Reducing Childhood Diarrhoea Morbidity in
the Tamale Metropolitan Area of Ghana:
the Need for Behavioural Change.
Kanton Osumanu
Department of Geography & Resource Development,
University of Ghana, Legon.
Map of Ghana, Showing the Location of Tamale.
Structure of presentation
The issues covered are presented in 5 parts.
• Section 1: Introduction and objective.
• Section 2: Sources of information.
• Section 3: Incidence and determinants of diarrhoea at the
local level
• Section 4: Cultural understandings and practices related to
diarrhoea in the study area.
• Section 5: Provides channels for effective public education.
Introduction
• Diarrhoea ranks among the top five health problems in
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•
•
•
many countries and is responsible for 4 to 6 million deaths
of children under 5 per year worldwide (WHO, 1981).
In Ghana, diarrhoea has been identified as the second most
common health problem treated in outpatient clinics.
It accounts for 84 000 deaths annually in Ghana with 25%
of these being children under 5 years (Ghana News Agency,
2003).
In the Tamale Metropolitan Area, diarrhoea is currently the
second most important cause of child morbidity and
mortality, after malaria.
It accounted for 5.8% and 7.2% of outpatients treatments
in the metropolis in 2003 and 2004 respectively (Tamale
Metropolitan Health Directorate, 2005).
Int. Cont.
• While there is reasonable evidence of the impacts of
improved water quantity and quality, and sanitation on
diarrhoea incidence, the facts are generally not clear and
consistent, most likely due to:
i. limitations in study design
ii. the confounding effects of several environmental factors
and cultural practices related to diarrhoea.
• Evidently, gains made in achieving infrastructure coverage
over the last two decades have not brought about as
significant a health impact as donors had anticipated.
• Larsen (2002) has suggested that one of the fundamental
weaknesses of the programmes undertaken by various
developing countries to attain the MDGs is the tendency to
give priority to water supply over sanitation and sanitation
over hygiene.
Int
.
Cont.
There seem to be a reasonable consensus that those
interventions that improve hygienic behaviour at
the household level and/or the community level
have the greatest impact on diarrhoea incidence.
• According to Cairncross (1996), hygienic disposal
of children’s stools is associated with 30 – 40%
less risk of serious diarrhoea.
• Several studies have also demonstrated that hand
washing at appropriate times with appropriate
techniques can reduce overall diarrhoeal disease
morbidity by 30 – 50% (Khan 1982; Clemens and
Stanton 1987; Black, 1981).
.
Int
Cont.
• Food has also been shown to be a common vehicle
for disease germs, accounting for an estimated 15
– 20% of diarrhoea disease incidence (Esrey and
Feachem, 1989).
• A case-control study in Manila also found out that
kitchen hygiene – cleanliness of food and water
storage containers and the sanitary condition of the
cooking and eating areas were strongly associated
with high risk of severe diarrhoea (Baltazar et al.,
1993).
Int. Cont.
• Viewed from the perspective of the health sector,
hygiene intervention has been shown to be highly cost
effective for control of diarrhoea in children under five
(Christoffers et al., 2005).
• Although improving the level of hygiene practices may
be highly effective, social and cultural factors may also
have a reinforcing or a restraining influence.
• This explains why many hygiene interventions that
attempted to reduce childhood diarrhoea failed to
demonstrate any positive effects (WHO, 1979).
Objective of the study
• The study sought to identify local adaptive
behaviours that could be modified and
implemented as culturally acceptable.
• The main objective is to provide the insights
needed
to
design
an
effective
communication programme to promote
behavioural change for diarhoea reduction.
Sources of data
• The analysis presented here is based on semi•
•
structured interviews and focus group discussions
conducted among 285 mothers.
The issues covered in the survey include: the
mother’s level of education; the household’s
access to and use of water and sanitation
facilities; and the occurrence of diarrhoea in
children under 5 years.
The point prevalence of diarrhoea and its
occurrence over the preceding two weeks were
measured by the mother’s recall, as recommended
in the WHO rapid assessment manual (WHO,
1979).
Data sources cont.
•
i.
ii.
iii.
iv.
v.
A composite variable representing the diarrhoea
history of the child was also constructed by summing
the responses to the following questions, to which
mothers responded according to their own
interpretation and recall:
Has your child had diarrhoea in the last two weeks?
(No = 0, yes = 5.)
Does your child have diarrhoea today? (No = 0, yes =
5)
Does your child often have diarrhoea? (Never =0,
rarely= 1, sometimes= 2, often =3, almost always =
5).
When was the last time your child had diarrhoea?
(Never=0, more than two months ago=1, last month
= 2, last week = 3, this week = 4.)
Was your child seriously ill with diarrhoea in the last
wet season? (No = 0, yes = 5.)
Data sources cont.
• The maximum composite variable score for this
scale is 24.
• The composite variable scores provide a
simplified scale for comparing the incidence (and
frequency of occurrence) of childhood diarrhoea
among the various risk factors covered in the
survey.
Incidence and major determinants of childhood diarrhoea in
the Tamale Metropolitan Area (TMA)
• Of the children covered in the survey, it was found that
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•
38% have had diarrhoea in the preceding two weeks of
the interview whilst only 6% had diarrhoea on the day of
the interview.
Analysis of the survey data (Figure 1) showed that the
children of mothers who had never been to school had
approximately 7 times as many cases of diarrhoea as the
children of mothers who had received tertiary education.
The association between childhood diarrhoea and maternal
education in the Tamale Metropolitan area agrees with the
findings of other studies in Ghana (Benneh et al., 1993;
Tagoe, 1995; Boadi and Kuitunen, 2005) and other parts of
West Africa (Togunde, 1999).
Incidence & determinants cont.
• Figure 1: Relationship
between
childhood
diarrhoea and maternal
education (%).
0.03
Percentage Prevalence
• F = 6.67, P =
70
63.6
52.5
60
50
40
25
30
9.1
20
10
0
No Education
•
Source: Based on Questionnaire
Survey, 2005.
Basic
Education
Sec.
Education
Tertiary
Education
Mother's Level of Education
Incidence & determinants cont.
• The study considered a number of household
conditions in determining the major risk factors
responsible for diarrhoea being found in children.
• Table 1 summarises the results of the composite
variable scores for the major household risk
factors.
Table 1: Major determinants of childhood diarrhoea in TMA, Ghana.
Risk Factor
Composite Variable Score (%)
0–8
9 – 16
17 – 24
Store water in pot
14.8
Share toilet with more than 4 households 15.6
Buy prepared food from street vendors
28.8
Feed children with cold leftover foods
10.8
Depend on water form vendors
12.0
Do not wash hands after defecation
16.7
Do not wash hands before cooking
28.0
Many flies in cooking area
44.0
Use borehole/well/dugout water
42.5
Have no toilet facility
47.0
Source: Based on Questionnaire Survey, 2005.
28.4
30.2
28.5
42.9
43.4
39.1
35.3
27.8
41.4
37.3
56.8
54.2
50.7
46.3
44.6
44.2
36.7
28.2
16.1
15.7
Incidence & determinants cont.
• The association between childhood diarrhoea and vended
water and toilet sharing has been adequately explained in
the literature (Benneh et al., 1993; McGranahan, et al.,
2001).
• Whilst admitting the fact that these conditions are made
possible by the lack of adequate water supply and
sanitation, it is also important to acknowledge the role of
confounding factors, arising from routine practices of water
and toilet use, in explaining the prevalence of childhood
diarrhoea.
• For example, when water has been obtained, it is often used
for several domestic chores. In this regard, the same water
that is used to wash vegetables is afterwards used to wash
dishes or hands.
Incidence & determinants cont.
• It must be noted that pots by themselves do not
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•
•
contaminate water. Of concern, however, is the way pots
and their contents are treated.
The consumption of contaminated water is further
increased by the failure of households to treat water, by
boiling or filtering, before drinking.
Households fail to treat water because of the lack of real
acceptance of the role of water in disease causation and
unwillingness to commit resources to purchase materials
for water treatment, particularly filtering.
Reasons for non-treatment of water were:
i. Materials for water treatment being expensive, 27.4%.
ii. Time consuming, 25%.
iii. Boiling of water produces flat taste, 24.6%.
iv. Good quality, 23%.
Incidence & determinants cont.
• Handing washing after defecation appears to be a function
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•
•
of the availability of a toilet facility in the home.
Generally, communal toilets (pit and KVIP latrines) do not
offer water for hand washing. Majority of users of these
facilities who wash their hands after defecating happened to
be Muslims who carry their own water any time they visited
the facilities, depicting a general situation where Muslims
wash their hands after defecating but in most cases without
soap.
Although the scarcity and cost of water influences the way
in which it is used, having water conveniently available
inside the house did not seem to affect hand washing before
food preparation.
Cultural beliefs related to the concept of ‘cleanliness’ ‘and
the social prestige attached to it seem to be most important
in explaining mothers’ hand washing behaviour.
Incidence & determinants cont.
There are four (4) kinds of ‘dirtiness’, and therefore
‘cleanliness’, which may lead mothers to wash their
hands:
1. Perceived ‘dirtiness’: when the hands look, feel or
smell dirty to the mother.
2. Contaminating ‘dirtiness’: when the hands have been
in contact with anything considered dirty, such as
garbage, human faeces or urine.
3. Social ‘dirtiness’: when mothers wish to improve their
general physical appearance.
4. Religious ‘dirtiness’: when mothers are compelled to
fulfill their religious obligations.
Incidence & determinants cont.
• Hand washing with soap is
largely dependent on the
educational attainment of the
mother (Figure 2).
90
• This finding is consistent with
80
Percentage
earlier findings in other parts
of the country (Benneh et al.,
1993; Gyimah, 2003; Boadi
and Kuitunen, 2005).
92.9
100
59.4
70
60
50
30
40
30
16.4
20
• Source: Based on Questionnaire
Survey, 2005.
10
0
No Schooling
Basic
Education
Sec.
Education
Tertiary
Education
Mother's Level of Education
Incidence & determinants cont.
• One factor which emerged in this study as a major
determinant of childhood diarhoea is feeding children with
cold leftover foods.
• For many low-income households in the metropolis
leftover cooked foods constitute a major component of
morning meals and, to a lesser degree, midday meals as
well.
• The role of leftover foods in the prevalence of childhood
diarrhoea emanates from improper food storage practices.
Incidence & determinants cont.
• When considering the presence of flies in the kitchen, and
therefore the risk of exposure to food and drink to flies, it
is important to recognize the role of many household
factors.
• The use of open containers to store solid waste in the
house before final disposal.
• The type of kitchen.
• Keeping domestic animals in the house.
• The use of ‘chamber pots’ for defecation by children.
Local Beliefs and Attitudes about Diarrhoea
The study revealed a relatively low level of knowledge about
the causes and effects of diarrhoea.
• Generally mothers identified two forms of diarrhoea – binsaa
and tirikanyera.
• Binsaa is common diarrhoea that is not accompanied by
vomiting. Bin is from the word bini which means faeces but
the whole word binsaa refers to watery stool.
• Mothers believe that binsaa is caused by ‘hot’ foods, hunger
and teething.
• It is seen as an old and traditionally known condition of
imbalance in life forces, and considered as a cleansing of the
‘inside’ of a child and washing away of impurities from the
child’s stomach.
• It is therefore seen as a normal part of growing up and not
an illness but a usual occurrence in the young child’s life.
LBAD cont.
• This is how a mother described the effects of binsaa:
“Binsaa is surely not dangerous, for all young children suffer
multiple episodes of it and most of them continue to live in
reasonably good health.”
• Tirikanyera is diarrhoea accompanied by vomiting.
• Tirikanyera is a compound word made up of tiri which
means vomiting and nyera which means defecating.
• This form of diarrhoea is believed to be caused by ingestion
of ‘dirty foods’.
• Traditionally, this form of diarrhoea is considered to be
dangerous, and therefore given some attention.
LBAD cont.
• Diarrhoea is simply not perceived as life-threatening, or even
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as debilitating.
This is due to the fact that many infected children do not
suffer to any great extent.
The economic and environmental conditions of low-income
community members also explain their inability to avoid
diarrhoea risk factors.
Again, the fact that the disease is chronic and usually
untreated by households leads to high rates of re-infection.
Appropriate medicine and visits to a clinic or health centre
are not considered necessary for a condition which is not
accepted as one of ill health.
However, in cases where diarrhoea persists for over 3 or 4
days, mothers usually provide some management in the
home.
Hints for Effective Public Education
1. Change is only achievable through:
i. community participation in identifying unacceptable
practices that needs to be changed.
ii. integrated hygiene education at the household level.
2. Improvement can be achieved by developing strong links
with identified community based organisations (CBOs) or
religious groupings.
3. Unhygienic practices can be altered by a combination of
mothers’ proper understanding of germ theory, of the
detrimental effect of unhygienic behaviours on health, and
of ways and benefits of hygienic practices.
END OF PRESENTATION
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