolitan Area of Ghana: the Need for Behavioural Change. Kanton Osumanu Department of Geography

Reducing Reducing Childhood Diarrhoea MorbidityChildhood Diarrhoea Morbidity in the Tamale Metropolitan Area of in the Tamale Metropolitan Area of

Ghana: Ghana: the Need for the Need for BehaviouralBehavioural Change. Change.

Kanton OsumanuKanton Osumanu

Department of Geography & Resource Development, Department of Geography & Resource Development,

University of Ghana, Legon. University of Ghana, Legon.

Map of Ghana, Showing the Location of Map of Ghana, Showing the Location of Tamale.Tamale.

Structure of presentationStructure of presentationThe issues covered are presented in 5 parts.The issues covered are presented in 5 parts.

• Section 1: Introduction and objective.Section 1: Introduction and objective.

• Section 2: Sources of information.Section 2: Sources of information.

• Section 3: Incidence and determinants of diarrhoea at the Section 3: Incidence and determinants of diarrhoea at the local levellocal level

• Section 4: Cultural understandings and practices related Section 4: Cultural understandings and practices related to diarrhoea in the study area.to diarrhoea in the study area.

• Section 5: Provides channels for effective public Section 5: Provides channels for effective public education. education.

IntroductionIntroduction

• DiarrhoeaDiarrhoea ranks among the ranks among the top five health problemstop five health problems in in many countries and is responsible for many countries and is responsible for 4 to 6 million 4 to 6 million deaths of children under 5 per year worldwidedeaths of children under 5 per year worldwide (WHO, (WHO, 1981).1981).

• In Ghana, diarrhoea has been identified as the second In Ghana, diarrhoea has been identified as the second most common health problem treated in outpatient most common health problem treated in outpatient clinics. clinics.

• It accounts for It accounts for 84 000 deaths annually84 000 deaths annually in Ghana with 25% in Ghana with 25% of these being children under 5 years (Ghana News of these being children under 5 years (Ghana News Agency, 2003).Agency, 2003).

• In the Tamale Metropolitan Area, dIn the Tamale Metropolitan Area, diarrhoea is currently iarrhoea is currently the the second most importantsecond most important cause of child morbidity cause of child morbidity and and mortality, after malaria.mortality, after malaria.

• It accounted for It accounted for 5.8% and 7.2%5.8% and 7.2% of outpatients treatments of outpatients treatments in the metropolis in in the metropolis in 2003 and 20042003 and 2004 respectively (Tamale respectively (Tamale Metropolitan Health Directorate, 2005).Metropolitan Health Directorate, 2005).

Int. Cont.Int. Cont.

• While there is reasonable evidence of the impacts of While there is reasonable evidence of the impacts of improved water quantity and quality, and sanitation improved water quantity and quality, and sanitation on diarrhoea incidence, the facts are generally not on diarrhoea incidence, the facts are generally not clear and consistent, most likely due to:clear and consistent, most likely due to:

i. limitations in study design i. limitations in study design ii. ii. the confounding effects of several environmental the confounding effects of several environmental

factors and cultural practices related to diarrhoeafactors and cultural practices related to diarrhoea. .

• Evidently, gains made in achieving infrastructure Evidently, gains made in achieving infrastructure coverage over the last two decades have not brought coverage over the last two decades have not brought about as significant a health impact as donors had about as significant a health impact as donors had anticipated. anticipated.

• Larsen (2002) has suggested that one of the Larsen (2002) has suggested that one of the fundamental weaknesses of the programmes fundamental weaknesses of the programmes undertaken by various developing countries to attain undertaken by various developing countries to attain the MDGs is the tendency to give the MDGs is the tendency to give priority to water priority to water supply over sanitation and sanitation over hygienesupply over sanitation and sanitation over hygiene. .

IntInt. . Cont.Cont.

There seem to be a reasonable consensus that There seem to be a reasonable consensus that those interventions that improve hygienic those interventions that improve hygienic behaviour at the household level and/or the behaviour at the household level and/or the community level have the greatest impact on community level have the greatest impact on diarrhoea incidence. diarrhoea incidence.

• According to Cairncross (1996), hygienic According to Cairncross (1996), hygienic disposal of children’s stools is associated with disposal of children’s stools is associated with 30 – 40% less risk of serious diarrhoea. 30 – 40% less risk of serious diarrhoea.

• Several studies have also demonstrated that Several studies have also demonstrated that hand washing at appropriate times with hand washing at appropriate times with appropriate techniques can reduce overall appropriate techniques can reduce overall diarrhoeal disease morbidity by diarrhoeal disease morbidity by 30 – 50%30 – 50% (Khan (Khan 1982; Clemens and Stanton 1987; Black,1982; Clemens and Stanton 1987; Black, 1981). 1981).

IntInt. . Cont.Cont.

• Food has also been shown to be a common Food has also been shown to be a common vehicle for disease germs, accounting for an vehicle for disease germs, accounting for an estimated estimated 15 – 20%15 – 20% of diarrhoea disease of diarrhoea disease incidence (Esrey and Feachem, 1989). incidence (Esrey and Feachem, 1989).

• A case-control study in Manila also found out A case-control study in Manila also found out that that kitchen hygiene – cleanliness of food kitchen hygiene – cleanliness of food and water storage containers and the and water storage containers and the sanitary condition of the cooking and eating sanitary condition of the cooking and eating areasareas were strongly associated with high risk were strongly associated with high risk of severe diarrhoea (Baltazar et al., 1993).of severe diarrhoea (Baltazar et al., 1993).

Int. Cont.Int. Cont.

• Viewed from the perspective of the health sector, Viewed from the perspective of the health sector, hygiene intervention has been shown to be highly hygiene intervention has been shown to be highly cost effective for control of diarrhoea in children cost effective for control of diarrhoea in children under five (Christoffers et al., 2005).under five (Christoffers et al., 2005).

• Although improving the level of hygiene practices Although improving the level of hygiene practices

may be highly effective, may be highly effective, social and cultural social and cultural factors may also have a reinforcing or a factors may also have a reinforcing or a restraining influencerestraining influence. .

• This explains why many hygiene interventions This explains why many hygiene interventions that attempted to reduce childhood diarrhoea that attempted to reduce childhood diarrhoea failed to demonstrate any positive effects (WHO, failed to demonstrate any positive effects (WHO, 1979).1979).

Objective of the studyObjective of the study

• The study sought to identify The study sought to identify local local adaptive behaviours that could be adaptive behaviours that could be modified and implemented as modified and implemented as culturally acceptableculturally acceptable. .

• The main objective is to provide the The main objective is to provide the insights needed to design an effective insights needed to design an effective communication programme to communication programme to promote behavioural change for promote behavioural change for diarhoea reduction. diarhoea reduction.

Sources of dataSources of data

• The analysis presented here is based on The analysis presented here is based on semi-structured interviews and focus group semi-structured interviews and focus group discussions conducted among 285 mothers.discussions conducted among 285 mothers.

• The issues covered in the survey include: The issues covered in the survey include: the mother’s level of education; the the mother’s level of education; the household’s access to and use of water and household’s access to and use of water and sanitation facilities; and the occurrence of sanitation facilities; and the occurrence of diarrhoea in children under 5 years.diarrhoea in children under 5 years.

• The The point prevalencepoint prevalence of diarrhoea and its of diarrhoea and its occurrence over the preceding two weeks occurrence over the preceding two weeks were measured by the mother’s recall, as were measured by the mother’s recall, as recommended in the WHO rapid assessment recommended in the WHO rapid assessment manual (WHO, 1979). manual (WHO, 1979).

Data sources cont.Data sources cont.

• A composite variableA composite variable representing the diarrhoea representing the diarrhoea history of the child was also constructed by history of the child was also constructed by summing the responses to the following questions, summing the responses to the following questions, to which mothers responded according to their own to which mothers responded according to their own interpretation and recall:interpretation and recall:

i.i. Has your child had diarrhoea in the last two Has your child had diarrhoea in the last two weeks? (No = 0, yes = 5.) weeks? (No = 0, yes = 5.)

ii.ii. Does your child have diarrhoea today? (No = 0, Does your child have diarrhoea today? (No = 0, yes = 5 ) yes = 5 )

iii.iii. Does your child often have diarrhoea? (Never =0, Does your child often have diarrhoea? (Never =0, rarely= 1, sometimes= 2, often =3, almost always rarely= 1, sometimes= 2, often =3, almost always = 5). = 5).

iv.iv. When was the last time your child had diarrhoea? When was the last time your child had diarrhoea? (Never=0, more than two months ago=1, last (Never=0, more than two months ago=1, last month = 2, last week = 3, this week = 4.) month = 2, last week = 3, this week = 4.)

v.v. Was your child seriously ill with diarrhoea in the Was your child seriously ill with diarrhoea in the last wet season? (No = 0, yes = 5.)last wet season? (No = 0, yes = 5.)

Data sources cont.Data sources cont.

• The The maximummaximum composite variable score composite variable score for this scale is for this scale is 2424. .

• The composite variable scores provide a The composite variable scores provide a simplified scale for comparing the simplified scale for comparing the incidence (and frequency of occurrence) of incidence (and frequency of occurrence) of childhood diarrhoea among the various childhood diarrhoea among the various risk factors covered in the survey.risk factors covered in the survey.

Incidence and major determinants of childhood Incidence and major determinants of childhood diarrhoea in the Tamale Metropolitan Area (TMA)diarrhoea in the Tamale Metropolitan Area (TMA)

• Of the children covered in the survey, it was found that Of the children covered in the survey, it was found that 38%38% have had diarrhoea in the preceding two weeks of have had diarrhoea in the preceding two weeks of the interview whilst only the interview whilst only 6%6% had diarrhoea on the day had diarrhoea on the day of the interview. of the interview.

• Analysis of the survey data (Figure 1) showed that Analysis of the survey data (Figure 1) showed that the the children of mothers who had never been to school had children of mothers who had never been to school had approximately 7 times as many cases of diarrhoea as approximately 7 times as many cases of diarrhoea as the children of mothers who had received tertiary the children of mothers who had received tertiary educationeducation..

• The association between childhood diarrhoea and The association between childhood diarrhoea and maternal education in the Tamale Metropolitan area maternal education in the Tamale Metropolitan area agrees with the findings of other studies in Ghana agrees with the findings of other studies in Ghana (Benneh et al., 1993;(Benneh et al., 1993; Tagoe, 1995; Boadi and Kuitunen, Tagoe, 1995; Boadi and Kuitunen, 2005) and other parts of West Africa (2005) and other parts of West Africa (Togunde, 1999).Togunde, 1999).

Incidence & determinants cont.Incidence & determinants cont.

• Figure 1: Relationship Figure 1: Relationship between childhood between childhood diarrhoea and diarrhoea and maternal education maternal education (%).(%).

• F = 6.67, P = F = 6.67, P = 0.030.03

• Source: Based on Questionnaire Source: Based on Questionnaire Survey, 2005.Survey, 2005.

63.6

52.5

25

9.1

0

10

20

30

40

50

60

70

Pe

rce

nta

ge

Pre

va

len

ce

No Education BasicEducation

Sec.Education

TertiaryEducation

Mother's Level of Education


• The study considered a number of The study considered a number of household conditions in determining the household conditions in determining the major risk factors responsible for diarrhoea major risk factors responsible for diarrhoea being found in children. being found in children.

• Table 1 summarises the results of the Table 1 summarises the results of the composite variable scores for the major composite variable scores for the major household risk factors. household risk factors.

Table 1: Major determinants of childhood diarrhoea in TMA, Ghana.Table 1: Major determinants of childhood diarrhoea in TMA, Ghana.

Risk FactorRisk Factor Composite Variable Score Composite Variable Score (%)(%)

0 – 80 – 8 9 – 169 – 16 17 – 2417 – 24

Store water in potStore water in pot 14.8 28.4 56.8 14.8 28.4 56.8Share toilet with more than 4 householdsShare toilet with more than 4 households 15.6 30.2 15.6 30.2

54.254.2Buy prepared food from street vendorsBuy prepared food from street vendors 28.8 28.5 28.8 28.5

50.750.7Feed children with cold leftover foodsFeed children with cold leftover foods 10.8 42.9 46.3 10.8 42.9 46.3Depend on water form vendorsDepend on water form vendors 12.0 43.4 44.6 12.0 43.4 44.6Do not wash hands after defecationDo not wash hands after defecation 16.7 39.1 44.2 16.7 39.1 44.2Do not wash hands before cookingDo not wash hands before cooking 28.0 35.3 36.7 28.0 35.3 36.7Many flies in cooking areaMany flies in cooking area 44.0 27.8 28.2 44.0 27.8 28.2Use borehole/well/dugout waterUse borehole/well/dugout water 42.5 41.4 16.1 42.5 41.4 16.1Have no toilet facilityHave no toilet facility 47.0 37.3 15.7 47.0 37.3 15.7

Source: Based on Questionnaire Survey, 2005.Source: Based on Questionnaire Survey, 2005.


• The association between childhood diarrhoea and The association between childhood diarrhoea and vended water and toilet sharing has been adequately vended water and toilet sharing has been adequately explained in the literature (Benneh et al., 1993; explained in the literature (Benneh et al., 1993; McGranahan, et al., 2001). McGranahan, et al., 2001).

• Whilst admitting the fact that these conditions are Whilst admitting the fact that these conditions are made possible by the lack of adequate water supply made possible by the lack of adequate water supply and sanitation, and sanitation, it is also important to acknowledge it is also important to acknowledge the role of confounding factors, arising from routine the role of confounding factors, arising from routine practices of water and toilet usepractices of water and toilet use, in explaining the , in explaining the prevalence of childhood diarrhoea. prevalence of childhood diarrhoea.

• For example, For example, when water has been obtained, it is when water has been obtained, it is often used for several domestic chores. often used for several domestic chores. In this In this regard, the same water that is used to wash regard, the same water that is used to wash vegetables is afterwards used to wash dishes or vegetables is afterwards used to wash dishes or hands. hands.


• It must be noted that pots by themselves do not It must be noted that pots by themselves do not contaminate water.contaminate water. Of concern, however, is the way Of concern, however, is the way pots and their contents are treatedpots and their contents are treated. .

• The consumption of contaminated water is further The consumption of contaminated water is further increased by the increased by the failure of households to treat water, failure of households to treat water, by boiling or filtering, before drinkingby boiling or filtering, before drinking. .

• Households fail to treat water because of the Households fail to treat water because of the lack of lack of real acceptance of the role of water in disease real acceptance of the role of water in disease causation and unwillingness to commit resources to causation and unwillingness to commit resources to purchase materials for water treatmentpurchase materials for water treatment, particularly , particularly filtering. filtering.

• Reasons for non-treatment of water were:Reasons for non-treatment of water were: i. i. Materials for water treatment being expensive, Materials for water treatment being expensive,

27.4%.27.4%. ii. Time consuming, 25%.ii. Time consuming, 25%. iii. Boiling of water produces flat taste, 24.6%.iii. Boiling of water produces flat taste, 24.6%. iv. Good quality, 23%.iv. Good quality, 23%.


• Handing washing after defecation appears to be a Handing washing after defecation appears to be a function of the availability of a toilet facility in the home.function of the availability of a toilet facility in the home.

• Generally, communal toilets (pit and KVIP latrines) do Generally, communal toilets (pit and KVIP latrines) do not offer water for hand washing. Majority of users of not offer water for hand washing. Majority of users of these facilities who wash their hands after defecating these facilities who wash their hands after defecating happened to be happened to be Muslims who carry their own water any Muslims who carry their own water any time they visited the facilities, depicting a general time they visited the facilities, depicting a general situation where Muslims wash their hands after situation where Muslims wash their hands after defecating but in most cases without soap. defecating but in most cases without soap.

• Although the scarcity and cost of water influences the Although the scarcity and cost of water influences the way in which it is used, way in which it is used, having water conveniently having water conveniently available inside the house did not seem to affect hand available inside the house did not seem to affect hand washing before food preparation. washing before food preparation.

• Cultural beliefs related to the concept of Cultural beliefs related to the concept of ‘cleanliness’ ‘cleanliness’ ‘and the social prestige attached to it‘and the social prestige attached to it seem to be most seem to be most important in explaining mothers’ hand washing important in explaining mothers’ hand washing behaviour.behaviour.


There are four (4) kinds of ‘dirtiness’, and therefore There are four (4) kinds of ‘dirtiness’, and therefore ‘cleanliness’, which may lead mothers to wash ‘cleanliness’, which may lead mothers to wash their hands:their hands:

1. 1. Perceived ‘dirtiness’:Perceived ‘dirtiness’: when the hands look, feel when the hands look, feel or smell dirty to the mother.or smell dirty to the mother.

2. 2. Contaminating ‘dirtiness’:Contaminating ‘dirtiness’: when the hands have when the hands have been in contact with anything considered dirty, been in contact with anything considered dirty, such as garbage, human faeces or urine. such as garbage, human faeces or urine.

3. 3. Social ‘dirtiness’:Social ‘dirtiness’: when mothers wish to when mothers wish to improve their general physical appearance. improve their general physical appearance.

4. 4. Religious ‘dirtiness’:Religious ‘dirtiness’: when mothers are when mothers are compelled to fulfill their religious obligations. compelled to fulfill their religious obligations.


• Hand washing with soap is Hand washing with soap is largely dependent on the largely dependent on the educational attainment of educational attainment of the motherthe mother (Figure 2). (Figure 2).

• This finding is consistent This finding is consistent with earlier findings in with earlier findings in other parts of the country other parts of the country (Benneh et al., 1993; (Benneh et al., 1993; Gyimah, 2003; Boadi and Gyimah, 2003; Boadi and Kuitunen, 2005).Kuitunen, 2005).

• Source: Based on Source: Based on Questionnaire Survey, 2005.Questionnaire Survey, 2005.

16.430

59.4

92.9

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nta

ge

No Schooling BasicEducation

Sec.Education

TertiaryEducation

Mother's Level of Education


• One factor which emerged in this study as a major One factor which emerged in this study as a major determinant of childhood diarhoea is determinant of childhood diarhoea is feeding feeding children with cold leftover foods.children with cold leftover foods.

• For many low-income households in the metropolis For many low-income households in the metropolis leftover cooked foods constitute a major leftover cooked foods constitute a major component of component of morning meals and, to a lesser morning meals and, to a lesser degree, midday mealsdegree, midday meals as well. as well.

• The role of leftover foods in the prevalence of The role of leftover foods in the prevalence of childhood diarrhoea emanates from childhood diarrhoea emanates from improper food improper food storage practicesstorage practices. .


• When considering the presence of flies in the When considering the presence of flies in the kitchen, and therefore the risk of exposure to food kitchen, and therefore the risk of exposure to food and drink to flies, it is important to recognize the and drink to flies, it is important to recognize the role of many household factors. role of many household factors.

• The The use of open containers to store solid wasteuse of open containers to store solid waste in in the house before final disposal.the house before final disposal.

• The The type of kitchentype of kitchen..

• Keeping Keeping domestic animals in the housedomestic animals in the house.. • The use of The use of ‘chamber pots’ for defecation‘chamber pots’ for defecation by by

children. children.

Local Beliefs and Attitudes about Local Beliefs and Attitudes about

DiarrhoeaDiarrhoea The study revealed a relatively low level of knowledge The study revealed a relatively low level of knowledge

about the causes and effects of diarrhoea. about the causes and effects of diarrhoea. • Generally mothers identified two forms of diarrhoea – Generally mothers identified two forms of diarrhoea –

binsaabinsaa and and tirikanyeratirikanyera.. • BinsaaBinsaa is common diarrhoea that is not accompanied is common diarrhoea that is not accompanied

by vomiting. by vomiting. BinBin is from the word is from the word binibini which means which means faeces but the whole word faeces but the whole word binsaabinsaa refers to refers to watery watery stoolstool. .

• Mothers believe that binsaa is caused by Mothers believe that binsaa is caused by ‘hot’ foods, ‘hot’ foods, hunger and teething. hunger and teething.

• It is seen as It is seen as an old and traditionally known condition an old and traditionally known condition of imbalance in life forces, and considered as a of imbalance in life forces, and considered as a cleansing of the ‘inside’ of a child and washing away cleansing of the ‘inside’ of a child and washing away of impurities from the child’s stomach. of impurities from the child’s stomach.

• It is therefore seen as It is therefore seen as a normal part of growing up a normal part of growing up and not an illness but a usual occurrence in the and not an illness but a usual occurrence in the young child’s lifeyoung child’s life. .

LBAD cont.LBAD cont.

• This is how a mother described the effects of This is how a mother described the effects of binsaabinsaa::

““Binsaa is surely not dangerous, for all young Binsaa is surely not dangerous, for all young children suffer multiple episodes of it and most of children suffer multiple episodes of it and most of them continue to live in reasonably good health.”them continue to live in reasonably good health.”

• TirikanyeraTirikanyera is diarrhoea accompanied by is diarrhoea accompanied by vomitingvomiting..

• TirikanyeraTirikanyera is a compound word made up of is a compound word made up of tiritiri which means vomiting and which means vomiting and nyeranyera which means which means defecating. defecating.

• This form of diarrhoea is believed to be caused by This form of diarrhoea is believed to be caused by ingestion of ‘dirty foods’. ingestion of ‘dirty foods’.

• Traditionally, this form of diarrhoea is considered to Traditionally, this form of diarrhoea is considered to be dangerous, and therefore given some attention.be dangerous, and therefore given some attention.

LBAD cont.LBAD cont.

• Diarrhoea is simply not perceived as Diarrhoea is simply not perceived as life-threatening, life-threatening, or even as debilitating. or even as debilitating.

• This is due to the fact that many infected children do This is due to the fact that many infected children do not suffer to any great extent.not suffer to any great extent.

• The economic and environmental conditions of low-The economic and environmental conditions of low-income community members also explain their income community members also explain their inability to avoid diarrhoea risk factors.inability to avoid diarrhoea risk factors.

• Again, the fact that the disease is chronic and usually Again, the fact that the disease is chronic and usually untreated by households leads to high rates of re-untreated by households leads to high rates of re-infection.infection.

• Appropriate medicine and visits to a clinic or health Appropriate medicine and visits to a clinic or health centre are not considered necessary for a condition centre are not considered necessary for a condition which is not accepted as one of ill healthwhich is not accepted as one of ill health. .

• However, in cases where diarrhoea persists for However, in cases where diarrhoea persists for over 3 over 3 or 4 daysor 4 days, mothers usually provide some , mothers usually provide some management in the home. management in the home.

Hints for Effective Public EducationHints for Effective Public Education

1.1. Change is only achievable through:Change is only achievable through: i. community participation in identifying unacceptable i. community participation in identifying unacceptable practices that needs to be changed. practices that needs to be changed.

ii. integrated hygiene education at the household level.ii. integrated hygiene education at the household level.

2.2. Improvement can be achieved by developing strong Improvement can be achieved by developing strong links with identified community based organisations links with identified community based organisations (CBOs) or religious groupings. (CBOs) or religious groupings.

3.3. Unhygienic practices can be altered by a combination Unhygienic practices can be altered by a combination of mothers’ proper understanding of germ theory, of of mothers’ proper understanding of germ theory, of the detrimental effect of unhygienic behaviours on the detrimental effect of unhygienic behaviours on health, and of ways and benefits of hygienic practices. health, and of ways and benefits of hygienic practices.

END OF PRESENTATIONEND OF PRESENTATION

THANK YOUTHANK YOU

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Reducing Childhood Diarrhoea Morbidity in the Tamale Metropolitan Area of Ghana: the Need for Behavioural Change. Kanton Osumanu Department of Geography