Behavioural and Cultural Factors That Influence Open Defaecation Among First Cycle School Pupils in the Eastern and Volta Regions of Ghana

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BEHAVIOURAL AND CULTURAL FACTORS THAT INFLUENCE OPEN DEFAECATION AMONG FIRST CYCLE SCHOOL PUPILS IN THE EASTERN AND VOLTA REGIONS OF GHANA

SAVIOUR VICTOR KWABLA ADJIBOLOSOO

(10213261)

THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF PHD ENVIRONMENTAL SCIENCE DEGREE

JULY 2017 University of Ghana http://ugspace.ug.edu.gh

DECLARATION I do declare that except for references to other persons investigations which I have duly acknowledged, this study hereby presented is the result of my own original research, and this thesis, either in whole or in part, has not been presented for another degree elsewhere.

………………………………...... ……………………………. Saviour Victor Kwabla Adjibolosoo Date

……………………………… …....………………………. Professor Philip Baba Adongo Date (Principal Supervisor)

...…………………………...... …………………………… Dr. Yirenya-Tawiah Dzidzo Date (Co-Supervisor)

……….……………………… …..…………………………. Dr. Benjamin D. Ofori Date (Co-Supervisor)

………………………………. …..………………………….

Dr. Stephen Afranie Date

(Co-Supervisor)

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ABSTRACT The influence of human behaviour and culture on open defaecation has attracted global concern in recent times. As a way of placing the behavioural and cultural factors influencing open defaecation behaviour in Ghana on the public agenda, a school-based cross-sectional study was conducted in eight first cycle schools selected from eight communities within the Eastern and Volta regions of the country. The objective of the study was to explore the behavioural and cultural factors influencing open defaecation among the pupils aged between nine and eighteen years. Self-reported data on attitudes, subjective norms, perceived control behaviour, behavioural intentions, culture and situational factors associated with school toilet systems were collected from 400 pupils in the selected schools. The study employed mixed methods—questionnaires, focus group discussions, in-depth interview, and checklist observation. Quantitative data was analyzed using Structural Equation Modelling (SEM) path analysis with the aid of AMOS software version 20 (IBM), and the qualitative data was also analyzed using thematic data analysis procedures.

The results of the study showed high level of open defaecation (64.3%) among the pupils with more female pupils (32.6%) than male pupils (29.4%) recording the higher open defaecation prevalence across the study schools. The overall knowledge level of risks associated with open defaecation behaviour was high (89.8%) among the pupils.

Knowledge of health risks of open defaecation behaviour was, however, low among the greater number (53%) of the pupils. Pupils’ knowledge of environmental risks associated with the open defaecation behaviour was found to be fairly high (52%). Attitude was found to have significant direct influence on pupils’ intention to engage in open defaecation behaviour (standardized mean positive effect size = 0.708; p<0.05) compared to the subjective norm (standardized mean positive effect size =0.035; p>0.05 and PBC

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(standardized mean effect size =-0.11; p< 0.05). The interaction effect size of subjective norms and perceived behavioural control variables was also found to be strong and statistically significant predictor (standardized mean positive effect size = 0.608, p<0.000) of pupils open defaecation behaviours. The interacting effect size of behavioural variables included on attitude, subjective norms and perceived behavioural control measuring scales on pupils open defaecation behaviours was also found to be strong and statistically significant determinant of open defaecation behaviours (standardized mean positive effect size (r) = 0.58; p<0.05). The study also noted that cultural factors-taboos and superstitions constituted the key variables influencing pupils’ open defaecation behaviours (63%) with the later exerting stronger and statistically significant influence (standardized mean positive effect size = 0.728, p <0.000). The interaction between behavioural and cultural factors was equally found to have greater effect size on pupils’ open defaecation behaviours (standardized mean positive effect size =0.682, p <0.000).

The conditions of the school toilet system, oscillating from toilet inadequacy, lack of privacy, poor ventilation, inappropriate squat hole sizes, community and rodents encroachment on school toilets, to inappropriate location of school toilets, constitute key situational variables causing pupils to engage in open defaecation practices.

The study findings revealed that open defaecation behaviour is being reinforced in the first cycle schools regardless of pupils’ high knowledge of health and environmental risks associated with the practice. Thus pupils’ open defaecation behaviour is largely policy and situation-driven which raises many questions about the level of attention the Ministry of

Local Government and Rural Development (MLGRD), Ministry of Education (MOE), and

Ghana Education Service (GES) give to open defaecation in schools. The MLGRD must

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make it a national policy that schools are provided with descent toilet facilities whose quality resonates with the benefits pupils attach to open defaecation practices. Secondly, the MOE, GES, Teacher Education Division (TED), Curriculum Research and

Development Division (CRDD) must introduce new courses that can help pupils to acquire knowledge on the environmental and health implications of open defaecation practices.

The pupils must also be educated on good sanitary practices.

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DEDICATION

This Thesis is dedicated to my wife and children for their sense of responsibility, sacrifice and love.

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ACKNOWLEDGEMENT

I wish to thank the Almighty God for the knowledge, guidance and strength given me in writing this work. In the writing of this Thesis, many people have assisted in diverse ways and I owe them lots of gratitude and appreciation. I wish, therefore to express my warmest gratitude and appreciation to my hardworking and enthusiastic supervisors: Prof. Philip

Baba Adongo (Principal supervisor), School of Public Health, University of Ghana,

Legon; Dr. Dzidzo Yirenya-Tawiah (Co-supervisor), IESS, University of Ghana; Dr.

Benjamin D. Ofori (Co-supervisor), IESS, University of Ghana; and Dr. Stephen Afranie

(Co-supervisor), University of Ghana, for their guidance and useful suggestions during every stage of the Thesis.

My deepest appreciation goes to my family for their encouragement, moral, financial and spiritual support throughout the period of writing this Thesis. Also, I owe a debt of gratitude to the following individuals who assisted in various ways: Samuel Otu and

Ibrahim. I acknowledged the field assistance from Mr. Robert Ansah of P.W.C.E. I thank all workers of Environmental Health Department of Nsawam-Adoagyiri Municipal

Assembly for their guidance and support during my internship. I am grateful to the following for the diverse roles they played to ensure a successful research work: Mr. Jacob

Nanor, Mr. Isaac Agbeko, Osae Richard, Mr. Evans, Mr. Eric Ansong, all of Presbyterian

Women’s Training College, Aburi; and all my course mates, especially Mr. Aboagye

Samuel and Mr. Bayitse Richard. To all others who contributed in one way or the other to make this work a success and whose names have not been mentioned, I am most grateful and God richly bless you all. This study would not have been possible without the financial support from Carnegie, University of Ghana. I am truly grateful for their sponsorship and series of annual workshops on data managements and analyses.

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TABLE OF CONTENTS

DECLARATION ...... i

ABSTRACT ...... ii

DEDICATION ...... v

ACKNOWLEDGEMENT ...... vi

TABLE OF CONTENTS ...... vii

LIST OF TABLES ...... xiv

LIST OF FIGURES ...... xvii

LIST OF PLATES ...... xviii

LIST OF ABBREVIATIONS...... xix

CHAPTER ONE ...... 1

INTRODUCTION ...... 1

1.1 Background to the Study ...... 1

1.2 Problem Statement ...... 5

1.3 General Objective ...... 6

1.4 Specific Objectives ...... 7

1.5 Research Questions ...... 7

1.6 Justification ...... 8

1.7 Thesis Organization ...... 9

1.8 Thesis Scope ...... 10

1.9 Thesis Limitations ...... 10

1.10 Definition of Terms ...... 11

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CHAPTER TWO ...... 13

LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK ...... 13

2.0 Literature Review ...... 13

2.1 Knowledge of Sanitation in the Global Environment ...... 13

2.2 State of Sanitation in Africa ...... 15

2.3 State of Sanitation in Ghana...... 18

2.4 Open Defaecation Prevalence in the Global Environment and Sub-Saharan Africa

...... 21

2.5 Open Defaecation Prevalence in Ghana...... 22

2.6 Excreta Management Systems in Ghana and in the First Cycle Schools ...... 24

2.7 Barriers and Threats to Toilet Use in Ghana ...... 28

2.8 Policy Framework for Provision of Toilet Facilities to First Cycle Schools ...... 30

2.9 Theoretical Foundation of Human Envirionmental Behaviour ...... 31

2.10 Theory of Planned Behaviour (TPB) and its Applications ...... 33

2.11 Theoretical Foundation of Culture and Human Behaviour Towards the

Environment ...... 37

2.12 Influence of Culture on Human Environmental Behaviour ...... 38

2.13 Culture, Behaviour and Sanitation: Africa and Ghana’s Perspectives...... 40

2.14 Culture, Behaviour and Open Defaecation: Global, Africa and Ghana’s

Perspectives ...... 42

2.15 Public Health and Environmental Implications of Open Defaecation ...... 46

2.16 Identified Critical Knowledge Gaps in Literature...... 50

2.17 Conceptual Framework ...... 51

2.17.1 Behavioural Factors ...... 53

2.17.2 Cultural Factors ...... 56

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2.17.3 Situational Factors ...... 57

2.17.4 Modifying Factors ...... 57

2.17.5 Open Defaecation Behaviour and Synergy Among Behavioural, Situational

and Modifying Factors ...... 58

2.17.6 Relevance of Conceptual Framework to the Present Study ...... 59

CHAPTER THREE ...... 61

METHODOLOGY ...... 61

3.1 Study Areas ...... 61

3.1.1 Description of the Study Areas ...... 64

3.2 Study Communities and Schools ...... 68

3.3 Study Design ...... 70

3.4 Study Participants, Sample Size and Sampling Methods ...... 71

3.5 Research Instruments ...... 73

3.5.1 Questionnaires ...... 73

3.5.2 Focus Group Discussions (FGDs) ...... 74

3.5.3 Structured In-depth Interview ...... 75

3.5.4 Checklist Observation Guide ...... 75

3.5.5 Desk Review of Policy Documents on School Toilet Provision ...... 76

3.6 Training of Research Assistants ...... 76

3.7 Ethical Requirement ...... 77

3.8 Pre-testing of Research Instruments ...... 78

3.9 Administration of Research Instruments...... 78

3.9.1 Questionnaire ...... 78

3.9.2 Focus Group Discussion (FGDs) ...... 79

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3.9.3 In-depth Interview ...... 81

3.9.4 Checklist Observation ...... 81

3.9.5 Desk Review of Policy Documents on School Toilet Provision ...... 82

3.10 Data Management and Analyses Methods ...... 82

3.10.1 Quantitative Data Management and Statistical Analysis ...... 83

3.10.2 Qualitative Data Management and Analysis Methods ...... 91

3.10.3 Analyses of Policy Documents Reviewed ...... 93

CHAPTER FOUR ...... 94

RESULTS ...... 94

4.1 Conditions and Usage of School Toilets ...... 94

4.2 Knowledge and Perception of Teachers on Conditions of School Toilets ...... 96

4.3 Pupils and Teachers Perception of Conditions of School Toilets ...... 101

4.3.1 Hygiene and Access in School Toilet ...... 101

4.3.2 Privacy and Safety in the School Toilets ...... 102

4.3.3 Smells and Ventilation in School Toilets ...... 103

4.3.4 Toilet Maintenance and Provision of Cleaning Logistics ...... 105

4.3.5 Community and Rodents Encroachment on School Toilet ...... 106

4.3.6 Toilet Suitability ...... 107

4.4 Socio-Demographic Characteristics of Study Participants ...... 112

4.5 Occurrence and Prevalence of Open Defaecation in the Study Schools ...... 113

4.6 Situational Factors That Influence Open Defaecation Behaviour in the Study

Schools ...... 116

4.7 Situational Factors that Prevent Open Defaecation in the Study Schools ...... 118

4.8 Behavioural Factors Influencing Open Defaecation Practices ...... 120

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4.8.1 Attitudes and Open Defaecation Behaviours ...... 120

4.8.2 Subjective Norm and Open Defaecation Behaviours ...... 122

4.8.3 Influence of Perceived Behavioural Control (PBC) on Pupils Open

Defaecation Behaviour ...... 125

4.9 Influence of Cultural Factors on Open Defaecation Behaviour ...... 127

4.10 Bivariate Test on Dependent and Independent Variables ...... 130

4.11 Effect of Behavioural Factors on Open Defaecation Behaviours ...... 133

4.11.1 Effect of Attitude on Open Defaecation Behaviour ...... 134

4.11.2 Effect of Subjective Norm on Open Defaecation Intention ...... 134

4.11.3 Effect of Perceived Behavioural Control (PBC) on Open Defaecation

Practices ...... 135

4.11.4 Aggregate Effect of Behavioural Factors on Open Defaecation Intention and

Open Defaecation Behaviour ...... 135

4.11.5 Effect of Individual Behavioural Factors on Intention & Open Defaecation

Behaviours ...... 137

4.11.6 Interaction Effect of Behavioural Factors on Open Defaecation Practices 138

4.12 Moderating Effect of Cultural Factors on Open Defaecation Behaviour ...... 139

4.12.1 Effect of Individual Cultural Factors on Open Defaecation Intention and

Open Defaecation Behaviour ...... 140

4.13 Interacting Effect of Behavioural and Cultural Factors on Open Defaecation

Behaviour ...... 141

4.14 Moderating Effect of Demographic Variables on Open Defaecation Behaviours

...... 143

4.15 Summary of Path Coefficients Estimated For the Dependent and Independent ....

Variables ...... 144

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4.16 Results of Policy Documents Review on School Toilets Provisions ...... 146

4.16.1 Toilet Suitability ...... 149

4.16.2 Pupil-Toilet Ratio ...... 149

CHAPTER FIVE ...... 150

DISCUSSIONS ...... 150

5.1 Socio-demographic Characteristics of Study Participants ...... 150

5.2 Conditions and Usage of Toilet Facilities in the First Cycle Schools ...... 150

5.2.1 Hygiene and Access in School Toilet ...... 150

5.2.2 Privacy, Safety and Ventilation in the School Toilets ...... 152

5.2.3 Community and Rodents Encroachment on the School Toilets ...... 155

5.2.4 Technology Drives ...... 157

5.3 Pupils and Teachers Assessment of Conditions and Usage of School Toilets .. 158

5.4 Occurrence and Frequency of Open Defaecation Behaviour in the Study Schools

...... 162

5.5 Situational Factors That Influence Pupils’ Open Defaecation Behaviour in Schools

...... 166

5.6 Factors that Prevent Open Defaecation Behaviour in the Study Schools ...... 168

5.7 Pupils’ Awareness and Perception of Health and Environmental Risk of Open

Defaecation Behaviour ...... 170

5.8 Results of Policy Document Review on Toilet Provision in First Cycle Schools..

...... 172

5.9 Behavioural Factors Influencing Open Defaecation in the First Cycle Schools 175

5.9.1 Effect of Attitudes on Open Defaecation Intentions ...... 175

5.9.2 Effect of Subjective Norm Behaviour on Open Defaecation Intentions ... 179

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5.9.3 Effect of Perceived Behavioural Control (PBC) on Open Defaecation

Behaviours ...... 184

5.9.4 Effect of Intention on Open Defaecation Behaviours ...... 187

5.9.5 Effect of Aggregate Behavioural Factors on Open Defaecation Practices . 189

5.9.6 Interaction Effect of Behavioural Factors on Open Defaecation Practices191

5.10 Cultural Factors and Open Defaecation Behaviours ...... 192

5.10.1 Effect of Pooled Cultural Factors on Open Defaecation Behaviours ...... 192

5.10.2 Effect of Individual Cultural Factors on Open Defaecation Behaviours . 196

5.11Interacting Effect of Behavioural and Cultural Factors on Open Defaecation

Behaviour ...... 200

5.12 Moderating Effect of Demographic Variables on Open Defaecation Behaviour

...... 201

5.13 Situational Contexts Pupils Expressed Their Open Defaecation Behaviours. 203

5.14 Contributions of the Study to Knowledge...... 205

CHAPTER SIX ...... 207

SUMMARY, CONCLUSION AND RECOMMENDATIONS ...... 207

6.1. Summary and Conclusion ...... 207

6.2 Recommendations ...... 209

6.3 Areas for Further Studies ...... 213

REFERENCES ...... 215

APPENDICES ...... 263

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LIST OF TABLES Table 3.1: Study Communities and Schools ...... 68

Table 4.1: Assessment Results of Conditions of Toilets used in the First Cycle Schools.

...... 94

Table 4.2: Knowledge and Perception of Teachers on Conditions of School Toilet ...... 96

Table 4.3: Socio-demographic Characteristics of Study Participants ...... 112

Table 4.4 (a): Occurrence and Prevalence of Open Defaecation Practices in Study

Schools ...... 114

Table 4.4(b): ANOVA Test Results for Frequency of Open Defaecation Practice in the

Study…………………..…………………………………………………...115

Table 4.5(a): Situational Factors That Influence Open Defaecation Behaviours in the

Schools ...... 116

Table 4.5(b): ANOVA Test Results for Factors Preventing Open Defaecation……….117

Table 4.6 (a) Situational Factors that Prevent Open Defaecation in the Study Schools

...... 118

Table 4.6 (b): ANOVA Test Results for Factors Preventing Open Defaecation

Practices………………...………………………………………………….115

Table 4.7 Pupils’ Awareness of Effect of Open Defaecation Behaviour by Study Schools

...... 120

Table 4.8: Pupils Perception of Effect of Open Defaecation Behaviour by Study Schools

...... 121

Table 4.9 : Pupils Knowledge of Environmental Effects of Open Defaecation Behaviour…..117

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Tables 4.10 : Pupils Knowledge of Health Effect of Open Defaecation Behaviour………...... 117

Table 4.11: Pupils General Knowledge of Open Defaecation Practices ...... 121

Table 4.12: Influence of Role Model on Pupils Open Defaecation Behaviour ...... 123

Table 4.13: Influence of Social Injunctions on Pupils Open Defaecation Behaviour .... 124

Table 4.14: Influence of Perceived Confidence on Pupils Open Defaecation Behaviour

...... 125

Table 4.15: Influence of Superstitions ...... 127

Table 4.16: Influence of Taboos on Open Defaecation Behaviour…………………….128

Table 4.17 (a): Influence of Traditional Norms ...... 128

Table 4.17 (b): ANOVA Test Results for Cultural Factors Influencing Open Defaecation

Behaviour in the Study Schools…………………………………………129

Table 4.18: Bivariate Test Result for Dependent and Independent Variables ...... 131

Table 4.19: Coefficients Result for Effect of Behavioural Factors on Open Defaecation

Practices ...... 133

Table 4.20: Effect of Individual Behavioural Factors on Intention of Defaecation

Intentions……………………………………………………………………133

Table 4.21: Aggregate Effect of Behavioural Factors on Intention and Open Defaecation

Behaviour ...... 136

Table 4.22: Effect of Individual Behavioural Factors on Open Defaecation Intention….

...... 137

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Table 4.23: Effect of Individual Behavioural Factors on Open Defaecation Practices

...... 137

Table 4.24: Interaction Effect of Behavioural Factors on Open Defaecation Practices….

...... 138

Table 4.25: Coefficients Results for Pooled Effect of Cultural Factors on Open

Defaecation Intention and Open Defaecation Behaviour ...... 139

Table 4.26: Coefficient Results for Effect of Individual Cultural Factors on Open

Defaecation Behaviours ...... 140

Table 4.27 : Effect of Individual Cultural Variables on Open Defaecation Intention…141

Table 4.28 : Interaction Effect of Cultural Variables on Open Defaecation…………...142

Table 4.29: Moderating Effect of Demographic Variables on Open Defaecation

Behaviours ...... 1433

Table 4.30: Summary of Path Coefficients Estimated For the Dependent and Independent

Variables…………………………………………………………………..144

Table 4.31: Coefficient Results for Effect Size of Individual Cultural Factors on Pupils

Open Defaecation Behaviours and Intentions……………………………..145

Table 4.32: Results of Policy Documents Review on School Toilets Provisions ...... 147

Table 4.33: Pupil-Toilet Ratio in the Study Schools and its Bad Effect on Pupils Toilet

use ...... 148

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LIST OF FIGURES Figure 2.1: Theory of Planned Behaviour ...... 32

Figure 2.2: Schematic Conceptual Framework ...... 52

Figure 3.1: Ghana’s Regional Open defacation Figures…...... 61

Figure 3.2: Map of the Study Areas Showing Districts, Municipalities, Communities

and the Study Schools ...... 63

Figure 3.3: SEM Path Diagrams for Estimating Effect Size of Attitude, Subjective norm,

Perceived Behavioural Control (PBC) on Open Defaecation Intention; Direct Effect of

PBC on Open Defaecation…………………..……………………...... 86

Figure 3.4: SEM Path Diagrams for Estimating Effect Size of Cultural Factors and

Satisfied Open Defaecation Intention on Open Defaecation…..………….....….86

Figure 3.5: SEM Path Diagrams for Estimating Interaction Effect Size of Psychological

and Cultural Variables on satisfied Open Defaecation behaviour…..……..……86

Figure 3.6: SEM Path Diagrams for Estimating Effect Size of Cultural Variables on Open

Defaecation Intention and Open Defaecation………………….………………87

Figure 3.7: SEM Path Diagrams for Estimating Effect Size of Attitudinal Variables on

Open Defaecation Intention and Open Defaecation Behaviours..………………87

Figure 3.8 SEM Path Diagrams for Estimating Effect Size of Variables on PBC on

Intention and Open Defaecation Behaviours…………..………………………88

Figure 3.9: SEM Path Diagrams for Estimating the Interaction Effect Size of

Psychological Variables on Open Defaecation Behaviour……...………………88

Figure 3.10: SEM Path Diagrams for Estimating Effect Size of Demographic Variables on

Open Defaecation Intention and Open Defaecation Behaviour………………89

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LIST OF PLATES Plate A: Filthy School Toilet (Faecal matter scattered all over the toilet floor)...... 98

Plate B: Filthy School Toilet (Leaves used as anal cleaning materials)...... 99

Plate C: Filthy School Toilet (Papers used as anal cleaning materials scattered on toilet

floor) ...... 99

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LIST OF ABBREVIATIONS AICD African Infrastructure Country Diagnostics

AMOS Analysis of Moment Structures

BC Before Christ

CBAS College of Basic and Applied Sciences

CLTS Community Led Total Sanitation

CRDD Curriculum Research and Development Division

DEA Department of Economic Affairs

DHS Demographic Health Survey

DPCU District Planning Coordinating Unit

FCUBE Free Compulsory Universal Basic Education

FDG Focused Group Discussion

GDHS Ghana Demographic Health Survey

GES Ghana Education Service

GHA Global Health Atlas

GPS Geographic Positioning System

GSS Ghana Statistical Service

IDI In-Depth Interview

IGC International Growth Centre

JHS Junior High School

JMP Joint Monitoring Programme

KVIP Kumasi Ventilated Improved Pit

MDG Millennium Development Goals

MICS Multiple Indicator Cluster Survey

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MLGRD Ministry of Local Government and Rural Development

MOE Ministry of Education

NDPC National Development Planning Commission

NESSAP National Environmental Sanitation Strategy and Action Plan

OD Open Defaecation

PBC Perceived Behavioural Control

PHC Population and Housing Census

SHEP School Health Education Programme

SDG Sustainable Development Goal

SEM Structural Equation Modeling

SSA Sub-Sahara Africa

TED Teacher Education Division

TPB Theory of Planned Behaviour

TRA Theory of Reasoned Action

UNDP United Nations Development Programme

UNDPI United Nations Department of Public Information

UNGA United Nations General Assembly

UNICEF United Nations International Children Emergency Fund

VIP Ventilated Improved Pit

WC Water Closet

WHO World Health Organization

WSMP Water and Sanitation Monitoring Programme

WSS Water and Sanitation Services

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CHAPTER ONE

INTRODUCTION 1.1 Background to the Study Access to basic sanitation is considered a fundamental human right by United Nations

General Assembly Resolution 64/292 (UNGA, 2010; WHO/UNICEF, 2014). Yet, over several decades now, about 2.5 billion people, representing 35% world over still do not have access to improved sanitation (WHO/UNICEF/JMP, 2014; Prasad, 2012; Colopy,

2012; Rahman, 2010; Peterson et al., 2008; Berntell 2005). One billion of this number has no toilet facilities and therefore defaecate in the open (WHO/UNICEF/JMP, 2014), a practice that poses huge health risk to individuals, poor and vulnerable communities and the environment. Of this figure, 75% live in rural communities in East Asia and sub-Sahara

Africa (WHO/UNICEF/JMP,2014). Global statistics show that since the periods 1990 to

2012, 2 billion more people have access to improved toilet facilities, thus increasing the sanitation coverage from 49% in 1990 to 64% in 2012 (WHO/UNICEF/JMP, 2014).

Despite this huge sanitation coverage, one billion people still engage in open defaecation as a result of increasing population (WSP, 2011 & WAG, 2013). This suggests that the world is far from attaining target 2 of the 2030 Sustainable Development Goal (SDG) 6 set by United Nations General Assembly (UNGA).

In the case of sub-Saharan Africa, the number of open defaecators has decreased by 11% within the period from 1990 to 2010 (WHO/UNICEF/JMP, 2012). Despite this reduction the absolute number of open defaecators has, in fact, increased by 33 million over the same time period, due to population growth (WHO/UNICEF/JMP, 2012). Projection indicates that for sub-Saharan countries to eliminate open defaecation practice, it needs to improve its sanitation facility coverage by 64% (WHO/UNICEF, 2012). This in absolute term

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means that the current number of people with improved sanitation in Africa needs to more than double. The implication of this to the global environment in general and sub-Saharan

Africa in particular, is that to achieve the 2030 SDG 6, much greater effort and commitment coupled with additional investments will be required to address inadequate sanitation challenges, especially the open defaecation prevalence.

In the case of Ghana, open defaecation prevalence (WSP, 2011 & WAG, 2013), has increased to 23% in 2010 from 19% in 1990, indicating that the number of Ghanaians engaged in open defaecation has increased from 4.8 million to over 5.7 million same periods. With the country’s current population of about 24,658,823 (GSS, 2012), the actual number of Ghanaians practicing open defaecation daily is now 5,743,100 (WSP, 2013).

This figure is significant and very much alarming and therefore requires pragmatic action plan to address it. The costs of waiting for economic growth to slowly solve the problem of rural and urban sanitation in general and open defaecation in particular in Ghana are almost certainly very high.

Studies showed that open defaecation creates a conducive breeding ground for millions of pathogens which easily spread a myriad of infectious diseases, including cholera, typhoid, parasites, hepatitis, diarrheal diseases and polio (Clasen et al., 2010; & WHO, 2008).

Hundreds of thousands of children, particularly those under five years, die from these diseases each year and those who survive are left stunted both physically and cognitively

(Fink et al., 2011; Black et al., 2010; Spears, 2013; Humphrey, 2009; & WHO, 2005).

Faecal contamination of the environment resulting from open defaecation has therefore been pinpointed as the fundamental cause of 1,800 bouts of cholera affecting Ghana annually (WHO, 2009). Ensuring proper disposal of faecal matter is crucial in this twenty-

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first era to help eliminate the negative health and environmental consequences associated with it. This will also assist the country to make progress towards the reliazation of the post 2015 sustainable development goal six target two, which states that all developing nations should endeavor to end open defaecation by the 2030.

The problems of open defaecation to the global environment, the individuals as well as the poor and vulnerable communities, particularly those in the rural areas cannot be overemphasized. It is against this background that the United Nations Deputy Secretary-

General, during the World Toilet Day Celebration in March 2013, urged all global sanitation stakeholders including governments, civil society, NGOs, the private sector and

UN agencies to collaborate in term of resources allocation to eradicate open defaecation practices by the year 2025. (UNWTO, 2013). This is a wake-up call for the Ghana government to address the national open defaecation challenges with concerted efforts.

Ghana’s efforts in addressing the increasing open defaecation behaviour challenges included provision of subsidized toilets facilities, implementation of Community Led

Total Sanitation (CLTS) intervention programmes, and extensive public education.

However, despite these intervention measures, the problem of open defaecation continues to prevail. It is now evident that ending open defaecation is not just a matter of having access to toilet (Jenkins & Curtis, 2005) as emphasized in CLTS and subsidized toilet provision measures; it also involves understanding open defaecation behaviours and culture and the situational contexts within which such behaviours are largely expressed.

Studies have reported the influence of both human behaviour and culture on sanitation in general and open defaecation in particular has been reported in many studies (WSP, 2012;

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Hart‐Davis, 2008; Ramaswamy, 2005). However, limited studies have been conducted across Ghana to understand sanitation behaviours of the Ghanaian in general and open defaecation behaviours in particular, and within which cultural and situational contexts within which these behaviours occur. Range of existing intervention measures comprising sanitation policies, grants and other incentive schemes, regulation, promotional campaigns, and a diverse range of funded programmes and projects have been used to encourage or discourage certain behaviours with the ultimate aim of achieving sustainable sanitation behaviours. Yet, these efforts have yielded no significant sustainable sanitation results as people’s existing attitudes and behaviours couple with their cultural values continue to promote open defaecation practices in Ghana.

Understanding sanitation behaviour in general and open defaecation behaviour in particular, of people who defaecate in the open, as well as cultural and situational contexts within which they express such behaviours, can contribute significantly to develop behaviourally and culturally appropriate responses that will help shift such open defaecators to sustainable toilet use. It is against this background that this study was designed to explore the behavioural and cultural factors influencing open defaecation in first cycle schools in Ghana, and use the outcomes to inform policy makers to develop behavioural and culturally intervention measures that will help shift open defaecators to sustainable toilet use. Although pupils in some first cycle schools have toilet facilities, it is not uncommon seeing them defaecating in the open areas of the schools.

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1.2 Problem Statement Open defaecation behaviour is a growing environmental and public health concern in

Ghana that has attracted national attention in recent times. Out of Ghana’s population of about 25 million (GSS, 2012), 4.8 million defaecate in the open (WSP, 2011). Open defaecation in Ghana, according to Water and Sanitation Program (2011), has increased from 19% in 1990 to 23% in 2010, indicating that the number of Ghanaians engaged in daily open defaecation has increased from 4.8 million to over 5.7 million within the same period. Problem of faecal matter disposal resulting from open defaecation alone contributes about 20% of sanitation challenges in Ghana (WSP/WB, 2010). In many urban poor settings the practice of open defaecation persists because the conditions that cause it and the drivers which continue to reinforce it have not been adequately analyzed before projects are started to address them. Open defaecation practices therefore remains a major challenge in Ghana today). Indiscriminate disposal of faecal matter contaminates the environment and increases public health risks.

Global statistics indicate that faecal contamination of the environment resulting from open defaecation practices has also been identified as the major cause of an annual average of

1,800 cases of cholera affecting children aged 0-5 years in Ghana (WHO, 2005; UNICEF,

2012). Besides, early childhood diarrhoea resulting from open defaecation does not only contribute significantly to stunting, wasting and reduced long-term cognitive development of children (Spears, 2012a) in schools but it also results in both school absenteeism and school dropout (Pelletier et al., 1995).

In Ghana programs designed to address sanitation challenges have been focused more on providing toilets facilities, usually on a subsidized basis, rather than on motivating their sustainable usage. Global view overwhelmingly points to the fact that providing toilet

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facilities either on CLTS basis or subsidized basis does not necessarily lead to enhanced behavioural change towards efficient and sustainable use of the facility (Biran et al., 2011;

WSP-SA, 2002c; Mukherjee, 2001). This study is therefore premised on the hypothesis that the practice of open defaecation is not always linked to the absence of toilets, but it is also dictated by the influence of behavioural and cultural factors.

This assumption was affirmed during the World Toilet day in November 2014 by UN

Deputy Secretary-General, Mr. Jan Eliasson in his address. He stated that “success at ending open defaecation goes beyond sanitation infrastructure provision and included the understanding of behaviour, culture, attitudes and social norm”. The notion of behavioural and cultural influence in this assertion over toilet provision, however, has not received the same level of attention in the literature in Ghana and therefore still persists.

There is therefore an overriding need to determine the extent to which behaviour and cultural are influencing open defaecation prevalince in Ghana. Understanding this would offer a useful insight into how to design the technical and social aspects of the interventions in order to make them decent and attractive to users. It is against this background that this study is designed to explore both quantitatively and qualitatively, the behavioural and cultural factors influencing open defaecation practices in first cycle schools thus contributing to the effort towards ending open defaecation practices in Ghana.

1.3 General Objective The general objective of this study is to explore the behavioural and cultural factors influencing open defaecation among pupils in the first cycle schools in Ghana.

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1.4 Specific Objectives The specific objectives of this study are to:

1. Conduct a situational assessment of existing school toilet systems and their usage

in the first cycle schools.

2. Assess the knowledge and perception of pupils and teachers on conditions and

usage of the school toilets.

3. Establish the occurrence of open defaecation behaviours among pupils in the first

cycle schools?

4. Assess existing attitudes, subjective norms, perceived control behaviour informing

open defaecation in the first cycle schools.

5. Assess existing norms, taboos, superstitions and values informing sanitation and

open defaecation behaviours in the first cycle schools.

1.5 Research Questions The study intends to answer the following questions.

1. What is the condition of the existing toilet systems available to pupils in the first cycle

schools?

2. What knowledge and perceptions do pupils and teachers have about the conditions of

their school toilets?

3. To what extent is open defaecation practiced among pupils in the first cycle schools?

4. What attitudes, subjective norms, perceived control behaviours are influencing open

defaecation in the first cycle schools?

5. What are the existing norms, taboos, superstitions and values informing open

defaecation behaviours in the first cycle schools?

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1.6 Justification The strength of this study lies in its focusing on describing the behavioural and cultural factors influencing open defaecation practices among first cycle pupils in Ghana. This study is justified because it has significance for theory, empirical studies, health, policy and environmental perspectives. Theoretically, the research is expected to provide relevant information on open defaecation behaviours of pupils in the first cycle schools.

Empirically, the results of the study will provide a better understanding of the measures that can be changed to reduce open defaecation behaviours among pupils in the first cycle schools and invariably preventing diarrhoea diseases which affect children every day and causing them stunting, wasting, weight loss and reduced long-term cognitive development.

Pupils health status, school enrolment, attendance, retention and learning would improve when children have access to behavioural and culturally appropriate toilets that meet their defaecation preferences. The research is expected to provide relevant information which school sanitation stakeholders such as Metropolitan, Municipal, District Assemblies

(MMDA),Ghana Education Service (GES), and parents need to address the open defaecation behaviour in particular and sanitation in general in the first cycle schools. A major constraint to successful sustainable sanitation in Ghana is deficient in national sanitation policies.

Governments in general and health ministries in particular cannot play their key roles as facilitators and regulators of sanitation without relevant sanitation policies. Hence from a policy point of view, this study is expected to provide the needed information that will assist sanitation stakeholders better understand why pupils defaecate outside toilets and be better able to develop appropriate policy to address it.

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Again, the results of this study will provide the needed information on sanitation behaviours that will inform policy-makers to make informed and appropriate policies decisions on efficient and sustainable excreta management in first cycle schools and the communities in which the schools were located.

From an environmental perspective, results of this study will help in preventing the greatest perceived impact of faecal matter on aesthetics including pungent smells it generates, and its visual deface appearance of the environment, particularly in towns and cities. The study is therefore expected to contribute information to the database of school sanitation stakeholders and institutions to enhance their decision making regarding efforts towards ending open defaecation in Ghana.

1.7 Thesis Organization The entire thesis has been organized into six chapters. Chapter one covers introduction which comprises the background to the study, problem statement, objectives of the study, research questions and justification of the study. Chapter two presents the review of relevant literature to the study and conceptual model. The study’s approach and methodology are also described in detail in chapter three. Detailed analysis of results of the study are presented in chapter four. Chapter five interprete the results and discusses the inferences extensively according to the study’s objectives and conceptual framework.

Key findings, conclusions, recommendations and areas for further studies have been presented in chapter six, which ends with references cited in the entire study, the appendices and relevant plates.

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1.8 Thesis Scope The study takes a more narrow approach by concentrating on open defaecation as opposed to other components of sanitation. The choice of open defaecation is, however, motivated by both the well-known synergy between open defaecation and disease transmissions, as well as the economic importance of open defaecation as a major contributor to national sanitation challenges in Ghana. Again the study involved only pupils aged between 9 and

18 years and in first cycle schools since they are more vulnerable to diseases transmitted via improper disposal of faecal matter. When children are encouraged to develop knowledge, attitudes and skills that support hygiene toilet use, it will go a long way to end open defaecation in schools and communities. The findings pertain to first cycle schools particularly those in the Volta and Eastern regions of Ghana. That said, the approach is therefore very relevant for the Ghanaian context.

1.9 Thesis Limitations This study is not without limitations. The first limitation had to do with reliance on self- report measures as the main source for gathering data. This may be biased by social desirability because the respondents would give responses which might be socially pleasing instead of accurately reflecting their thoughts, beliefs, or actions (Nancarrow &

Brace, 2000). Because of this, there is a possibility for the validity and reliability of the measurement to be biased and later bias the inferred conclusions. Nevertheless, as pointed out by Armitage and Conner (2001), this method is common in research adopting behavioural decision-making models such as Theory of Reasoned Action (TRA) and

Theory of Planned Behaviour (TPB). In addition, Ajzen (1985) and Hartwick and Barki

(1994) maintain that just as objective methods, self-report measures are equally valid because they are more comprehensive, when subjects respond to them, and they tend to consider various contexts. As mentioned in some previous sanitation studies in Ghana

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(van der Geest, 2007) some fears were also encountered when speaking openly about issues of defaecation and toilets since this is related to social stigma and general awkwardness.

The second limitation is that collecting accurate data on sensitive and private issues such as open defaecation behaviour and culture presented many challenges as pupils were not willing to divulge some sensitive information the study required.

Besides, there was difficulty in obtaining a more current data source that the study required since interest in investing in the production and publication of regular, accurate and timely data and statistics to facilitate effective assessment, monitoring and evaluation of the outcome of government policies and programmes was very lean among Ghanaian.

Gathering accurate data on sensitive issues such as open defaecation also presented many challenges as some respondents felt uncomfortable sharing some sensitive information or thoughts, opinions, beliefs, and experiences the study required. In social interactions like interviews and focus group discussions, there may be the tendency for respondents to give responses that are socially desirable. To avert this the researcher used mixed data collection methods as well as data triangulation to ensure that the final data reflect the situation in the schools.

1.10 Definition of Terms In order to have a common understanding of what is discussed in this study, the terms used in the discussion are defined below. These definitions do not aim to provide worldwide meaning but intend to put the researcher and readers on an equal footing:

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Behaviour: In the context of this study, behaviour is defined as any action by a person that can be observed or heard (Alberto & Troutman, 2003).

Culture: This refers to conventions that comprised knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society

(Tylor, 1871). In the context of this study, culture is used to connote norms, taboos, superstitions and values that influence sanitation and open defaecation behaviours.

Open Defaecation: This involves depositing human excreta outside designated place such as fields, forests, bushes, bodies of water (WHO/UNICEF, 2008).

First Cycle School: This comprised 3 year pre-school education, 6 year primary education and 3 year Junior High School Education (Ghana’s 1992 Constitution).

Sanitation: Sanitation encompasses safe collection, storage, treatment/re-use of human excreta, and practice of safe hygiene behaviour and management. In this study, sanitation is used broadly to connote safe collection, storage, and treatment of human faeces to prevent its contact with humans (Murray & Keiru, 2011).

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CHAPTER TWO

LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK

2.0 Literature Review

This chapter focuses on the concept of sanitation and the current state of knowledge regarding sanitation in the global environment, sub-Saharan Africa (SSA) and Ghana. This was then narrowed to open defaecation behaviours in global environment, sub-Saharan

Africa and Ghana. Also encompasses in the theoretical review were the influence of culture and behaviour on sanitation in the global environment, sub-Saharan Africa and

Ghana. The association among open defaecation, culture and behaviour has also been reviewed extensively. The review was concluded with open defaecation and environmental and public health; the impacts of open defaecation on the environment and health, and the critical gaps identified in the existing literature which call for the present study.

2.1 Knowledge of Sanitation in the Global Environment

Globally, 2.5 billion people do not have access to an improved sanitation facility

(WHO/UNICEF/JMP, 2014) and out of this 784 million people use a shared facility of an otherwise improved type with a point difference of 23 million people over the 2011 figure;

732 million used a facility that does not meet minimum hygiene standards with a point difference of 39 million people over the 2011 figure; whereas the remaining one billion

(representing 15% of the world population with the majority (71%) of those without sanitation live in rural areas, where 90% of all open defaecation takes place

(WHO/UNICEF/JMP, 2014).

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Between the period 1990-2012, global statistics indicates that access to improved sanitation has, however, increased in all developing regions except Oceania, where it remained steady at 35% (WHO/UNICEF/JMP, 2014). Within Southern Asia, India increased access for 291 million people, and within Eastern Asia, China increased access for 623 million people, largely contributing to regional total. The global average of the use of improved sanitation facilities stood 54% at end of the 2015 MDG targets year

(WHO/UNICEF/JMP, 2015) suggesting that the world has fallen short on the set sanitation target of 77%, thus leaving 2.4 billion people without improved toilets facilities

(WHO/UNUCEF/JMP, 2015). Between 1990 and 2012, open defaecation, however, has decreased from 24% to 14% globally (WHO/UNICE/JMP, 2014) and South Asia saw the largest decline, from 65% to 38% (WHO/UNICE/JMP. (2014). Ethiopia, for example, have resulted in decrease to 37% from 92% giving a percentage point of 55%

(WHO/UNICE/JMP, 2014). Nepal and Cambodia have achieved similar declines. While some success has been chopped on reducing open defaecation and improving sanitation, there were some disparities across regions, between the rich and the poor, the marginalized as well as between urban and rural settings (WHO/UNICEF/JMP, 2014).

The vast majority of those without sanitation are poorer people living in rural areas. For example, in rural India, open defaecation is largely practiced than in urban India—about

70% of the Indian population live in rural areas. According to the Shivakumar, & Girija

(2013), Indian population census, 89% of households who were without toilet live in rural areas. Despites decades of government’s spending on toilet construction and sustained economic growth, rural open defaecation has remained very high. Globally, open defaecation is much more common in India than it is in many of the poorest countries of the world such as the Democratic Republic of the Congo, Malawi, Burundi and Rwanda –

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to say nothing of richer countries that are still much poorer than India, such as Kenya and

Bangladesh (WHO/UNICEF/JMP, 2014).

Today, progress on sanitation continues to benefit wealthier people. In Sub-Saharan Africa for example, at the current rate of progress, it would be very difficult to achieve the sanitation Millenium Development Goal (MDG) at the stupilated time frame—2015.

Although difficult to predict using current sanitation models, some suggest it may even be as late as 2076 (UNDP, 2006). Achieving a world of dignity for all requires that we fashion out a post-2015 Sustainable Development Framework that will eliminate these disparities

(WHO/UNICEF/JMP, 2014). No one should lack safe hygienic toilet. Improved and accessible sanitation for all can only be attained with pragmatic and concerted efforts among the global communities. The global MDG target for sanitation has been met as almost 700 million people (68%) of the global population now have access to improved sanitation WHO/UNICEF/JMP, 2014). The only developing regions to meet the sanitation target were the Caucasus and Central Asia, Eastern Asia, Northern Africa and Western

Asia. Since 1990, the world’s urban and rural population with percentage point of 82% and 51% respectively used improved toilets. The least developed countries did not meet the sanitation target, and only 27% of their current population has gained access to improved sanitation since 1990 (WHO/UNICEF/JMP, 2015). With the close of the global

MDG 2015 target year, 2.4 billion people still lack improved sanitation facilities and 1 billion of this figure practiced open defaecation (WHO/UNICEF/JMP, 2015).

2.2 State of Sanitation in Africa Africa faces serious constraint to meeting the challenges of providing adequate and improved sanitation for its rural and urban inhabitants. During the Africa Sanitation conference held in Durban in South Africa, approximately 300 million Africans were

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without access to basic sanitation facilities (WHO/UNICEF, 2008a). This figure, however, has increased even more since then. According to that report (WHO/UNICEF/JMP, 2008a) only 60% of the African population has access to improved sanitation services. This number further grew by about 195 million in Africa between 1990 and 2011

(WHO/UNICEF/JMP, 2013). Although this is a definite improvement, the figures are still too low to achieve the MDG sanitation targets by 2015 suggesting that more proactive and innovative strategies are needed to accelerate achievement of the Millenium Development

Goals (MDG) targets for sanitation (WHO/UNICEF/JMP, 2008b).

Although several African countries including Nigeria, Uganda, and Zambia tried to introduce CLTS previously and achieved some success the model was inherently time consuming and requires a high level of effort at the community level

(WHO/UNICEF/JMP, 2008). In 2006, only 38% of African population used improved sanitation facility with the largest proportion (68%) in Northern Africa and lowest (24%) in Western Africa (WHO/UNICEF/JMP, 2008). The proportion using shared facilities in

Western and Southern Africa stood at 22% and 21% respectively. Open defaecation is highest in Eastern Africa where 33% of the population used no sanitation facility. Eastern

Africa, however saw a 25% decline in open defaecation since 1990 (WHO/UNICEF/JMP,

2008). Despite this decline in open defaecation the number of people practicing open defaecation had increased from by 159 million in 1990 to 589 million people in 2006 due to population growth (WHO/UNICEF/JMP, 2008).

In sub-Sahara Africa, sanitation coverage has gone through checked history. In 2010, more than 2.5 billion people still lacked access to improved sanitation and therefore defaecate

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in the open (Mara et al., 2010). The number of people with access to improved sanitation facilities grew by about 129 million between 1990 and 2011(WHO/UNICEF/JMP, 2013).

Despite this increase, the majority of sub-Saharan African countries have very limited access to improved sanitation, with an average of only 30% across the whole region

(AMCOW, 2012).

The current trend of sanitation services in sub-Saharan Africa (SSA) which served as home to less than 10% of the global population have been very devastating. For example, information for 32 countries in the African Infrastructure Country Diagnostic (AICD)

(2007) indicates that traditional pit toilets constitutes the most common form of sanitation in sub-Saharan Africa. Another major characteristics associated with sanitation in most sub—Saharan African nations is that almost 31% of the population use shared public toilets facilities as a means of reducing open defaecation and thereby controlling its consequences (WHO/UNICEF, 2010).

According to AICD (2007), for each year, several countries have succeeded in moving at least 3% of their populations further up the sanitation ladder. At the bottom end of the ladder, countries such as Uganda and the Democratic Republic of Congo, Côte d’Ivoire, as well as Ethiopia are shifting more than 3% of their population each year into the use of traditional latrines (AICD, 2007). Ethiopia for example, is making large stride progress in reducing open defaecation through moving more than 2% of its population annually from open defaecation practice (WHO/UNICEF, 2010). Rwanda, Burkina Faso, and

Madagascar, constituted the second group of nations making great effort in moving not less than 3% of the population to improved toilet use annually. Finally, at the top end of

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the ladder, only Senegal has achieved a comparable pace of expansion for septic tanks

(AICD, 2007).

Today, there is a global acknowledgment that the major share of the responsibility to improve sanitation rests firmly with the African and South Asian regions. From that time, a number of African governments started developing comprehensive sanitation policies and sanitation implementation programmes. One such policy is CLTS which originated from Bangladesh (Mara et al., (2010). While the CLTS program has proved highly effective at triggering a shift away from open defaecation, the question of how to provide long term support for continued behaviour change and improved sanitation provision largely remains a challenge. Also, achieving widespread national sanitation coverage using the CLTS model is inherently time consuming and requires a high level of effort at the community level. Where open defaecation remains prevalent, promoting appropriate sanitary behaviour is critical for two reasons (AICD, 2007). First, to ensure that toilets provide the corresponding health benefits—less a matter of toilets used and more a matter of good practices and behaviours. Second, to ensure that toilets are actually used when available, since there is widespread global evidence that such facilities may be altogether ignored by beneficiary households if there is no effort to engender behavioural change

(AICD, 2007). There is therefore the need to ensure that toilet provision takes into consideration behavioural and cultural background of the toilet users as well as their varied sanitation preferences.

2.3 State of Sanitation in Ghana A report on MDG activities in Ghana by National Development Planning Commission

(NDPC) and United Nations Development Programme (UNDP) indicates that the improved sanitation coverage in Ghana was very low (Bartram et al., 2005). This low

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coverage of improved sanitation is as a result of the fact that the shared sanitation facilities was not categorize as improved facilities by the Joint Monitoring Programme (JMP)

(Bartram et al., 2005). The reason being that shared toilet facilities may not be clean, suitable and provide adequate privacy for users (WHO/UNICEF/JMP, 2008b). Many stakeholders in the sanitation sector in Ghana have considered shared toilet facilities in

Ghana as one that provides all the necessary parameters that characterize an improved toilet facility (WHO/UNICEF/JMP, 2008b).

Again, sanitation development in Ghana has concentrated in urban centres and southern areas, while the poorest coverage is in the northern regions and rural communities

(NDPC/UNDP, 2010), thus giving wide disparities in access to sanitation between and within the regions, and between rural and urban settings. Ghana, according to

WHO/UNICEF/JMP, (2012) has the highest proportion of population (58%) using shared sanitation facilities worldwide. Comparing Ghana and Bolivia in terms of shared toilet usage, Ghana topped Bolivia, which recorded the second highest shared sanitation category, giving 22% points difference. This illustrates the exceptionally high usage of shared sanitation facilities in Ghana (WHO/UNICEF/JMP, 2012).

In the global environment the use of shared toilets is characteristically common with urban settings and also in Ghana it is widespread in urban areas than rural settings (WSP, 2010,

GSS, 2012). Seventy-three percent (73%) of urban population is sharing sanitation facility whereas in rural areas the corresponding proportion is 43% (WHO/UNICEF/JMP, 2012).

A study by WSP (2010) showed that the predominant use of shared toilets in urban areas is largely due to residence patterns of several households living in compound housing, but

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a more worrying development is the heavy reliance by many on shared sanitation facilities- public toilets.

Ghana has the fourth lowest rate of sanitation coverage on human development index grading worldwide (WHO/UNICEF (2010) occupying 152nd position out of 182 nations.

The average national coverage estimate for sanitation for Ghana is 55 %, with very low numbers for some regions (West Region:50 %, Central Region: 55 %, Greater Accra

Region: 80%, Volta Region: 35 %, Eastern Region: 60%, Ashanti Region: 65 %, Brong

Ahafo Region: 45%, Northern Region: 20%, Upper East Region: 10%, and Upper West

Region: 20 %) (GSS, 2012). While WHO/UNICEF/JMP (2013) reports showed gradual improvements over the last 20 years in access to improved sanitation in Ghana, huge challenges still remain in serving rural communities with improved sanitation. The open defaecation prevalence in Ghana, for example, is one of the highest in Africa and stands at 18% as at 2014, while only 14% of the population uses improved sanitation (NDPC/UNDP, 2010). In 2015, only 15% of Ghana’s population has access to improve sanitation with a national prevalence of open defaecation pegged at 19% but a higher prevalence rate of 34% for the rural population (Wrigley-Asante, 2008).

The current challenge with sanitation in Ghana, with extension to open defaecation is largely devastating. For example, in the Greater Accra region of Ghana 25% of the population have access to improved sanitation while in the Northern region the corresponding proportion is 3% (NDPC/UNDP, 2010), suggesting that sanitation development has concentrated on urban centres and southern areas, while the poorest coverage is in the northern regions and rural communities (NDPC/UNDP, 2010).

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2.4 Open Defaecation Prevalence in the Global Environment and Sub-Saharan

Africa

Globally, over 2.5 billion people representing more than 35% of the world population, still do not have access to improved sanitation system (WHO/UNICEF, 2012) and a large proportion of these live in Africa and Asia. This situation is most severe in sub-Saharan

African countries, where 63% of the population lack access to basic sanitation facilities and one billion of this number representing 75% live in rural communities in East Asia and sub-Saharan Africa (WHO/UNICEF/JMP, 2013). Open defaecation has declined considerably in all developing regions to 17% in 2012 from 31% in 1990. Southern Asia, the home to two thirds of the world’s open defecators, saw the largest decline of 27% points, from 65% in 1990 to 38% in 2012. South-eastern Asia, Northern Africa and Latin

America and the Caribbean also recorded great reduction in open defaecation. Open defaecation in sub-Saharan Africa showed a decline of 11% points between 1990 and 2012

(WHO/UNICEF, 2008). Despite significant declines of a little over one billion people in open defaecation since 1990, this still represents 15% of the world’s population practicing open defaecation due to increasing population (WHO/UNICEF/JMP, 2013). The majority of this figure estimated at 949 million (71%) lives in rural areas (WHO/UNICEF/JMP,

2013). As at 2015, the MDG sanitation target year, the proportion of people still defaecating in the open has declined from 24% to 14% between 1990 and 2012

(WHO/UNICEF/JMP, 2014). Despite this decline, open defaecation is still a major problem globally, though some countries and regions have made remarkable progress in reducing the practice.

In sub-Saharan Africa, though the proportion of open defaecators has reduced by 11% from 1990 to 2010, the absolute number of people practicing open defaecation has actually

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increased by 33 million over the same period due to population growth (WHO/UNICEF/

JMP, 2012). In 2010, 8% and 35% of the urban and rural population respectively practiced open defaecation in sub-Saharan Africa (WHO/UNICEF/JMP, 2012). A study conducted by Water Aid, an NGO, in 34 sub-Saharan African countries to estimate open defaecation prevalence for 2005, 2010 and projection for 2015 indicates that 22 out of 34 countries, had between 1% and 9% reduction in open defaecation prevalence. Nine countries, however, had no reduction or an increase in open defaecation. Eleven of the sub-Saharan

African countries had greater than 50% open defaecation prevalence in 2005. Based on the

2000–2010 open defaecation trends, 6 out of 34 countries are expected to reach equal to or less than 10% open defaecation by 2015 (WAG, 2013). At present open defaecation prevalence within the sub-Saharan Africa sub-region stood at 8% in the rural areas and

35% in urban areas (WHO/UNICEF/JMP, 2015). The number of people practicing open defaecation has actually increased in sub-Saharan Africa, and the region now accounts for a greater share of the global total than in 1990. At the current rates of reduction, open defecation will not be eliminated among the poorest in rural areas by 2030 according to

WHO/UNICEF/JMP, (2015). The post 2015 Sustainable Development Goal (SDG) which aims at eliminating open defaecation by 2025, needs to strengthen strong global partnerships among government through formulation of viable sanitation policies with increasing budgetary allocations that can make this happen. Addressing the sanitation crisis goes to ensuring good health, a clean environment and human dignity for all.

2.5 Open Defaecation Prevalence in Ghana For the past three decades, open defaecation continues to be a serious health and environmental problems in Ghana and its prevalence rate according to WAG (2013) has increased to 23% in 2010 from 19% in 1990, indicating that the number of Ghanaians

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engaged in daily open defaecation has increased from 4.8 million to over 5.7 million same periods. With the country’s current population of 24,658,823 (≈25 million) (GSS, 2012), the actual number of Ghanaian practicing open defaecation daily is now 5,743,100

(WSP/WB, 2013). The 2006 Multiple Indicator Cluster Survey (MICS) indicates that as much as 4 million Ghanaian representing 20% of its population in all the ten regions still practice open defaecation. While the national average figure, according to the report, is

24%, the practice is largely widely observed in the Upper East, Upper West, and Northern regions with percentage proportion of 82%, 79% and 73%, respectively (GSS, 2012).

A research by WAG (2013) involving 2,864 households drawn from 78 communities indicated that respondents who practice open defaecation in the Tamale Metropolis,

Gushiegu, Wa East, and Kwahu North have percentage points of 30, 90, 64 and 29 respectively. The open defaecation prevalence in Ghana since 2011 stands at: rural (32%), urban (6%), and national (18%) (Wrigley-Asante, 2008; WHO/UNICEF/JMP, 2013) due to population growth.

A survey conducted by WHO/UNICEF/JMP (2014) showed that 82% of the one billion open defaecators in the world live in just 10 countries, of which Ghana is one. Coplan

(2010) estimates that Ghana will take 500 years to eliminate the open defaecation practice due to the slow pace at which strategies, laws and interventions are being implemented. In

2015, use of improve sanitation covered only 15% of Ghana’s population with a national rate of open defaecation pegged at 19%, but a higher prevalence rate of 34% for the rural population (Wrigley-Asante, 2008). For Ghana to attain improve sanitation status and end open defaecation behaviours, massive budgetary allocation and investment in sanitation

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infrastructural at the national, community, school and individual level are needed in addition to insights into the current barriers to uptake of sanitation.

2.6 Excreta Management Systems in Ghana and in the First Cycle Schools Excreta management in Ghana encompasses the collection, transport and hygienic disposal methods of human excreta comprising off and on-sites management systems including pit latrines, Septic Tanks, “Aqua Privies”, Kumasi Ventilated Improved Pits (KVIPs),

Ventilated Improved Pits (VIPs), Water Closets (WC) and pit latrines as well as ecological sanitation facilities (MLGRD (2010). These constituted households level and public sanitation management technologies (National Environmental Sanitation Strategy and

Plan) (NESSAP: 2010-2015-25 (MLGRD, 2010). Studies showed that availability of sanitation coverage facilities in Ghana is very low and only 10% of Ghanaian population used improved toilet facilities (WHO/UNICEF/JMP, 2010).

In addition, about 20% of Ghanaians defaecate into drains, fields, streams, the bush and the beaches (WSMP, 2008). Today, Ghana placed second in open defaecation practices in

Africa after Sudan, with 19% of its population defaecating in the open (GhanaWeb Report,

2017). This practice caused the country $79 million annually, besides its fatal consequences on human health particularly the most vulnerable, including young children

(GhanaWeb Report, 2017).

One major constraint affecting sustainable sanitation system in Ghana over the years is lack of appropriate national sanitation policies coupled with increasing population. The

Government as well as the key sanitation stakeholders failed to play their roles due to absence of relevant sanitation standards and guidelines that focused on behaviours change, community action, that promote demand creation, and that enable health systems to

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incorporate sanitation and hygiene. Population growth and increasingly high population densities in urban and peri-urban settlements has made sanitation service provision very challenging and herculean tasks.

Another challenge associated with success in faecal management in Ghana is lack of treatment plants and disposal points. Faecal matter from collection points like septic tanks and pit latrines like are largely discharged untreated into unauthorized sites including bush, drains, irrigation fields, open lands, refuse dumps or surface waters due to absence or inadequate landfill site (Strauss et al., 2006). This does not only poses health hazards to people from direct contact with the excreta but it also serve as breeding grounds for house flies as excreta are often spilled when it is being removed or conveyed to disposal sites.

Vacuum tankers provided by the MMDAs are responsible for the conveyance of the excreta to the disposal sites.

There are technical limitations, however, to the use of these vacuum tankers. These include inadequate road access to the collection points, frequent breakdown of the vacuum tanker due to overuse, shortage of spare parts and lack of funds to purchase fuel. Large vacuum tankers are simply unable to traverse the narrow paths in the community due to unplanned settlements. Emptying pit toilets is a herculean task in most communities and schools in

Ghana (Strauss et al., 2006). Ghana therefore needs clear sanitation standards and guidelines for rural-urban sanitation infrustrural development. The MMDAs must issue permits for new construction as well as for additions to and remodeling of exixting buildings and structures. Most repairs or alterations must require building permits. Toilet facilities, particularly pit latrines, located in unaccessible places must be demolished and construcytion and use of communal toilets should be encouraged. Hence behaviour change

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related issues is a priority research areas as there is a pressing need for motivating people to use toilets and avoid open defaecation.

In addition to these problems, the vacuum tankers are expensive to purchase and maintain and can lead to large tariffs for the owners that they cannot pay. This often leads to the operators practicing indiscriminate dumping of faecal matter to cut their costs. A vacuum truck of human excreta indiscriminately disposed of into the environment is equivalent to

5,000 people defaecating in the open (Strauss et al., 2006). The human and environmental health consequences of this are largely dependent on the location (Strauss et al., (2006).

Construction of modern landfill sites away from human settlements is critical in addressing these public health and environmental challenges associated with indiscriminated disposal of human excreta. The MMDAs must also intensify their oversight supervisory role over sanitation delivery agencies in ensuring efficient and proper disposal of human excreta within their areas of jurisditions.

The faecal matter management technologies used in most schools in Ghana include KVIP, water closets, pit latrines, “aqua-privies” and biofill toilets and no technology or commonly referred to as open defaecation (GSS, 2012). Whilst septic tanks, KVIP, and pit latrines are common in rural schools, water closets (WC) and “aqua-privy”, however, dominate in the urban schools. Open defaecation, which does not separate humans from faecal contact, and termed “unimproved”, is common in both rural and urban settings.

These technologies are unimproved. To be accepted as ‘improved’, a sanitation facility is required to be used exclusively by only one household. Based on this definition, it is clear that most first cycle schools in Ghana are using “unimproved” sanitation facilities since more than 50 pupils depends on one squat hole (WHO/UNICEF/JMP, 2010).

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WHO/UNICEF/JMP (2010) defines improved sanitation as a sanitation system in which excreta is disposed of in such a way that they reduce the risk of faecal-oral transmission to its users and the environment. Specific types of improved sanitation facilities recognized by the WHO/UNICEF/JMP include flush or pour-flush latrine, pit latrine with a slab, ventilated improved pit (VIP) toilets and the composting toilet (Karnib, 2014).

Provision of appropriate and adequate toilet facilities to first cycle schools has been faced with many challenges in Ghana. Reasons for this phenomenon were the introduction of free compulsory universal basic education (FCUBE), the school feeding programme and the free school uniform concept (MOE, 2009). These programmes have resulted in an increased basic school enrolment. Out of a total of 11,140 first cycle schools throughout the country, 5,360, representing 48%, had toilet facilities (MOE, 2009). This means that as at 2009, there were 5, 780 (52%) first cycle schools without toilet facilities (MOE,

2009). In 2014, the number of public schools without toilet facilities has risen to 10,000.

The number is half the estimated 20,000 public schools in Ghana, apart from the thousands of privately owned schools that may not have toilet facilities (GhanaWeb Report, 2014).

The Ghana Education Service, an agency of the Ministry of Education (MOE), responsible for provision of toilet facilities to first cycle schools had some challenges in coordinating and harmonizing the interventions programmes resulting in various stakeholders and donors agencies using their own project specific standards and strategies thus providing inappropriate toilet facilities which do not meet the defaecation preference, age and sex of the pupils in first cycle schools. This situation has resulted in pupils engaging in open defaecation though they have toilet facilities. Some communities also have no toilet facilities and therefore shared toilets with the schools and this continues to result in undue

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pressure on the existing toilets. This situation compelled some of the pupils to resort to open defaecation practices in the catchment areas of their schools (GNA Report, 2015;

Field Observation, 2013).

Another challenge that hinders effective and efficient faecal matter management in the first cycle schools is finance. Though the government has well defined sanitation policy direction, this is not supported with adequate budgetary allocation. As a result, effective implementation and evaluation of sanitation intervention programmes in the schools are not well executed. The provision of sanitation facilities to schools by the GES through the

MMDAs could not keep pace with increasing school enrolment (Strauss et al., 2006) and this has resulted in school children either queuing to access the limited toilet facilities or result in looking for alternative defaecation sites (bushes, forests, beaches and drains).

2.7 Barriers and Threats to Toilet Use in Ghana When maintenance system breaks down, the facility will become unpleasant to use

(Schaub-Jones et al., 2006). In Ghana, the major barriers to toilet use include payment of toilet user fee, inappropriate sanitation technologies, level of service provision, user satisfaction, and low budgetary allocation. Input from payment of toilet user fees are essential for long—term sustainability of a system. These fees are used to ensure sustainable functioning toilets. Payment of toilet user fees can also serve as barrier to sanitation use by poverty-ridden proportion of the population (Moe & Rheingans, 2006).

Beside these, understanding the reasons why people are dissatisfied with existing toilet facilities would also provide useful insight into designing appropriate technical and social aspects of the interventions in order to make them attractive to the targeted beneficiaries.

With the limited sanitation facilities in Ghana, studies have identified some technical and

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non-technical factors that affect their regular usage, level of service and user satisfaction

(Jenkins & Scott, 2007; Appiah & Oduro-Kwarteng, 2011). These include design and construction, mechanisms to desludge excreta, siting of facilities and user behaviour relating to convenience and prestige (Jenkins & Scott, 2007; MLGRD, 2010b; Appiah and

Oduro-Kwarteng, 2011). They demonstrated that where one or combination of these factors do not meet the defaecation preference of toilet users, the facility is discarded.

As reported by the Department of Economic Affair (DEA), sanitation currently attracts a very small fraction of the budget allocation (from public funds): the budget share to support water was 0.3% of the total allocation to water and sanitation (WSS), which is itself 3% of the national budget (Jenkins & Scott, 2007). While the latter figure equates to that in some other countries in sub-Saharan Africa (Jenkins & Scott, 2007) the figure of

0.3% is very low. Ghana therefore continues to face low toilet use due to unhygienic conditions comprising unimproved toilet facilities, faecal waste disposal challenges as a result of poor development planning, inadequate funding for logistics, infrastructure and landfills and ineffective coordination of sanitation delivery agencies at the MMD levels.

Ghana therefore needs to improve on its strategies to expedite actions on maintaining the progress made in line with MDG 7C on sanitation.

Today, the number of Ghanaians without improved toilet facilities stood at 18.7 million

(WHO/UNICEF/JMP, 2015). Measured in budgetary terms as regards the allocation of public funding is largely essential if the existing proportion of the population without improved sanitation is to be covered by improved sanitation facilities. In the school system, the major barriers identified to be preventing toilet use included poor maintenance, smelly and dirty latrines (Vernon et al., 2003), lack of sanitation facilities, overcrowding

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(Lundblad, 2005) and financial management. These factors play significant role on whether pupils will use the school toilets. Younger children, especially, felt uncomfortable using the school toilets in such unappealing conditions.

2.8 Policy Framework for Provision of Toilet Facilities to First Cycle Schools The required number of toilets cubicles or squat holes for every school depends on the school enrolment. A maximum of 40 pupils using squat hole or toilet cubicle per day is recommended in the Ministratry of Local Government Act 462 of Revised 2010 Toilets

Provision Policy Guidelines (MLGRD, 2010). Also, separate toilet blocks for boys and girls and changing room for adolescent girls and female teachers in each toilet block for girls is highly acceptable since this ensures adequate privacy for each gender group

(MLGRD, 2010). Toilets for children should be appropriately sized to ensure that children are comfortable and feel safe in the use of the toilet (MLGRD, 2010). Foot rests for squatting units appropriately sized and positioned for age and sex. Toilet cubicle doors must have bolts which are lockable from inside in order to provide maximum security to all users. Asides this, toilets must be located at reasonable distances to the school buildings for easy accessibility, increases maximum usage, and maintenance (WHO/UNICEF/JMP,

(2010). The school staff should be provided with two toilet cubicles preferably one for females and one for males (Zomerplaag & Mooijman, 2005). Again, physically challenged pupils requires separate toilet fitted with wide door and enough space inside for a wheelchair user and the provision of support structures such as a handrail and a toilet seat

(Jones & Reed, 2005). This can make school toilets easily accessible to physically challenged pupils in the school system.

To ensure convenient and safe usage toilet should be located reasonable close to classrooms with the entrances positioned to provide maximum privacy in entering and

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leaving and also minimizes risk of violence (Jones & Reed, 2005). The location of toilets should also take into account the need to minimize odours and avoid contamination of water supplies and food (Franceys, et al., 1992). In addition to these, toilets should be appropriate to local cultural and social conditions prevailing in the community to which the school children live (Franceys et al., 1992). According to Zomerplaag & Mooijman

(2005), younger children need toilets that provide comfortable, convenient and safe to use.

The drop holes for example, needs to be smaller, and footrests closer together for younger children (Zomerplaag & Mooijman, 2005).

2.9 Theoretical Foundation of Human Envirionmental Behaviour For many decades now, understanding and predicting human environmental behaviour has been of particular interest to researchers. Moreover, the assumption that knowledge of attitudes will help in the task of predicting human behaviour has formed the basis for much social research. It has therefore generally been presumed that prediction of behaviour is best achieved by the understanding and measurement of cognitive variables (Krosnick et al., 2005). Hence, occupying a central position in the study of behaviour research is the concept of attitude (Krosnick et al., 2005). Attitudes are assumed to play an important role in human behaviour theory as the vital link between what people think and what they do.

The most fundamental assumption underlying the attitude concept is the notion that attitudes in some way, guide, influence, direct, shape, or predict actual behaviour (Ajzen

& Fishbein, 1974; Kraus, 1995). Thus, researchers interested in human behaviour theory assign great importance to the role of attitudes in predicting and explaining human actions.

Nevertheless, a number of theories have contextualized and explained human behaviour

(Taylor & Toad, 1995; Ajzen & Driver, 1992; Ajzen, 1991; Ajzen & Madden, 1986).

These theories of human behaviour emanate from all disciplines of the social sciences and basically developed to help understand which factors promote or inhibit environmental

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behaviour (Steg & Vlek, 2009). One of these most widely used theories to explain human environmental behaviour and which is relevant to this study is Theory of Planned

Behaviour (TPB) Figure 2.1.

Figure 2.1: Theory of Planned Behaviour. Source: Adapted from Ajzen(1991)

The TPB adopts a cognitive approach to explaining human behaviour and has received broad support in empirical studies of environmental behaviours and social psychology related literature (Ajzen, 1991; Taylor & Todd, 1995). The TPB has successfully been used to predict stealing, disobedience, lying, fighting, cheating, lateness, rudeness, destructiveness, sex offence/harassment, cruelty, smoking, and drinking alcohol in human organizations. The choice of this theory was therefore based on its utility in examining the antecedents of environmental behaviour such as open defaecation intention and actual open defaecation behaviour.

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2.10 Theory of Planned Behaviour (TPB) and its Applications The TPB is an extension of the theory of reasoned action (TRA) made necessary by the original model’s limitations in dealing with behaviours over which people have incomplete volitional control (Ajzen, 1991). As discussed by Liska (1984) and other researchers the

TPB developed by Ajzen (1989, 1991, & 2001) postulates that the intention of individual to perform a certain behaviour is dependent on whether individuals evaluate the behaviour as positive-attitude-and if they judge others as wanting them to perform the behaviour- subjective norm. As explained by Fazio (1986), most people hold both positive and negative beliefs about an object and attitude are viewed as corresponding to the total effect associated with their beliefs. The TPB is based on and guided by three kinds of beliefs and cognitive outcomes. These include: (i) behavioural beliefs (ii) normative beliefs and (iii) control beliefs.

The behavioural beliefs, also refers to as attitude, comprises belief about the expected outcome of the behaviour which produces a positive or negative attitude towards the behaviour (Armitage & Conner, 2001). Normative belief, on the other hand, is the beliefs about what others expect and the desire of the individual to follow those expectations often referred to as normative expectations. These beliefs result in the degree of social pressure to comply or subjective norm. That is what they think others for example, peers, and family members want them to perform the behaviour). The control beliefs constitutes factors that exist that will either motivate or block the performance of the behaviour resulting in the degree of perceived behavioural control (Ajzen, 1989, 1991, & 2005). All three cognitive outcome factors—attitude, subjective norms, and perceived behavioural control combine to determine individual behavioural intention (Ajzen, 1989, 1991, & 2001). For example, the more favourable the attitude towards the behaviour, and the more favourable the

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subjective norm, and the greater the perceived behavioural control, the potential of the intention to perform the behaviour largely increases in strength. Ajzen and Fishbein view behavioural intentions as the immediate antecedents of corresponding overt behaviours; hence, the best prediction of behaviour is a person’s intention to perform the behaviour

(Ajzen, 1989, 1991, & 2001).

According to Ajzen and Fishbein (2005), two factors exist which can disrupt the intention- behaviour relationship and these include the duration between the stated intentions and the actual time of performing the behaviour. Sometimes there can be inconsistencies between the intentions and behaviours (Ajzen, 2005). For example, time can affect the individual's intention to carry out an action. As time elapses, the likelihood that the intentions are influenced by unforeseen events increases. Sejwacz et al., (1980) reported a decrease in the correlation between the intentions and behaviours over a two-month period from 0.72 to 0.47 respectively. Nonetheless, when an appropriate measure of intention is obtained, it provides the most accurate prediction of the behaviour (Ajzen & Fishbein, 2005).

The intention to perform a certain action, according to the TPB is directly inﬂuenced by three central predictor components including antecedents of intention which describes personal attitude, subjective norms (social influence) and perceived behavioural control

(Ajzen, 1989 & 1991). These components, however, are influenced by both situational and psychological factors (Ajzen, 2001). Both factors act to shape intentions toward action and behaviour itself. The situational factors reflect personal circumstance, dependent on the contextual, demographics, and experiential factors and largely dependent on either where one lives (rural or urban) or demographic situations, particularly age and sex (Ajzen,

2001). Alternatively, the psychological factors all relate to personal perceptions which

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comprised a diverse number of variables that have been related to specific behaviour. The situational and psychological factors together with behavioural intention can be used directly to predict human behaviour (Ajzen, 2001).

The relationship between attitude and intention is stronger than the relationship between intentions and actual behaviour (Kim & Hunter, 1993) because the relationship between intentions and behaviour is under the powerful inﬂuence of external factors more than the psychological variables which are cognitive processes. Ajzen and Fishbein (1980) postulated that an intention is a volitional behaviour which transforms individual psychological state into guided bodily responses. Although the exact nature of the transformational process remains little understood, at least to date, the postulation of such a process overcomes one serious drawback with acceptance of a direct path from attitudes to behaviour in the theory of reasoned action.

The TPB, however, has limitations in predicting behavioural intentions and behaviour when people do not have volitional control over their behaviour (Ajzen, 1991; Taylor &

Todd, 1995). The choice of the TPB was therefore based on its utility in examining the antecedents of environmental behaviour such as open defaecation. Also the TPB however, has been found to be associated with some uncertainties causing its moderating effect size to be influenced by some powerful situational factors (Azjen, 1998, 2002). This suggests to the present study that the school environment (nature of the schools and built environment) and the level of comfort pupils obtain from engaging in open defaecation can largely influence their defaecation behaviour in their schools.

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On the basis of application, the TPB is one of the best studied and applied theories use to predict human behaviour (Ajzen, 2011). For the past two decades, the TPB has been widely applied and extended to studies on individual behaviour, especially in the prediction of individual’s intention to behave and the actual behaviour (Fishbein & Azjen, 2005). The intention to engage in a specific behaviour is based on attitudes toward the behaviour as well as subjective norms. Ajzen (1988; Beck & Ajzen, 1991) extended the theory to enable prediction of behaviours that an individual may not be able to perform at will. Since then, the model has been used in many areas of behaviour research including both healthy and unhealthy behaviours such as exercising, drinking, smoking, dishonest, cheating and lying

(Kiriakidis, 2008; Beck & Ajzen, 1991) with considerable precisions, thus giving it its extensive usage. Another reason attributed to the extensive applications of the TPB is its embracement of new variables in the prediction of behavioural intentions (Beck & Ajzen,

1991).

Again, the TPB has been applied to a wide range of behaviours in attempt to better understand which individuals behave in which way, and have provided evidence for the predictive validity of intentions (Chatzisarantis et al., 2007). Studies showed that the TPB can explain, on average, between 40% and 50% of the variance in intentions to act, and between 19% and 38% of the variance in behaviour performance (Sutton, 1998). For a wide range of behaviours, attitudes-intentions mean correlations ranges between 0.45 to

0.60 (Chatzisarantis et al., 2004; Beck & Ajzen, 1991) intention-subjective norms correlations ranges from 0.34 to 0.42 and intention-perceived behavioural control ranges from 0.35 to 0.46 (Armitage & Corner, 2001).

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The TPB is therefore relevant to the present study since it can help explain why pupils— aged between 9 to 18 years—avoid toilet use and defaecate in the open. It was therefore the purpose of this study to use the TPB, first as the theoretical foundation to investigate behavioural and cultural factors influencing open defaecation behaviour among pupils in the first cycle schools in Ghana, and second as a model to guide the study of open defaecation behaviour intentions and the actual behaviour among first cycle pupils in the

Eastern and Volta Regions of Ghana.

2.11 Theoretical Foundation of Culture and Human Behaviour Towards the Environment Despite a century of efforts to define culture adequately, there was in the early 1990s no agreement among anthropologists regarding its nature. Culture, according to Tylor (1871), as cited in Abasiekong, 2010 & Avruch, 1998), is that complex whole which includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society. Kroeber & Kluckhohn (1952) also viewed culture as one comprising patterns of behaviour acquired and transmitted by symbols. They argued that the essential core of culture consists of traditional—that is historically derived and selected—ideas and especially their attached values. They were of the view that culture systems may, on the one hand, be considered as “products of action, on the other, as conditional elements of future action.” Culture therefore includes modalities of actual behaviour and a group's conscious, partly conscious, and unconscious designs for living.

Schwartz (1992) argues that culture is the collective programming of the mind which distinguishes the members of one category of people from another. This view was shared by Spencer-Oatey (2008), who posits that culture is a set of basic assumptions and values, orientations to life, beliefs, policies, procedures and behavioural conventions that are shared by a group of people, and that influence each member’s behaviour and his

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interpretations of the ‘meaning’ of other people’s behaviour. Culture therefore comprises series of important values and beliefs that are characteristic for the members of a particular society and are relevant to their view of the world as well as to the ideals worth to strive for. Culture in its simplest form and for the purpose of this study can be said to be the way of life of a people.

Based on the definitions of culture presented above, it is evident that culture is not inherited but transmitted through observation and learning from one’s social environment.

Observing how adults react and communicate with new babies is an excellent way to see the actual symbolic transmission of culture among people (Spencer-Oatey, 2008). The people with whom the children interact will praise and encourage particular kinds of behaviours (Lustig & Koester, 1999). The notion that culture is acquired through the process of learning has several important implications for this study. In a social setting such as family, peer group or a community, where open defaecation is the norm, members of the group will accept such open defaecation behaviour and express them overtly. The younger generations born to such social setting will emulate the open defaecation norm and express it when they grow and take up certain social roles and responsibilities. Human environmental behaviour is therefore largely influenced by culture settings, cultural beliefs and taboos related to sanitation behaviour hence children’s attitudes and behaviour lean towards the cultural norms of their families, peers, and communities.

2.12 Influence of Culture on Human Environmental Behaviour According to Matsumoto (2007), individual behaviour can be explained by three major factors comprising personality, culture, and basic human nature. These factors according to him are largely moderated by some powerful situational variables which determine their

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relative contributions in influencing behaviour (Matsumoto, 2007). The personality component consists of individual role identities and this is moderated or guided by personal and subjective norms. Whilst the personal norms describes one’s feelings

(attitudes) toward performance of a behaviour (de Groot & Steg, 2010), subjective norms constitutes one’s sense that significant others expect a certain pattern of behaviour (de

Groot & Steg, 2010). The culture component comprises individual’s social roles and responsibilities and these are moderated by values, social norms and level of education and knowledge. Values explains the underlying reasons why people exhibit certain environmental behaviours (Treven & Treven, 2007). Values therefore predict behaviour, and as that behaviour begins to solve the problem which prompted it in the first place, the value gradually is transformed into an underlying assumption about how things really are- beliefs (Treven & Treven, 2007).

Human behaviour is also influenced by social norms which impose uniformity of behaviour within a given social group (Bicchieri, 2006; Sugden, 1986; & Coleman, 1990).

Social norms according to (Gilbert, 1989) are conventions enforced in a community to ensure appropriate human environmental behaviour and these are largely influenced and sustained by threat of social disapproval and punishment for norm violations (Sugden,

1986; & Coleman, 1990).

Aside psychological factors, values and social norms, education has also been identified as an important predictor of environmental behaviour. The higher the education one attained the more concerned individual exhibits towards the environment (Arcury &

Christianson, 1993; Chanda, 1999; Hsu & Rothe, 1996; Klineberg et al., 1998,

Rothenbach, 1998; Ostman & Parker, 1987). A study by Robelia & Murphy (2012) in

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United States of America (USA) found a very high level of knowledge about some environmental problems but “discouraging” levels of knowledge about others. The authors demonstrated that making informed positive choices are difficult if one has no or inaccurate knowledge about an intended behaviour (Levine & Strube, 2012). They further reported that having the right knowledge of behaviour enhances one’s intention towards the performance of that behaviour (Levine & Strube, 2012). Knowledge is therefore regarded as a necessary and sufficient condition for salutary decision-making (Levine &

Strube, 2012) and self-reported knowledge, fallible as it may be, seems to predict more environmental behaviour (Fielding & Head, 2012). This proposition has been supported by norm activation theory which states that awareness of need, awareness of consequences, personal norms, and subjective norms are essential in the performance of environmental behaviour (de Groot & Steg, 2010).

The implication of this to the current study is that any intervention that seeks to shift open defecators to toilet use in any setting can be successful when specific culture underlying open defaecation practices and behaviours of those engaged in it are adequately addressed.

It is therefore essential that any environmental behaviour such as sanitation and open defaecation must be analyzed critically before intervention measures are developed to address such a behaviour holistically.

2.13 Culture, Behaviour and Sanitation: Africa and Ghana’s Perspectives The African continent, one of the largest continents of the world, is a multi-ethnic society with its peculiar nature and diverse practices (Ojua & Omono, 2012). The cultural practices of people not only affect their health but also affect all aspects of life including sanitation behaviours. Culture and behaviour taken together operates as fundamental

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context defining knowledge and making decision relating to sanitation practices (Briggs,

2003). In African countries, diverse and complex explanations for sanitation behaviours evolve in relations to individual situated experiences which are nested in cultural factors of beliefs, traditional values, norms and religion (Briggs, 2003). Sanitation behaviour is, in fact, the result of two decisions (Cameron et al., 2013). First is a household-level decision about whether or not to own a latrine; and second is a person-level decision about whether or not to use a latrine, among people who have access to one (Cameron et al.,

2013).

Many studies by Jenkins & Curtis (2005) indicate plethora factors that influence personal choices about sanitation practices. One study in Benin revealed eleven drivers for sanitation uptake that are broadly categorized as prestige-related, well-being, and situational (Jenkins & Curtis, 2005). The drivers categorized as well-being included protecting family health and safety from mundane dangers and infectious diseases, convenience and comfort, protecting personal health and safety from supernatural dangers, cleanliness, and privacy. Asides these, other reasons discovered for toilets adoption according to Jenkins & Curtis (2005) comprised easing restricted mobility, increasing rental income, identifying with urban elite, leaving a legacy for your family, and living the good life. Other reasons ascribed to toilet use include lack of smell, lack of flies, cleaner, and privacy (Cairncross & Kinnear, 1992).

A study in Ghana by Jenkins & Scott (2007) shows that toilet use occurs in three behavioural stages namely preference, intention, and choice. A person’s preference shifts when he or she becomes dissatisfied with current sanitation options, and then they intend to build a latrine when the idea of a latrine becomes preferable. Finally, they chose to

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install a toilets when they have access to good information, materials, finances, and product choices (Jenkins & Scott, 2007).

Gender differences have also been reported for motivations for adopting toilet use (Jenkins

& Scott, 2007). One study demonstrated that men’s desired for toilets is mostly for prestige purposes, and displayed higher aversion to the perceived smell and dangers of toilets than women (Jenkins & Scott, 2007). There are also documented cases of open defaecation among people that have access to toilets (Burra et al., 2003). In these cases it is necessary to find out why people choose open defaecation over hygienic toilet options. One study found multiple reasons, including no choice, privacy, convenience, and safety (Arnold et al., 2010). Another study in Ghana also reported that in some urban areas people had to choose between inferior public facilities and expensive private facilities (Burra et al.,

2003).

2.14 Culture, Behaviour and Open Defaecation: Global, Africa and Ghana’s

Perspectives

Open defaecation is a common behaviour in some cultures and it is sustained through local cultural norms (WSP, 2013) throughout the global environment including Africa and

Ghana. In some regions such as India and East Java, open defaecation is a social norm and practiced since childhood and strongly nurtured by designated sites allocated for it (WSP,

2013). A study by WSP (2013) indicates that socio-demographics and environmental factors including age, sex, and access to water, perceptions of soil quality, seasonal factors respectively, provided important contextual information for sanitation and open defaecation behaviours.

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A review of what influences open defaecation and toilet ownership in rural households within the global environment by Kathryn (2014) identified several factors including knowledge, enforcement of rules or regulations, values, intention to build toilets, roles and decision-making, and beliefs and attitudes to be responsible for open defaecation in both rural and urban settings. Studies also revealed that in some ethnic culture, traditional beliefs such as a father-in-law and daughter-in-law cannot use the same toilet, has also compelled many people to go for open defaecation options (Kathryn, 2014). In other culture especially in the mid and far western region, menstruating women are banned from toilet use with a belief that they are untouchable during those menstruating days Kathryn

(2014).

There are also documented cases of open defaecation behaviours among people that have access to toilets. Arnold et al., (2010) in a study to find out why people prefer open defaecation to toilet use, discovered that the major reasons why people engaged in open defaecation comprised no choice, privacy, convenience, and safety. Jewitt (2011), in a similar extensive literature review, also reported taboos and superstitions surrounding human excrements, enhanced status of individuals, among other as key socio‐economic and physical factors endorsing open defaecation behaviours. In Madagascar for example, it is a taboo to store sewerage underground for fear of contaminating the dead; and putting one person’s faeces on top of another’s both of which exclude the use of drop and store systems (Black & Fawcett, 2008; Ramanantsoa, 2004). Also, in Uganda it is a taboo using cesspits for fear of sorcerers using the excreta to inflict pains on individuals. In urban and rural India, it is a belief that women are forced to defaecate in the open due to lack of access to toilets (WHO/UNICEF/JMP, 2010). However, many rural people belief that open

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defaecation is a natural and positive part of village life, and really seen as socially acceptable and unshameful to defaecate in public places (WHO/UNICEF/JMP, 2010).

There are some places where social rules accepted that adults and older children should not defaecate in certain designated environments: near someone’s house, temple, and crops soon to be harvested (Caldwell, 1993). However, most other places – including the shores of ponds, the banks of rivers, along well-travelled roads or paths, behind public buildings, and in canals, fields, orchards, and forests – are socially acceptable places to defaecate

(WHO/UNICEF/ JMP, 2015). Also, as reasons to promote toilet use in rural India, the government documents raise the dignity of women (GOI, 2012a). Similar studies in rural north India reported that people belief toilets used in other parts of the developing world as dirty and ritually polluting (Coffey et al., 2014). In contrast, open defaecation is not only socially acceptable, but it is also seen as a wholesome activity that promotes physical health and the purity of the body (Coffey et al., 2014); long-standing habit, more comfortable, and provides an opportunity to take in fresh air (Coffey et al., 2014). Finally, open defaecation has been seen as traditional legacy of ancestors handed over to the younger generation and therefore must be continued.

In Africa, open defaecation behaviour has also been reported in several studies (Devine,

2010; WA, 2008). As reported by some communities in Sierra Leone, the people of

Kampala also believe that pregnant women should not use the toilet because of fear of the death of the foetus (WA, 2008). More so, in other communities it is a taboo to share toilets among some members of the family. A good example is found among the Luo in Kenya,

Uganda and Tanzania. In these countries, it is taboo for in—laws to share a toilet (Devine,

2010). The belief is that you will be cursed if you undress in the same space as your in-

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laws. Similar beliefs have also been reported among pregnant women where it is believed that pregnant women may lose their fertility if they use pit latrines Caldwell, 1993). In some parts of Uganda, it is a common belief that if children’s excreta is disposed in a pit latrine they won’t grow up to be healthy (Caldwell, 1993). Among the Malian and Idoma people in Nigeria, open defaecation is seen as an ancestral practice passed down through generations (WA, 2008). Open defecation is culturally encouraged in Idoma communities as it is a taboo to defaecate in a building or super structure, and many older people still refuse to defaecate in any sort of enclosed environment. Among the Idoma communities, husbands do not allow their wives or daughters to share latrines with them, and will generally refuse to pay to build latrines for the use of female family members (WA, 2008).

A study conducted on open defaecation in rural communities to determine the cultural factors that reinforced its practice in four West African countries—Burkina Faso, Ghana,

Mali, and Nigeria revealed that the practice of open defaecation was surrounded by cultural taboos and beliefs particular to many of the ethno-linguistic groups who live there (WA, 2008). For example, a study by WA (2008) in Ghana demonstrated that fear of being possessed by demons and losing one’s magical powers constituted leading cause of open defaecation behaviour seen across all the study areas. Nearly half of the respondents’ in Tamale believed that public toilets are surrounded by evil spirits and therefore should be avoided, with a significant group of respondents in the Wa East district believing that latrine use will strip the user of their magical powers.

The impact of social norms on safe excreta disposal has also been identified by

Devine (2010). The author discovered that people imitate others (defaecating indiscriminately) thinking that it is good practice. These cultural norms continued to

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prevent people from toilet use and thus increasing sanitation challenges in the global,

Africa and Ghana. There is therefore, the need to thoroughly understand and build on local cultural assumptions if behaviour change in relation to open defaecation is to be successful.

Oberkircher and Hornidge (2011) have suggested the incorporation of available local value base in passing necessary information to local groups than using the Western secular approach. In this context, the use of available local traditional and religious value structures could pass the needed environmental health information given the wider respect and acceptability that such structures enjoy among the rural populace.

2.15 Public Health and Environmental Implications of Open Defaecation The global burden associated with open defaecation cannot be underestimated. Open defaecation spreads a myriad of faeco-oral diseases including cholera, typhoid, parasites, hepatitis, diarrheal diseases and polio. Hundreds of thousands of children die from diseases related to open defaecation each year and those who survive are left stunted, both physically and cognitively (Spears, 2013; Fink et al., 2011; Humphrey, 2009; & Feachem et al., 1983). Global statistics reports indicates that faecal contamination of the environment resulting from open defaecation has also been identified as the major cause of about 1,800 cases of cholera affecting children aged 0-5 years in Ghana annually (WHO,

2005; UNICEF, 2012). Early childhood diarrhea resulting from open defaecation does not only contribute significantly to stunting, wasting and reduced long-term cognitive development of children in schools (Spears, 2012a), but it also results in intermittent school dropout (Pelletier et al., 1995). Open defaecation kills babies, impedes the physical and cognitive development of surviving children, and reduces the human capital of

Ghana’s workforce. Aggregate figures across Africa and globally points to sanitation- related diseases, as the second greatest killer of children–more than the aggregate effects

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of AIDS, malaria and measles (WHO/UNICEF/JMP, 2008). According to Liu et al.,

(2012), an estimated 801,000 children younger than 5 years die from diarrhea diseases annually, mostly in developing countries. This amounts to 11% of the 7.6 million deaths of children under the age of five and means that about 2,200 children are dying every day as a result of diarrhea diseases (Liu et al., 2012). These rates, however, are not representative of the real problem, as most cases of diarrhea are addressed at the household level and not the clinic (Liu et al., 2012).

Open defaecation has led to continued spread of sanitation related diseases, such as cholera, typhoid, schistosomiasis, amoebic dysentery, skin diseases and increased high incidence of worms and diarrhoea affecting mainly children (WHO/GHA, 2009). In India for example, it was reported that 600,000 under-five children died due to diarrhoea resulting from unsafe sanitation conditions, and inadequate hygiene practices (UNICEF,

2010). Lack of improved sanitation facilities has resulted in the death of over 6,000 children in developing countries each day (UNDP, 2006) and approximately 84% of these deaths are children under age 5. Children from sub-Saharan Africa are five hundred times more likely to die from diarrhoeal disease caused by contamination of water sources by faecal matter than a baby from the developed world (WHO, 2005). According to Bartram et al., (2005) far more people suffer from poor sanitation and water supply than by war, terrorism and weapons combined. If suffering from diarrhoea multiple episodes it has been shown to result in malnutrition and in “permanent shortfalls in physical and cognitive development, with decrements of up to 8 cm in growth, 10 intelligent quotient points, and

12 months of schooling” (Peterson et al., 2008; Berntell, 2005).

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Open defaecation also causes stunting in children. According to Case and Paxson (2008), physical height has its origins in early childhood development and found to be more pronounced in poor countries where environmental threats to health are more important than they are in rich countries, relative to genetics (Martorell et al., 1977; Spears, 2012b).

Two existing literatures indicate that early-life exposure to faecal germs in the environment reduces children’s subsequent height. First, medical and epidemiological literatures have documented the mechanisms linking open defecation to poor health and early life human capital accumulation. Humphrey (2009) documents that chronic but subclinical “environmental enteropathy”—a disorder caused by repeated faecal contamination which increases the small intestine’s permeability to pathogens while reducing nutrient absorption-could cause malnutrition, stunting, and cognitive deficits, even without necessarily manifesting as diarrhea (Petri et al., 2008; Mondal et al., 2011).

According to Ghana Demographic Health Survey, 1 in 5 children under five in Ghana are stunted due to exposure to persistent faecal matter. Fecal contamination of the environment resulting from open defaecation has largely been implicated to be the root cause of an annual average of 1,800 cases of cholera affecting Ghana (WHO/GHA, 2009).

Aside the health implications, open defaecation also has economic and social costs.

According to WSP poor sanitation costs Ghana 420 million cedis each year, equivalent to

US$290 million (WSP/WB/JMP, 2010). This sum is the equivalent of US$12 per person in Ghana per year or 1.6% of the national Gross Domestic Product (GDP). In reality, the economic implications of a cholera outbreak go beyond the immediate health system response; there are also costs related to productivity loss and premature death, diverting expenditures from other essential items and leading to losses in trade and tourism revenue

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(WSP, 2012). Ghana loses 420 million Cedis each year due to poor sanitation (WSP,

2012). Apart from its financial burden on the Ghana’s economy, open defaecation also has considerable social costs. Loss of dignity and privacy and risk of physical attack and sexual violence may not be easily valued in monetary units, but these issues are the reality when sanitation facilities are either inadequate or not available (WSP/WB/JMP, 2010).

Diarrhoea, resulting from poor sanitation, causes many school children to miss days from school (WSP/WB, 2010). Although there are many different reasons for school drop-out among school girls, the lack of improved toilet facility at school is potentially one of the reasons (Eshelby, 2007). The impact tends to be more sensitive for secondary school students as the drop-out rate is higher than that of the primary school pupils (Eshelby,

2007; Kov et al., 2008). This can be explained by the fact that when the girls attain puberty age, more privacy for toilet going is needed (Kov et al., 2008). Studies show that about half the girls in Sub-Saharan Africa who drop out of primary school do so because of poor sanitation facilities (UNDP, 2006). Research also shows that one in four girls do not complete primary school, compared with one in seven boys (UNDP, 2006). Besides, there is also loss of dignity associated with a lack of privacy in sanitation accesses (UNDP,

2006).

Besides its public health concern, open defaecation seriously compromises environmental cleanliness and safety. In regions where a large proportion of the population is not served with adequate sanitation, sewage flows directly into streams, rivers, lakes and wetlands, polluting the coastal and marine ecosystems and fouling the environment (UN, 2003). The greatest perceived impact of faecal matter on aesthetics is the fact that it generates pungent smells and defaces visual appearance of the environment, particularly in towns and cities

(UN, 2003).

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According to UNICEF (2012) open defaecation leads to methane and carbon dioxide generation, which eventually leads to global warming thus contributing significantly to economic losses (WB, 2010). Open defaecation also reduces the aesthetic beauty of an area and is one of the major causes that hinder growth in tourism (UNICEF, 2012). The sewage dumped into the seas, rivers, streams and dams increases their nitrogen contents resulting in eutrophication leading to the loss of fish and other species, and destroying coral reefs (UNDPI, 2002). In the developing world as a whole, around 90% of sewage is discharged untreated into surface water bodies polluting them and affecting plant and aquatic life (UNDPI, 2002).

2.16 Identified Critical Knowledge Gaps in Literature The literature reviewed was within the framework of both Millennium Development Goal

Target 7(C), which is to be halved, by 2015, the proportion of the population without sustainable access to basic sanitation and the post Sustainable Sanitation Goals (SDG) 6 target 2 which aims at ending open defaecation in developing countries by the year 2030.

One of the objectives of this literature review was to highlight where gaps in knowledge which might justify the need for the present study. From the literature reviewed, the following important observations were made and identified as knowledge gaps in literature:

(i) most studies published on open defaecation in Ghana concentrated more on social, economic and physical factors as key determinants of open defaecation practices and largely silent on behavioural and cultural factors and their interactive effects on open defaecation practices; (ii) most studies on sanitation and open defaecation behaviours published in Ghana stressed on adults’ attitude and behaviour changes and largely silent on attitudes and behaviour changes of children below nineteen years (WA, 2008); (iii)

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published literature on school based behavioural and cultural factors in relation to open defaecation behaviours has been limited in literature reviewed in Ghana; (iv) most studies published on open defaecation behaviours were geared towards the larger communities leaving the schools as an important miniature community in the larger community; (v) again, the literature reviewed was silent on limitations associated with the school toilets’ squat holes and feet rests dimensions and their effects on school sanitation system and pupils toilet use; and (vi) Finally, there has been limited situational assessment of conditions of the school toilets in first cycle schools in Ghana, although many new toilets built in the schools have raised the issue of poor sanitation behaviours from the point of view of school toilets’ provision. These gaps in knowledge are therefore used to define the research objectives and research questions in the study’s framework.

2.17 Conceptual Framework The framework guiding this study is based on the TPB model developed by Ajzen (1989,

1991, & 2001). The TPB model postulates that the intention of individual to perform a certain behaviour is dependent on whether individuals evaluate the behaviour as positive or negative (attitude) and if they judge others as wanting them to perform the behaviour

(subjective norm) and perceived behavioural control (control belief), which connotes one's perception of internal or external controls constraining the behaviour in question (Ajzen,

1989, 1991, & 2001). Internal controls may include the person’s ability to perform the intended behaviour (self-efficacy), while external control refers to the availability of external resources needed to perform that behaviour (facilitating conditions). Given a sufficient degree of actual control over the behaviour, people are expected to carry out their intentions when the opportunity arises. The central factor in the theoretical framework is individual’s intention to perform a given behaviour (Ajzen, 1991). Intentions are assumed to capture the motivational factors that influence behaviour and the stronger

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the intention to engage in a behaviour, the more likely should be its performance

(Ajzen, 1991). According to the theory, perceived behavioural control, together with behavioural intention, can be used directly to predict behaviour (Ajzen, 1991). Although there is no perfect relationship between behavioural intention and actual behaviour, intention can be used as a proximal measure of behaviour (Ajzen, 1991).

Figure 2.2: Schematic Conceptual Framework. Source: Student’s Construct (2015)

As shown in Fig. 2.2, the conceptual framework is based on and guided by three kinds of beliefs and cognitive outcomes namely: (i) attitudes toward the behaviour (guided by behavioural beliefs) (ii) subjective norm (guided by normative beliefs) and (iii) perceived behavioural control (guided by control beliefs). This model assumes that attitude,

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subjective norm, perceived behavioural control are key determinants of individual intention and subsequent behaviour (Ajzen, 1989, 1991, & 2001).

The four (4) major components of the conceptual framework for this study are illustrated in Figure 2.2 above. This encompasses the behavioural components of TPB (attitude, subjective norm, perceived behavioural control and intention) which are latent variables influencing likelihood of individual intention and actual action. However, to fit the context of this study, three other variables including the cultural factors, conditions of the school toilets, and modifying factors (age, sex, education and locality) were introduced into the conceptual framework. These new variables which may interact with the three fundamental predictor variables suggested by Ajzen (1991) for predicting human behaviour intentions constitute the situational factors. The influence of situation factors on the behavioural components are largely moderated by modifying factors (age, sex, education & locality) presented on the conceptual framework. Detailed explanation of the major components of the conceptual framework is presented in the following discussions.

2.17.1 Behavioural Factors Attitude in the conceptual framework constitutes individual’s positive or negative valuation of behaviour and this determines one’s feeling about performing a given behaviour. Attitude had been reported in many studies to correlate well with people behavioural intention and the average correlations ranged between 0.45 and 0.60 (Ajzen,

1985; Armitage & Conner, 2001; Beck & Ajzen, 1991). In this study, five behavioural variables included in the attitude measurement scale and on which data were collected were: (i) knowledge of open defaecation risks; (ii) awareness of open defaecation risks;

(iii) perceived toilet comfortability/convenient; (iv) perceived privacy in the school toilets; and (v) perceived benefits of open defaecation. The study measured and reported the

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moderating effect size of each of these independent behavioural variables on the dependent variable—pupils open defaecation behaviours, in addition to intention as its antecedent dependent variable.

The next behavioural component on the conceptual framework is subjective norms (or social pressure). The perception of individuals whether to perform an intended behaviour is largely influenced by people important to that person generally referred to subjective norm (social groups comprising family members, peer groups, friends). For example, an individual may engage in open defaecation behaviour if his or her intention to perform that behaviour is motivated by social environment (pressure from those around him or her), and in addition to his/her own knowledge of the behaviour outcome(s) (Hernandez &

Mazzon, 2007). This proposes that an individual will feel social pressure to carry out a behaviour if he/she is motivated to comply with groups, individuals or believes that the behaviour will be approved by significant others. Ajzen and Fishbein (1980) reported that for many practical reasons an identification of the subjective norm, attitude and their relative importance may be adequate to form behavioural intention. Individuals having adequate knowledge of bad effect of open defaecation on the environment and health, for example, may desist from engaging in open defaecation practices. The opposite is also true. This suggests to the present study that pupils’ environment can influence them to engage in open defaecation behaviour (Gary et al., 2007) also reported in a study to determine the environmental attitudes and behaviour of children and reported that environmental attitudes and behaviour of parents largely have greater influence on the development of children’s environmental attitudes and behaviours.

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In the conceptual framework of the present study, the behavioural variables included on the subjective norm measurement scale and on which data were collected included the following: descriptive norm (social injunctions), role model, and extrinsic motivation. The study measured and reported the mean moderating effect sizes of these independent variables on the dependent variable—pupils open defaecation behaviours.

Perceived behavioural control (PBC) formed the third behavioural component of the conceptual framework, connotes the ease or difficulty individual faces in performing an environmental behaviour and this largely relates to individual’s previous and anticipated restrictions and challenges to be encountered in the course of execution the intended behaviour (Azjen & Fishbein, 2005). This suggests to the present study that the level of self-efficacy of pupils in the first cycle schools can have significant effect on their open defaecation behaviours if resources and opportunities are available. In the conceptual framework of this study, PBC variables considered include (i) perceived confidence, and

(ii) motivation (intrinsic value). These variables, in their individual and combined states, have been measured to determine their influence on pupils open defacation behaviours.

The fourth behavioural component included on the conceptual framework is intention.

People’s intention to engage in an environmental behaviour has been found to be the central element of TPB model (Ajzen, 1991) and largely considered to be the greatest motivator of human environmental behaviours. Studies (Ajzen, 1991; Fazio, 1986) found that the stronger the intention to perform a behaviour, the more likely the behaviour is executed. Besides, it has also been demonstrated that behavioural intention have strong synergy with environmental behaviour only if the intended behaviour is under volitional control (Fazio, 1986; Ajzen, 1991)—that is individuals are not forced or

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compelled to perform the behaviour. Relating this to the present study, it is relevant to indicate that choice of place of defaecation, can be considered a volitional behaviour and can therefore exhibit some relationship with pupils’ intentions.

According to the TPB, perceived behavioural control, together with behavioural intention, can be used directly to predict behaviour (Ajzen, 1991). The intention to perform a certain action, according to the TPB model is inﬂuenced directly by three central component causer factors comprising behavioural proximal antecedents of intention which describes personal attitude, subjective norms and perceived behavioural control (Ajzen, 1989, 1991,

& 2001). The study measured and reported the mean effect size of intention variable on the dependent variable—pupils open defaecation behaviours.

2.17.2 Cultural Factors

Cultural factors constituted the first new variables introduced into the TPB model and for that matter the study’s conceptual framework. Cultural factors have been demonstrated in several studies to have moderating influence on environmental behaviours (Matsumoto,

2007; Coleman, 1990; Bicchieri, 2006; Sugden, 1986). Pupils living in an interactive community are affected by what happens in his /her environment and how he or she reacts to it. This suggests to the present study that the cultural background of the pupils may influence their sanitation preferences. The cultural factors included on the cultural measurement scale in this study were taboos, traditional norms, superstitions, and traditional values. The influence of these variables in their individual or combined state on pupils open defaecation behaviours were measured in this study and their relative effect sizes reported.

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2.17.3 Situational Factors Besides behavioural and cultural predictor variables, the conditions of the toilets pupils used in the school can determine, to a large extent, the prevailing sanitation practices/behaviours of the pupils. Previous studies (WSP-SA, 2002c; Mukherjee, 2001) overwhelmingly points to the fact that providing toilet facilities does not necessarily lead to enhanced behavioural change towards efficient use of the facility.

Evidence from the extensive literature reviewed on sanitation in Ghana indicated that no study has investigated the influence of stuational factors (conditions of school toilets) on pupils’ open defaecation behaviours in the first cycle schools in Ghana using the TPB model and mixed methods. Hence the conditions of the school toilet systems have been introduced into the TPB model to help conceptualize the situational factors associated with the school toilets and which are influencing open defaecation behaviour among the pupils in the study schools. Seven (7) perceived predetermined situational variables associated with the conditions of the school toilets and which were included on the study’s conceptual framework were: (i) hygiene status of school toilet; (ii) privacy; (iii) scent and ventilation in the school toilet; (iv) disease infection from using the school toilet; (v) rodents in the school toilet; and (vi) maggots in the school toilets and (vii) flies in the school toilets. The study measured and reported the moderating effect sizes of these situational variables on the dependent variable—pupils open defaecation behaviour.

2.17.4 Modifying Factors The influence of demographic characteristics on individual intention regarding environmental behaviour has been identified as a significant issue in the behavioural literature (Ajzen & Fishbein, 1980; Venkatesh et al., 2003). For example, a study by

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Venkatesh et al., (2003) found that there are differences between males and females in their environmental behaviour-related variables. They demonstrated that sex and age, for example significantly moderate the influence of the determinants (attitudes, subjective norms and perceived behavioural control amidst situational factors) on behaviour intention. This suggests to the present study that pupils’ demographic characteristics such as sex, age, education, as well as the locality in which they live can influence their open defaecation practices/behaviours. These variables were therefore included in the conceptual framework of the present study and their moderating effect sizes on pupils open defaecation behaviour tested using the SEM path analysis procedure.

2.17.5 Open Defaecation Behaviour and Synergy Among Behavioural, Situational and Modifying Factors

The open defaecation behaviour in the conceptual framework is the dependent variable in addition to intention as its antecedent dependent variable and may be largely influenced by the other behavioural factors.

Several studies (Venkatesh et al., 2003; Ajzen, 1985; Ajzen & Fishbein, 1980; Ajzen &

Madden, 1986) have documented the interaction effects of behavioural, situational, and modifying factors on intentions toward environmental actions and behaviour itself. The behavioural factors relate to personal perceptions and comprise a diverse number of variables that have been related to specific environmental behaviour (Ajzen, 1985). They are all fundamentally linked by the fact that they are personality characteristics of the individuals and the perceptions of those individuals toward the actions that they are undertaking (de Young, 1986).

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A further behavioural variable that has importance with regard to environmental behaviour such as open defaecation behaviour is the degree to which the behaviour problem is perceived to be a tangible threat to personal well-being. Belief that environmental problems can be perceived as so much of a threat to well-being and health that they override many of the traditional predictors of environmental behaviour in their importance

(Baldassare & Katz, 1992). It seems logical to expect that there would be a tangible relationship between the extent to which individuals perceive the open defaecation problem, as the case in this study, to be serious and a consequent behavioural response.

The situational factors on the other hand reflect personal circumstance, dependent on the contextual, socio-demographics (age, sex & education), and experiential (knowledge, awareness and perception), factors and largely dependent on environmental settings

(locality) of individuals—rural or urban. The modifying factors (demographic factors) can have some degree of control over all the other two (behavioural and situational factors) variables included in the conceptual framework. The situational and behavioural factors together with behavioural intention can be used directly to predict human behaviour

(Ajzen, 1989, 1991, & 2001).

2.17.6 Relevance of Conceptual Framework to the Present Study

To fit the context of this study, the TPB has helped put into a comprehensive conceptual framework information on key areas the study is focusing on and encompassed the behavioural variables namely attitudes, subjective norm, perceived behavioural control

(PBC) and behavioural intentions and open defaecation; and incorporating a wide number of significant variables (cultural factors, conditions of the school toilet system) that may influence open defaecation behaviour. In addition, the framework also provides a means

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of placing these variables within a logical and comprehensive framework for predicting the key determinants of open defaecation behaviours of pupils aged between nine and eighteen years.

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CHAPTER THREE

METHODOLOGY

3.1 Study Areas The study was conducted in two Administrative Regions of Ghana namely Volta and

Eastern Regions. One municipality and one district were selected from each of the two regions. Eight communities made up of two (2) from each district and municipality were also drawn and included in the study. From each of the eight communities, one public school was selected giving a total of eight schools which formed the unit of the study. In addition, six classes from each of the eight schools were selected. From the primary section, classes 4, 5 and 6 were selected; and from the Junior High section, all the three classes—1, 2 and 3 that constitute the Junior High School system were selected. These regions were selected based on their regional open defaecation prevalence figures (Table

3.1). Though it occupies the 4th position in the regional open defaecation prevalence, the

Volta Region was included in the study.

REGIONAL OPEN DEFAECATION FIGURES

ASHANTI 3.4 EASTERN 5.1 B . A H A F O 6.4 G . A C C R A 8.1 WESTERN 12.8 CENTRAL 18.1 Regions VOLTA 30.8 NORTHERN 72.9 U . W E S T 78.7 U E A S T 81.9

0 10 20 30 40 50 60 70 80 90

Open Defaecation Prevalence (%)

Figure 3.1: Ghana’s Regional Open Defacation Figures. Source: WSMP(2008)

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The inclusion of the Volta Region was informed by three factors. First, the researcher is a native of the region and therefore not only familiar with the sanitation conditions of the selected communities in the region but he could also speak the dialect of the indigenes and therefore could conduct meaningful research within the region. Second, the researcher can neither speak, write nor understand the languages of the three northern regions, and therefore be able to conduct a meaningful research in any of the communities in the regions. Third, these reasons were supported by the fact that there are communities in the

Volta Region that are equally described as high open defaecation communities

(GSS,2012). and are comparable to communities in the three northern regions. The inclusion of Eastern Region, however, was due to its low open defaecation prevalence

(5.1%) described by WSMP (2008). The region is therefore included in the study to serve as a potential “contrast region”.

The study communities were selected using both purposive and simple randomization sampling techniques. The purposive technique was used because, to satisfy the inclusion criteria, the community must benefited from Community-Led-Total Sanitation (CLTS) program and also have at least a first cycle public school with functional toilet facilities.

In situations where a community has more than one first cycle public schools, the simple randomization technique was employed in the selection process. The selection of the eight schools was based on the same principles used in the selection of the study communities.

In the selection of the six classes purposive sampling technique was employed. This selection was based on the fact that the pupils in these classes can read and write and also be able to express themselves using the English Language. Figure 3.2 shows the location map of the study regions, districts, municipalities, communities and the schools.

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Figure 3.2: Map of the Study Areas Showing Districts, Municipalities, Communities and the Study

Fig. 3.2: Map of the Study Areas Showing Municipalities, Districts, Communities and Study Schools.

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3.1.1 Description of the Study Areas 3.1.1.1 Volta and Eastern Regions

The study was conducted in the Volta Region and Eastern region of Ghana. The Volta

Region is one of the ten administrative regions of Ghana which derived its name from the

Volta River, which virtually separates it from the rest of the country (GSS, 2012). Among the ten regions, the Volta Region is the longest and has all the ecological zones and ethnic groups found in Ghana living in it. The region is located between latitudes 50 45‟North and 80 45‟North along the southern half of the eastern border of Ghana, which it shares with the Republic of Togo (GSS, 2012). To the west with Greater Accra, the region shares boundaries with Eastern and Brong Ahafo Regions; to the north with the Northern Region and has the Gulf of Guinea to the south. Its total land area is 20,570 square kilometres, representing 8.7% of Ghana’s total land area (GSS, 2012). From south to north, the region is about 500 kilometres in length and spans all the vegetation zones of the country including costal grassland, mangrove swamps, guinea savannah, semi deciduous forests,

Sahel-savannah and mountainous wooded savannah in the north. The middle and northern belts are mainly mountainous, with Mount Afadzato (885 m) being the highest peak in the country. The south is flat with sandy portions and marshy areas. These coastal areas are estimated to be less than 15 metres above sea level (GSS, 2012).

The Eastern region is one of the ten administrative regions of Ghana and currently had 15 districts and six (6) municipalities at the 2010 PHC (GSS, 2012). The population of the

Eastern region is the third highest after Ashanti (19.4%) and Greater Accra (16.3%) regions (GSS, 2012). On the basis of physical features, the region lies between latitudes 6 and 7 degrees North and longitude 1.30 West 0.30 degrees East. The region is the sixth largest region in Ghana with a land area of 19,323 kilometres square, which is 8.1% of the

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land area of Ghana (GSS, 2005). The region shares boundaries with five other regions comprising Central, Ashanti, Greater Accra, Volta, and Brong Ahafo Regions. The topography of the region is quite diverse with low lying areas around the valley of the

Volta River and Lake and one of the highest reliefs, the Akwapim-Togo-Ranges. The region is well drained by the Volta Lake covering large stretches of the land. By it, transportation is made possible between the southern and northern parts of the country.

3.1.1.2 Fanteakwa District

Fanteakwa District is one of the study districts. It is one of the eighteen districts in the

Eastern Region of Ghana and lies within longitudes 0°32.5’ West and 0°10’ East and latitudes 6° 15’ North and 6° 40’ North. It has a a total land area of 1,150 square kilometers and bounded to the North by the Volta Lake, Lower Manya Krobo District to the East and to the South by the Yilo Krobo District. The district has a population of 108,614, comprising males 54,010, and females 54,604 (GSS, 2012) with its corresponding estimated growth rate of 3.17%. The district has a total of 79 pre-schools comprising 73 public and 6 private schools. Out of this number, 110 and 54 were primary and JHS schools respectively. The district also has a total of 197 public toilets and 515 household toilets (GSS, 2012). Again, most (60.6%) of the people use toilet facility outside their homes and 39.4% use toilet facility within their houses (GSS, 2012). As much as 82.6% of those who use toilets outside their houses travel a distance less than 1km to use a toilet facility (GSS, 2012). It is therefore clear that the Fanteakwa District is faced with sanitation challenges compelling portion of the inhabitants to resort to open defaecation.

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3.1.1.3 Akatsi South District

The Akatsi South District was established by Legislative Instrument (LI) 2165 of 15th

March, 2012. The District is one of the 25 Administrative Districts in the Volta Region of

Ghana and it is located between latitude 6° South-7° North 0° West-1 ° West and has a total land area of 960.445 sq. km. Located on its south is Keta Municipality, and Ketu

North District forms the eastern boundary; to the north is North Tongu District. At the western border are Adaklu Anyigbe District and the Republic of Togo. Akatsi South

District has a population of 88,500 comprising 46 % males and 54% females (GSS, 2012).

There are a total number of 233 schools both privately and publicly owned in the district

(GSS, 2012). Toilet facilities used by households include Water Closet(WC), Kumasi

Ventilated Improved Pits (KVIPs), PAN and no facility at all (open defaecation). Eighteen point six percent (18.6%) of households have no toilet facilities and therefore resort to the use of the bush. The use of pit latrine (40.1%) and public latrines 30.4% by households is quite common in the rural areas of the District while household’s use of KVIP (36.9%) is also in the urban areas of the District (MLGRD, 2010) . The district has 29 health facilities of which 25 are government owned while the remaining four are privately owned (Akatsi

South District Assembly, 2010).

3.1.1.4 Keta Municipality

Keta Municipal lies within Longitudes 0.30East and 1.05 East and Latitudes 5.45 North and 6.005 North. (Fig.3.3). The Municipality shares common borders with Akatsi

South District to the North, Ketu South District to the South, Tongu District to the West and the Gulf of Guinea to the South. Out of the total land surface area of 1,086km2, approximately 362km2 (30%) is covered by water bodies. The largest of these is Keta

Lagoon, which is about 12 km at its widest section and 32km long. Hence, the remaining

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land area is only 724km2 a situation which creates severe constraints on access to land for development in the Municipality. The population of Keta Municipality is 147,168 representing 7.0% of the region’s total population (GSS, 2012). Males constitute 46.4% and females represent 53.6% of the total population (GSS, 2012). The Ewes forms the major ethnic group (98.7%) in the Municipality while the other ethnic groups constitute the remaining 1.3 % (GSS, 2012). The Municipality has various educational institutions comprising 126 Pre-schools, 103 Primary schools, 77 Junior High schools, 12 Senior

High/Technical schools, and 4 Technical/Vocational giving a total of 320 (GSS, 2012).

The sanitation facilities used in the Municipality is communal. The construction of communal latrine has been the responsibility of the Municipal Assembly and the communities. Since there are no planned policies on it, these latrines are built with no emphasis on operation and maintenance. Inadequate education was given to the communities on ownership and management hence no effective operation and maintenance of the facilities. It must be emphasized however that observations made by

DPCU during the health and environmental sanitation survey in December, 2000 indicate that sanitation facilities are still not adequate judging from open defaecation along beaches, lagoon sides, open spaces, in the bush.

3.1.1.5 Nsawam-Adoagyiri Municipality

Nsawam-Adoagyiri Municipality is one of the eight Municipalities in the Eastern Region of Ghana (GSS, 2012) and located between latitude 5’.45 N and 5’.58 N and longitude

0.07’W and 0.27’ W. (Fig.3.2). The Municipality is approximately 23km from the national capital, Accra and covers 19,323km2 of the total land area in the region. The Municipality has a population of 86,000 comprising male and female proportion of 49.7% and 50.3% respectively (GSS, 2012). More than half (59.1%) of the population in the Municipality

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reside in urban localities (GSS, 2012). In terms of ethnic group living in the Municipality, the Akans constitutes the dominant groups (63%) followed with Ewes (9%), Ga-

Adamgbes (7%) and other tribes. Almost half (46.4%) of the population in the municipality are in primary schools. Those in JHS and Kindergarten form 18.2% and

13.6% respectively. The most common toilet facility used in the municipality is public toilet constituting 51.1% followed by W.C (17.7%). About 17.0% of the population in the municipality have KVIP toilet facility. A total of 5,838 households (27.5%) in the municipality use water closet and KVIP facilities in their homes (GSS, 2012). Households that use unhygienic facilities constitute 28.5%. A little more than half of the total number of households in the urban areas (51.1 %) use the public toilet. Pit latrine is very common in the rural areas with 37.5% of total rural households using the facility. The Nsawam

Adoagyiri Municipal has only one Government hospital which provides health services to the people (GSS, 2012).

3.2 Study Communities and Schools The study was conducted in eight first cycle schools comprising four rural and four urban.

The schools were selected from eight communities shown in Table 3.1.

Table 3.1: Study Communities and Schools

Regions Districts/Municipals Communities Schools

Kofisah Kofisah M.A. Primary & JHS

Nsawam-Adoagyiri Akuffokrom Akuffokrom M.A. Primary & JHS

Eastern Begoro Begoro Presby Primary B & C, & JHS

Fanteakwa Oboaho Oboaho D.A Primary & JHS

Keta Keta A.M.E. Zion Primary & JHS

Keta Kedzi-Havedzi Kedzi-Havedzi A.M.E. Primacy & JHS

Volta Akatsi Akatsi Demons. Primary & JHS

Akatsi South Monome Monome D.A. Primary & JHS

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The study communities were selected because of their poor sanitation status. These communities have at least one first cycle schools with KVIP toilet facility ranging from two to seven sitter capacities (GSS, 2012). Irrespective of age and sex, these toilets facilities are used by both pupils and teachers. Sources of water common to the communities and schools included streams, rivers, bore holes, and wells (GSS, 2012). The population and percentage distributions of dependency of study communities on these water sources are: Kofisah 3,768(80%); Akuffokrom 5,127(74%); Begoro 23,070 (68%);

Oboaho 2,942(86%); Keta 147,618(64%); Kedzi-Havedzi 2,099(73%); Akatsi 4,1638

(78%) and Monome 3,321(69%) (GSS, 2012). Besides these water sources, these communities depended on sachet water. Water from these sources are used for different purposes including domestic chores, livestock watering and drinking (GSS, 2012).

Residents of these communities are from multi-cultural ethnic groups comprising Ewes,

Moshi, Guan, Akuapem, Ga-Dangme and Akans, with the first and the last constituting the dominant ethnic groups in the communities selected from the Volta and the Eastern

Regions respectively (GSS, 2012). Christianity is the dominant religion in all the eight study communities and is followed by Islamic and Traditional Religions in that order

(GSS, 2012). The populations of these communities ranged from three thousands to five thousand people giving them the rural and urban characteristics (GSS, 2012). For example, the population of Kedzi-Havedzi community is 2,099 comprising 938 male and 1,161 female (GSS, 2012).

The major economic activities of the respective study communities included the following:

Kofisah and Akuffokrom (crop farming & quarrying); Begoro and Oboaho (crop farming and livestock rearing) Keta and Kedzi-Havedzi (fishing, and livestock farming); Akatsi

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and Monome (crop farming, gari’ processing, and charcoal production). of these communities included farming and petty trading. All the eight study schools have female

SHEP Coordinators who are responsible for ensuring proper sanitation in the schools.

3.3 Study Design The study was school-based cross-sectional survey which sought to investigate the behavioural and cultural factors influencing open defaecation behaviours among pupils in the first cycle schools in Eastern and Volta Regions of Ghana. The study used both qualitative and quantitative research techniques. The qualitative phase followed the quantitative phase to further explain the results obtained during the quantitative stage

(Creswell, 2015; Klassen et.al., 2012). The study was conducted in five distinct stages. In stage one, formal permission was sought from the Districts and Municipal Education

Offices to undertake the study in the schools under their jurisdictions.

In stage two a reconnaissance visits was made to the selected communities to observe the sanitation situations in the communities and also to map out the study schools that formed the data collection points. During the visit, informal discussions of the objectives of the study with the stakeholders (school authorities, Education Directors, Traditional

Authorities), were held.

In stage three, the selection of study participants (pupils) and discussion with them the objectives of the study and the need to participate in the study were held. This was followed by stage four which involved the administration of the research instruments—structured questionnaire, FGD, in-depth interview and checklist observation of the school toilets. In

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stage five, a policy framework documents on provision of toilet facilities in the first cycle schools were thoroughly reviewed.

3.4 Study Participants, Sample Size and Sampling Methods Four hundred (400) pupils aged between 9 and 18 years formed the study participants.

These participants were selected from eight public first cycle schools in two districts and two municipalities of the Eastern and Volta Regions of Ghana using simple randomization method. They were in classes four (4), five (5), and six (6) and Junior High School (JHS) forms one (1), two (2) & three (3). Pupils in lower primary classes one (1), two (2), & three (3) were excluded from the study because of their inability to articulate their thoughts during the FGDs and also understand the items on the questionnaire guide. The sample size for the quantitative survey was determined using the statistical formula stated below.

(Cochran, 1977).

n = Z2 PQ d2 Where, n = required sample size

Z = Reliability coefficient for 95% confidence level usually set at 1.96.

P = proportion of the population having the desired characteristics.

As a rule of thumb, 50% was used because there was no reasonable estimate of pupils who defaecate in the open in literature reviewed.

Q = 1—p d = the degree of accuracy desired set at 0.05 probability level. p = 50%; q = 0.5; d = 0.05;

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n = [1.962 (0.5 x 0.5/0.05 x 0.05] = 384

Therefore the sample size for the study was 384. This, however, was adjusted for a non- response rate of 4% thus increasing the sample size to 400 pupils. Fifty percent (50%) of the participants were female pupils, and 50% were male pupils. This representation was chosen to help give good comparative analysis of open defaecation behaviours of the two sex groups.

The study participants for both quantitative and qualitative studies were selected using simple randomization method. The participants for the qualitative study were selected out of the those who reported to have engaged in at least one episode of open defaecation seven days prior to questionnaire administration time. In addition to the 400 pupils who formed the sample population, 45 school authorities (teachers and head teachers) comprising both female and male from the eight study schools were recruited using simple randomized sampling technique. Also, four District and Municipal Education Directors were purposively recruited to be part of the study. These two categories of respondents

(school authorities and Education Directors) were included in the study to provide information that were used to validate data collected from the sample population (pupils).

The District and Municipal Education Directors were selected using purposive sampling technique. This technique was used because they occupied positions that qualified them to provide relevant information on school sanitation system in the schools under their jurisdictions.

Global positioning system (GPS) was used to locate the geographic coordinates of all the selected schools, communities and households. The unit of data collection and analyses

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was the schools. Each pupil who participated in the study was given five exercise books, pens and 2 note 3 books at the end of the field work.

3.5 Research Instruments The research instruments used to gather data for this study were structured questionnaire, focus group discussions, in-depth interview, checklist observation and policy documents review.

3.5.1 Questionnaires

Two sets of structured questionnaire were constructed. The first set of questionnaire was for the study pupils. The items on the questionnaire were adapted from semantic scales developed by Ajzen and Fishbein, 1980; Ajzen, 1985, 1991; & Taylor & Todd, 1995). The questionnaire was in nine (9) parts. Part I was based on pupils’ demographics characteristics. Items on parts II—VIII reflected on pupils’ attitude, subjective norm,

Perceived Behavioural Control (PBC). The questionnaire for pupils is presented in appendix 1.

The first set of questionnaire was used to gather data from pupils on both behavioural and cultural factors influencing them to engage in open defaecation practices. The second set of questionnaire was designed for the school authorities and was in two (2) parts. Part I requested for demographics details of respondents. Part II was based on conditions of the school toilets. The items on this questionnaire guide were adapted from GSS, 2012 population and housing census survey instruments. The questionnaire for school authorities is presented in appendix 2. This second set of questionnaire was used to collect

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information from both pupils and teachers on their awareness, knowledge and perception of open defaecation practices and conditions of their school toilet facilities.

According to Ameworwor (1995) using questionnaire to gather relevant information allows many respondents to be reached within a short period of time. Employing questionnaire to collect data for this explorative study is therefore more appropriate because it is both cost-effective and time saving. In sum, the objective herein was to explore the behavioural and cultural factors influencing open defaecation practices among first cycle school pupils aged between nine and eighteen years.

3.5.2 Focus Group Discussions (FGDs)

The focus group discussion was used to elicit information on pupils’ behavioural variables including attitude, subjective norm, perceived behavioural control and open defaecation behaviour intention. The FGD guide was organized in four (3) parts. Items on parts I—III were used to collect data on pupils’ open defaecation behaviours. Data on conditions of the school toilets and their usage were also gathered using items on part III of the FGD guide. All the items on the FGD guide were developed through extensive literature review, responses from questionnaire guide for pupils and behavioural and cultural experts’ consultations. The items were simplified and sorted into main topics and follow-up items.

The follow-up items were designed to help seek further explanations and clarification of responses from study participants. Focus group discussion guide is presented in appendix

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3.5.3 Structured In-depth Interview

The in-depth interview was used to gather data from District and Municipal Education

Directors on school sanitation and open defaecation behaviours in schools within their

Districts and Municipalities. Also, a cross-section of the pupils who reported practicing open defaecation and those who did not engaged in open defaecation behaviours in the selected schools were also interviewed on factors influencing their behaviours. The interview protocol was organized in two parts. Part I covered demographic details of the respondents. Part II was developed based on responses of pupils during FGDs, teachers responses to the questionnaire items and researcher’s field observations. In all, there were eleven items on the interview guide. The in-depth interview guide is presented in appendix

4).

3.5.4 Checklist Observation Guide

A self-developed checklist observation guide was used to assess the conditions of toilet facilities used in the first cycle schools. There were ten themes designated as A, B, C, and

D, E, F, G, H, I and J on the checklist guide. Part A was used to collect data on school toilet location and accessibility. Parts B, C and D were respectively used to elicit data from pupils on toilet apartments, toilet hygiene, and toilet maintenance. Parts E, F, G and H were also used to collect data on school toilet adequacy, pupil-toilet ratio (toilet adequacy), ventilation in the school toilets, and privacy and safety statuses of the school toilets, respectively. The items on the last two parts (I & J), of the checklist observation guide were used to gather data on presence of rodents in the toilet premises and community encroachment on the school toilets, and toilet suitability drives, respectively. The checklist observation guide is presented in appendix 5.

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3.5.5 Desk Review of Policy Documents on School Toilet Provision

Policy documents containing guidelines for provision and construction of toilet facilities and faecal matter management practices in first cycle schools in Ghana were also reviewed extensively. The objective of the review was to compare the policy provisions in the framework with the physical structure of the school toilets and assess the disparity in terms of toilet type, toilet location, number and sizes of toilet squat holes and vent pipes, (if any).

The appropriateness of these features was also determined from the views and opinions of toilet users (pupils) gathered from the FGDs sessions. In all, the study was designed to capture the open defaecation beliefs and behaviours of pupils in the eight studied schools.

Special efforts were made to minimize social desirability bias, and other forms of bias in the responses.

3.6 Training of Research Assistants Two environmental health and sanitation workers were recruited and trained as research assistants. The training of these research assistants was aimed at making them understand the purpose of the study, research processes, school and community entry procedures, questionnaire administration procedures and proper data management. They also participated in pre-testing the questionnaire to be used during the study. Administration procedures that were covered in the training programmes included the importance of not influencing the pupils to give certain responses, providing a relaxed atmosphere for the pupils to complete the items on the instruments, and emphasizing to the pupils that there is no right or wrong answers.

Another area covered during the training was reading of items on the instruments aloud to the sample pupils, at the same time. Allowing adequate time for respondents to answer

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items on the instruments was also discussed extensively during the training sessions. The need to provide adequate time for participants to provide adequate responses to each item was also featured in the training program.

Finally, checking every item on the instrument to ensure that they were fully responded to by the participants were also discussed extensively during the training section. All these were done to ensure quality and validity assurance of study’s data and final results.

3.7 Ethical Requirement A central feature of research is to make results and findings public, to provide descriptions and explanations that are publicly available. However, the consent to participate in focus group, and in-depth interview was sought from respondents prior to the administration of the research instruments. A verbal assent was obtained from parents or appropriate guardians of eligible sampled pupils before they were used in the study. The parents of recruited pupils were reached through the teachers via the district and municipal education directors. Verbal Assent and consent for photographing, audio and/or video recording of pupils’ voices were also sought from both parents and the sampled pupils respectively.

Permissions to undertake the study in the selected schools was also sought from GES districts and municipal education directors in charge of the schools. Verbal consent was also sought from community leaders including chiefs, assembly men and women and other key opinion leaders to conduct the study in the schools within the communities. Ethical

Clarence Certificate No. ECBAS 035/15-16 to undertake the study was given by Ethical

Committee for Basic and Applied Sciences (CBAS), University of Ghana. (Appendix 7).

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3.8 Pre-testing of Research Instruments

Each of the data collection instruments was pre-tested with 20 pupils in non-selected first cycle schools but with comparable demographic and educational characteristics and who were then excluded from the main study before using them in the main phase of the study.

The rationale behind this was to identify any potential sources of uncertainty such as their face values, wording, and grammatical errors, cultural and behavioural measuring competency of the items on the questionnaire and correct them (if any) before using them in the fields with the target population. Based on their comments, the questionnaire was modified and carried out the second pilot test to ensure that the questionnaire can satisfy its intended purpose. The pre-testing provided prior knowledge of the problems encountered during the conduct of the main study. Internal consistency of the instrument was tested using Cronbach’s Alpha reliability test (Cronbach, 1951). The Cronbach Alpha for items reliability of all the individual construct are presented together with the bivariate test results (page 139).

3.9 Administration of Research Instruments

3.9.1 Questionnaire

The questionnaire was administered by the researcher supported by two trained research assistants recruited from Nsawam-Adoagyiri Environmental Health Department. Study participants were asked to sit in a classroom purposely prepared for the exercise. The questionnaires were distributed to all randomized selected pupils and the procedures for completing each item on the questionnaire were explained to study participants (pupils).

Items on the questionnaire were then read to participants one by one. After reading each item, participants respond to them. Throughout the process, items that were unclear to pupils were explained to them before they responded to them. In all, data was gathered on

400 individual participants.

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Administration of the questionnaire to school authorities (headterchers, teachers and SHEP coordinators) was carried out during break periods by the researcher assisted by trained research assistants. The questionnaire was given to each respondents to complete. Prior to this activity, formal permission was sought from the heads of the schools through the

Municipal and District Directors of Education. The objectives of the study were also discussed with the teachers. The completed questionnaires were collected after they were fully completed by respondents. Quality control measures such as the need for independent completion of the questionnaires were followed.

In all, 400 pupils and 45 teachers responded to their respective questionnaires. The completed questionnaires were collected after cross-checking to ensure that every item on the questionnaire was appropriately completed by the respondents. This procedure was replicated throughout the administration of the questionnaires in all the eight studied schools.

3.9.2 Focus Group Discussion (FGDs)

Four (4) focus group discussion sessions (FGDs) comprising two for female pupils and two for male pupils were conducted in each of the eight studied schools. Each FGD consisted of 6 to 9 pupils. The FGD was conducted on class level basis (JHS & Primary levels). The reason was to create homogenous target populations (in terms of age and sex), to encourage the group to speak their opinions, share their beliefs, perceptions and views more freely about the subject (behavioural & cultural reasons for non-use of toilets) without fear or intimidation of being judged by others. Also, condusive and accepting environment was created for participants in order to put them at ease allowing them to

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thoughtfully discuss issues under consideration and in their own words and add meaning to their opinions.

Prior to this, the participants were informed about the objectives of the FGDs, confidentiality of information provided, how the findings would be used and shared with them. During each FGD session, the participants discussed the factors they perceived to be influencing them to engage in open defaecation behaviours. English language was the main language used during the FDGs. However, where participants deemed it more convenient to use the local dialect instead of the English, they were encouraged to do so.

Where local dialect was used, this was transcribed into the English language before using them in the data analysis. Each item on the FGD guide was read to participants and discussed extensively by the participants until a consensus is reached. The FGDs sections were audiotaped using digital audio-recorders.

During the data gathering process, qualitative field notes captured on daily basis on subtle events, conversations and interviews during group discussions were analyzed after the day’s work. The rationale is to keep track of important issues that cropped up in the days work and prepare adequately for the next day. It is also to look for consistencies and inconsistencies between knowledgeable informants and find out why focus group discussants agree or disagree on important issues. Ethical issues in relation to FGDs were strictly adhered to throughout the administration process.

In all, data on 192 participants open defaecation behaviours were gathered from the FGD sessions. The discussion was guided by FGDs protocol developed by the researcher. On average, each FGD session lasted between 45-60 minutes.

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3.9.3 In-depth Interview

The in-dept interview session was conducted on one-on-one basis and in the convenient locations decided on by each education director. The English language was used during each interview section. The interviewees were briefed about the objectives of the study.

The questions on the interview guide were asked and participants provided answers to them. In some cases, further probing questions were asked to elicit further explanations to responses provided by the interviewees. The interview sections were audiotaped using digital audio-recorders. Ethical issues such as consent for photographing, audio recording of participants’ voices were strictly adhered to throughout the interview process. In all, four (4) education directors and twenty-four (24) pupils (ie. 3 from each study school) took part in the interview. Each interview session lasted between 35-40 minutes for the directors and 15-20 minutes for the non-open defaecators.

3.9.4 Checklist Observation

The checklist was conducted to assess the conditions of toilet facilities available to pupils in the studied schools and to identify the barriers (situational factors) associated with the school toilets facilities which are influencing them to engage in open defaecation behaviours. The observations took place during all time spent in the schools during the data collection. During the observations notes were taken to better remember and organize the observations for better analysis, interpretation, discussions and conclusions.

Policy documents containing guidelines for provision and construction of toilet facilities and faecal matter management practices in first cycle schools in Ghana were collected from the municipal and district assemblies reviewed. The objective of the review was to compare the policy provisions in the framework with the physical structure of the school

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toilets and assess the disparity in terms of toilet type, toilet location, number and sizes of toilet squat holes and vent pipes, (if any). The appropriateness of these features was also determined from the views and opinions of toilet users (pupils) gathered from the FGDs sessions. In all, the study was especially designed to capture the open defaecation beliefs and behaviours of sample population in the eight schools included in the study. Special efforts were made to minimize social desirability bias, and other forms of bias in the responses.

3.9.5 Desk Review of Policy Documents on School Toilet Provision

The review process covered the design, construction and maintenance of the school toilets specified in the policy framework. Specifically, the following components of the toilets were reviewed thoroughly. Toilet type, toilet location, toilet capacity and sizes of toilet squat holes and vent pipes, (if any), maintenance schedules including periods of desludgement, cleaning, repairs and replacement of broken parts. These were compared with checklist observation results. Suitability of the toilets to age and sex were also determined.

3.10 Data Management and Analyses Methods The study applied structural equation models (SEM) path analysis, a probit model and analysis of variance to the sample of 400 completed questionnaires to estimate the effect sizes of pupils attitudes, subjective norms, perceived behavioural control, behavioural intention, and cultural factors on their open defaecation behaviours. Descriptive statistics was also used to estimate the effect size of situational drivers associated with school toilets on the pupils open defaecation behaviours.

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3.10.1 Quantitative Data Management and Statistical Analysis

The researcher reviewed all the forms completed each day, checked for completion, and other errors. SPSS version 20 (IBM) software (SPSS Inc. Chicago, IIIinois, USA) was used to analyze the data. The data collected on each variable in the model using the questionnaires were then coded and entered into the SPSS software version 20 (IBM) after they have been cleaned and checked for completeness and consistencies against the items on the questionnaire guide.

A series of hierarchical statistical tests including descriptive statistics, bivariate, multivariate, Cronbach Alpha and SEM path analyses were conducted. The descriptive analysis was conducted to determine the frequency and percentage distributions of the independent variables (behavioural and cultural variables) in the sample in order to establish the occurrence and prevalence levels of open defaecation behaviour among the pupils in first cycle schools. Again, the pupils’ level of awareness and perception of open defaecation behaviour and its environmental and health risks were determined using descriptive statistics. Pupils’ open defaecation behaviour across urban and rural localities, the two sex groups, and the study schools were also determined using the same descriptive statistics (frequencies and percentages).

To establish whether any correlation or association existed between independent and dependent variables on the conceptual framework and on which data was gathered,

2 bivariate tests (Pearson correlation (r) and Chi-square (ᵡ ) tests) were conducted. Also, to estimate the interaction effects of independent variables on the dependent variables in order to provide empirical bases on which to make assumptions on the data, a multivariate test was conducted. The reasons given by those who did not engage in open defaecation to

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support their behaviours were also compared across the sex groups, localities and the study schools using a one way ANOVA. The objective was to find out if any spatial disparities existed in the reasons (factors) cited. The intent of these comparisons is to use the results to inform policy recommendations and intervention programs.

The Cronbach’s alpha statistics was conducted to determine whether the measuring scales used were internally consistent and provide a good empirical basis (goodness of fit of each model) for analyzing the data from the questionnaire within the analytical process postulated by the study’s conceptual framework. Test items reliability and internal consistency were determined using Cronbach’s alpha statistics. The Cronbach’s alpha coefficient values for all the pooled sub-scales items were reported alongside the bivariate and multivariate analyses results.

All quantitative analyses were carried out at 5% level of precision (95% confident interval) with p-values reported in both one and two tailed significant levels. Relevant statistical tables were generated using Microsoft Excel Software version 10. The results of bivariate tests provided significant bases for conducting further robust statistical tests to estimate the moderating effect size of each set of pooled independent variable on the two dependent variables. Primarily, independent variables included on attitudes, subjective norm, PBC, and cultural measuring scales that have p-value <0.05 or 0.01 at bivariate and multivariate analysis levels were used to develop structural equation modeling (SEM) path hypothesized descriptive models (Fig.3.3—3.10).

Fourteen SEM path models designated as M1,—M14 and one descriptive statistics model

(M13) were developed based on independent and dependent variables (satisfied open defaecation intention and actual open defaecation behaviour) included in the study’s 84

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conceptual framework and strictly guided by the TPB model (Azjen, 2005). The models established significant positive correlation between open defaecation intention and actual open defaecation behaviour and all three antecedents’ psychological variables (attitudes, subjective norm, PBC) and culture variables. The data were then represented on SEM path diagrams using the same construction as the conceptual framework of this study. These structural equation path modeling were applied because they enable the evaluation of multivariate path models, allowing the simultaneous evaluation of the direct, indirect, and aggregate or total effects of a set of predictor variables on multiple mediators and multiple outcome variables. The analysis, which involved estimation of relative mean moderating effect sizes of independent variables which were found to have significant correlation or association with pupils’ satisfied open defaecation intention and actual open defaecation behaviour at bivariate analyses stages, was conducted according to the 14 SEM path hypothesized models developed based on the dependent and independent variables included on the study’s conceptual framework (Figure 3.3—3.10).

Figure 3.3: SEM Path Diagrams for Estimating Effect Size of Attitude, Subjective norm, Perceived Behavioural Control (PBC) on Open Defaecation Intention; Direct Effect of PBC on Open Defaecation. 85

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Figure 3.4: SEM Path Diagrams for Estimating Effect Size of Cultural Factors and Satistified Open Defaecation Intention on Open Defaecation.

Figure 3. 5: SEM Path Diagrams for Estimating Interaction Effect Size of Psychological and Cultural Variables on satisfied Open Defaecation behaviour.

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Figure 3. 6: SEM Path Diagrams for Estimating Effect Size of Cultural Variables on Open Defaecation Intention and Open Defaecation.

Figure 3. 7: SEM Path Diagrams for Estimating Effect Size of Attitudinal Variables on Open Defaecation Intention and Open Defaecation Behaviours.

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Figure 3.8 SEM Path Diagrams for Estimating Effect Size of Variables on PBC on Intention and Open Defaecation Behaviours.

Figure 3.9: SEM Path Diagrams for Estimating the Interaction Effect Size of Psycological Variables on Open Defaecation Behaviour.

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Figure 3.10: SEM Path Diagrams for Estimating Effect Size of Demographic Variables on Open Defaecation Intention and Open Defaecation Behaviour.

In M1 and M2 independent variables (attitudes, subjective norm, PBC) which were found to have significance association with pupils satisfied open defaecation intention and open defaecation behaviour at bivariate analysis stage were subjected to SEM path analysis to estimate their relative direct moderating effect sizes on pupils open defaecation intention.

In the same M1 and M2, I also predicted the direct effect size of pupils’ PBC on their open defaecation behaviour in addition to its indirect effects.

In M3, pooled cultural factors and satisfied open defaecation intention were subjected to

SEM path analysis to estimate their direct relative effect sizes on pupils open defaecation behaviour. In M4, the aggregate effect size of interaction of pupils’ self-reported attitudes, subjective norm, PBC variables on their open defaecation behaviours was estimated using

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the SEM path analysis. In M5, the direct moderating effect size of psychological variables interacting with cultural variables on pupils satisfied open defaecation behaviour were determined using SEM path analysis. Also in M5, the effect size of pooled cultural variables on pupils open defaecation intention was estimated.

In M6, and M7, the effect sizes of individual’s cultural variables included on cultural measurement scales on open defaecation intentions and actual open defaecation behaviour were estimated respectively. The individual effect size of variables on attitude measuring scales on open defaecation intention and open defaecation behaviours were also estimated in M8 and M9 respectively. In M10 and M11, the effect sizes of each variable on PBC measurement scale on satisfied open defaecation intention and actual open defaecation behaviour were determined. In M1—M14, the statistical test used was SEM path analysis in AMOS Software version 20 (Arbucle (1997).

The interaction effect size of behavioural attitude and subjective norm variables on pupils open defaecation behaviour were determined using the SEM path analysis in M12. In the same M12, the interaction effect size of behavioural attitude and PBC variables on pupils open defaecation behaviour were determined using the SEM path analysis. In M13 and M14, the moderating effect size of demographic variables on pupils’ open defaecation intention and actual open defaecation behaviours were determined. Finally, the moderating effect size of situational variables related to perceived conditions of school toilets on pupils open defaecation behaviours was estimated using descriptive statistics. The direct, indirect and aggregate (total) moderating effect sizes obtained in path models M1—M14 that remained statistically significant were reported together with non-significant effect sizes.

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Also, the percentage moderating effect size of situational variables (related to perceived conditions of school toilet) on pupils open defaecation behaviour were reported. All quantitative analyses were carried out at 5% level of precision (95% confident interval) with p-values reported in either one or two tailed significant levels. Significant effect sizes reported in M1—M14 included path coefficient of determination (r); standard errors (SE); t—statistics (critical ratio); and their corresponding probability values (p-values). In M13, only the frequencies and percentage weights were reported. In all the SEM path analyses

(M1—M14) Analysis of moment structures (AMOS) software version 20 was employed.

This SEM path model does not rule out the influence and operation of other exogenous and endogenous variables (labeled as “errors” in the SEM path diagrams) but posit psychological variables (which are central antecedents of behavioural intention) as one of the driving forces of environmental behaviour.

3.10.2 Qualitative Data Management and Analysis Methods

The data collected using the focus group discussions (FGDs), and the in—depth interview

(IDI) were first transcribed into Microsoft Word for Windows and then analyzed using thematic analytical procedures outlined in Krippendorf (2004); Miles et al., (1994) and described in detailed. The qualitative data analysis was done in five distinct stages. The features and uses of these methods are explained below.

In stage one, data collected using the FGDs and in-depth interview (IDI) were first transcribed verbatim to identify the core categories that emerge from the data. After familiarization with transcripts through extensive reading and discussions with colleagues, a thematic framework was developed with themes (drives) organized into three broad areas. These was then summarized and categorized into themes relevant to research objectives and conceptual framework. In stage two, the data was examined with respect to

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each theme and then by using key findings from the study, all categorizations were

constructed under each drive. The three categories were selected and named from the

analysis. They included psychological drive, cultural drive and situational drive. The three

broad drives and the themes under each are presented below.

1. Psychological Drive

Major themes under this drive comprised perceived influence of: (i) attitude towards open

defaecation, (ii) subjective norms towards open defaecation, (iii) perceived behavioural

control (PBC) towards open defaecation and (iv) intention towards open defaecation.

2. Cultural Drive

Major themes under this drive included perceived influence of: (i) taboos, (ii) superstitions,

(iii) traditional values, and (iv) traditional norms.

3. Situational Drive (Conditions of School Toilets)

Major themes under the situational drive comprised perceived influence of: (i) hygiene in

the school toilets, (ii) privacy and safety in the toilets, (iii) scent and ventilation in the

school toilets (iv) infection status of the school toilets, (v) rodents encroachment on the

school toilets, (vi) community encroachment on the school toilets, (vii) flies in the school

toilets and (viii) toilets suitability with reference to sex, age, squat hole size, and feet rest

sizes (ix) maggots in the school toilets

These categories served as the basis for further analysis. These further analyses involved

two basic levels including manifest and latent descriptive analyses. During the manifest

analysis, descriptive account of the data (what study participants said) was carried out

dwelling most on what was actually said, documented or observed with nothing read into

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it and nothing assumed about it. Also, during the interpretive stage, descriptive analysis was carried out extensively dwelling on what were meant by the responses, what was inferred or implied. In stage three, the data was put together in new ways and this was achieved by identifying causal relationships between core categories and sub-categories.

The objective of this was to make explicit connections between categories and sub- categories. Relationships between categories were then identified and this helped understand the phenomenon to which they relate. In stage four, relationships between core categories were selected and related to each other through validation of relationships, filling in, and refining and developing those categories. Relevant illustrative quotes that reflected group opinions were identified. In stage 5, detailed descriptive analyses of the final categories were carried out to compare the opinions of participants (pupils) from the sampling schools on the bases of sex, locality and schools using the quotes to support them.

3.10.3 Analyses of Policy Documents Reviewed

The policy document review process compared the technical requirements of the school toilet facility outlined in the policy framework with what was observed from the fields using the checklist. The data collected with the checklist were described using descriptive statistics. The results of the checklist observation, in-depth interview (IDI), and teachers questionnaires, and policy document review were used to validate the findings from pupils’ self-reported data collected using the focus group discussions (FGDs) and questionnaire. The objective of triangulating the findings from these robust methods was to ensure thrust and validity of the study’s final conclusions. The quantitative and qualitative analyses results were presented in the following sections and triangulated.

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CHAPTER FOUR

RESULTS

4.1 Conditions and Usage of School Toilets The situational assessment of conditions of school toilets was conducted using observation

checklist. The assessment result is presented in Table 4.1.

Table 4.1: Assessment Results of Conditions of Toilets used in the First Cycle Schools

Frequency/Percentage Distribution of Drives in the Sample [N=Number of School =8] Organizing Drives Describing Condition Of School Toilets Yes(%) No (%) Themes (A) Toilet is accessible to all pupils 4 (50) 4(50.0) Toilet Toilet is accessible to physically challenged pupils* 1(12.5) 7(87.5) Accessibility Pupils use the toilet at specific school hours 0(0.00) 8(100) Toilet for both sexes are in same block 8(100) 0(0.00) Toilet key is placed at accessible point for all pupils* 0(0.00) 8(100)

Toilet for the girls has changing room attached to it* 1(12.5) 7(87.5) (B) Toilet has washroom attached to it* 2(25.0) 6(75.0) The school has separate toilet for Pre-school pupils* 0(0.00) 8(100) Toilet Apartments The school has separate toilet for Primary pupils. 2(25.0) 6(75.0) The school has separate toilet for JHS pupils 2(25.0) 6(75.0) The school has separate toilet for Teachers* 0(0.00) 8(00.0) The pre-school, primary & JHS use the same toilet 1(12.5) 7(87.5)

Faeces present on toilet floor* 8(100) 0(0.00) (C) Faeces present on toilet squat holes.* 8(100) 0(0.00)

Hygiene Status Faeces present on toilet feet rest* 8(100) 0(0.00) of Toilet Faeces around toilet premises 5(62.5) 3(37.5) Urine present on toilet floor/squat holes/foot rests* 7(87.5) 1(12.5) Teachers supervise the cleaning of the toilet 8(100) 0(0.00) (D) Toilet Pupils provide their own cleaning materials* 8(100) 0(0.00) Maintenance Pupils protect themselves from infections during toilets And Cleaning cleaning (e.g. wear nose masks, hand gloves)* 0(0.00) 8(100)

School has waste disposal bins in the toilet* 0(0.00) 8(100) Anal cleaning materials packed in safe container(s) 1(12.5) 7(87.5)

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Table 4.1 (Cont’d)

(E) Based on pupils enrolment, the number of toilet cubicles 0(0.00) 8(100) Pupils-Toilet for pupils is adequate* Ratio & Pressure Pupils queue to use the toilet* 7(87.5) 1(12.5) on use of School Toilet

Toilet has functional vent pipes 7(87.5) 1(12.5) (F) Toilet produces heat through the squat holes* 8(100) 0(0.00) Scent and Scent from the toilet gets to the classrooms* 7(87.5) 1(12.5) Ventilation in School Toilets Toilet entrance is positioned away from the school 5(37.5) 3(62.5) (G) compound. Toilet is locked during classes hours 1(12.5) 7(87.5) Privacy and Safety Toilet doors is locked during off—school hours 8(100) 0(0.00) Status in the School Toilet Toilet has door (s) to every cubicle* 1(12.5) 7(87.5) Toilet provides adequate privacy to pupils/users 2(12.5) 6(75.0) Toilet cubicle doors are in good shape 5(62.5) 3(37.5) Toilet cubicle doors have inner locks 3(37.5) 5(62.5) (H) Rodents in toilet premises* 8(100) 0(0.00) Presence of Toilet premises is weedy 6(75.0) 2(25.0) Rodents in Toilet Toilet is safe for all users irrespective of age and sex* 0(0.00) 8(100) Premises

(I) Community Community also uses the school toilet* 4(50.0) 4(50.0) Encroachment on School Toilets Toilet squat holes are appropriate for pupils age and sex 3(37.5) 5(62.5)

Toilet feet rests are appropriate for pupils’ age. 3(37.5) 5(62.5)

Toilet location is psychologically appropriate for pupils 2(25.0) 6(75.0) (J) Toilets have recommended number of vent pipes 6(75.0) 2(25.0)

Technology Toilets vent pipes have appropriate dimensions 8(100) 0(0.00) Drive

Toilets have appropriate height of vent pipes 8(100) 0(0.00) Note: ‘Yes’= means drive is present with the school toilet. ‘No’= means drive is absent with the toilet. Numbers outside parenthesis in the ‘Yes’ column refers to number of schools in which drive is present. That of ‘No’ column refers to number of schools drive is absent. Numbers within parenthesis are percentage values for drives. *= major drives associated with the school toilets.

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4.2 Knowledge and Perception of Teachers on Conditions of School Toilets

The knowledge and perception of teachers on conditions of school toilets is presented in Table 4.2

Table 4. 1: Knowledge and Perception of Teachers on Conditions of School Toilets

Descriptive Statistics N=45 Responses Response Percentage Categories of Characteristics Category Frequency (%)

Toilet squat holes are appropriate for all users Yes 35 77.8

No 10 22.2

School toilet hygiene status (cleanliness) Always clean 22 48.9 Always filthy 4 8.9 Sometimes clean 14 31.1 Sometimes filthy 3 6.7 Others 2 4.4

School toilet maintenance schedule is Daily 13 30.2 Weekly 15 34.9 Monthly 2 4.7 Yearly 9 20.9 Others 4 9.3

Who provides funds for toilet The school 29 80.6 maintenance/cleaning Municipal 2 5.6 PTA 4 11.1 Others 1 2.8

Frequency of provision of maintenance fund Daily 2 6.2 Weekly 7 21.9 Monthly 12 37.5 Yearly 11 34.4 Community influence—community using the Yes 26 57.8 school toilet. No 19 42.2 Effects of community influence on school toilet Makes toilet 1 5.0 cleaning difficult Does not affect 2 10.0 school sanitation Makes toilet dirty 16 80.0 Others 1 5.0

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Table 4.2 (Cont’d)

Descriptive Statistics N=45 Categories of Characteristics (Items) Category Response Percentag Response Frequency e (%) Pupils less than 5 years also use same toilet. Yes 29 65.9 No 15 34.1 Pupils queue to use the toilets Yes 6 13.3 No 25 55.6 Neutral 14 31.1 n=42* In your view, what is the pupils’ Provide 8 19.0 responsibility regarding toilet cleaning? logistics/cleaning materials Only scrub the toilet 31 73.8 They have no 1 2.4 responsibility Others 2 4.8 n=39* What challenge does the school face in No challenge 3 7.5 ensuring proper use of the school toilet? Funds for securing 15 40.0 logistics Community 10 25.0 encroachment Misuse of toilet by 5 12.5 pupils Pupils reluctant to clean 2 5.0 the toilet Others 4 10.0

The results of the situational assessment of conditions of the school toilets revealed that all the eight studied schools had KVIP toilet located within the school compound and all the toilets were visible from the classrooms. Each toilet had at least two, three, four or five or six squat holes serving between 200 and 544 pupils. Out of the eight school toilets assessed, only one had facility purposely designed for physically challenged pupils.

Across all the eight studied schools, pupils use the toilets at any time they are needed as evident in the assessment results. Toilet for both sexes are in the same block in all the eight schools and keys to the toilets were placed in places where individual pupil has to request for before accessing the facility. Toilets for female pupils have no changing and wash

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rooms’ components. There are no separate toilets for preschool pupils. They all used the same toilets irrespective of age, squat hole and feet rest sizes. Indeed, the assessment results reveal that some of the school toilet facilities have squat holes either smaller or larger than MLGRD Act 462 of revised 2010 policy recommendations. All the school toilets observed had patches of faecal matter and urine present on their floors, edges of squat holes, and the feet rests making the toilets unhygienic. Plates A, B & C.

Plate A: Filthy School Toilet (Faecal matter scattered all over the toilet floor)

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Plate B: Filthy School Toilet (Leaves used as anal cleaning materials).

Plate C: Filthy School Toilet (Papers used as anal cleaning materials scattered on toilet floor)

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Most of the toilets lacked adequate privacy and ventilation, with the later condition causing unpleasant odour in the toilet premises and its environs. Privacy in school toilets was seriously identified by assessment results as a key issue in sustainable toilet use by pupils in the study schools. The assessment results also reveal that toilet facilities were inadequate looking at the pupils’ enrolments in schools. This was evident throughout the one week period of assessment of sanitation in each school where pupils queued to use the toilets, particularly during break periods. The assessment results again reveal that the community residents also used the school toilets as place of convenience. This community encroachment on the school toilets makes daily cleaning and maintenace of the toilets very challenging.

On the issues of school toilet maintenance and sanitary conditions, the assessment results revealed that the toilets facilities in all the studied schools were left unmaintained and as a result appeared very filthy and in unhygienic state. These conditions of the toilets attract rodents of various types (rats, mice, gerbils, squirrels) into the toilets premises.

Anal cleaning materials are either dropped into the toilet pits or left on the toilet floors with the former condition contributing to early filling of the toilets pits and the later situation making the toilet premises unhygienic and disease-prone environment. These assessment results suggest that the filthy and odorous conditions of the school toilets are adequate enough to serve as strong barriers to sustainable toilet use by pupils and can invoke open defaecation behaviours among the pupils.

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4.3 Pupils and Teachers Perception of Conditions of School Toilets In the section 4.3, the conditions of toilet facilities used in the study schools was reported.

Described in this section is pupils and teachers perception of the conditions of the school toilets. The teachers views on condition of the school toilets are presented in Table 4.2 above and described together with pupils views below.

4.3.1 Hygiene and Access in School Toilet

The issue of cleanliness in relation to the school toilets was a serious concern to most of the pupils and teachers. These concern was raised by discussants throughout the FGDs held in all the eight study schools. Pupils described the hygiene status of the school toilets as very bad. These concerns were supported by two justifications.

“…The toilet is not clean and when you go there, you will see faeces and anal cleansing materials scattered on toilet floor”—(Female pupil, FGDs, Begoro Presby Basic School).

“…It is not neat because people from the town smoke there and also ease on the squat holes and footrests”—(Female pupil, FGDs, Begoro Presby Basic School).

“Sometimes, they urinate on the toilet floor and defaecate around it making it dirty”—

(Male pupil, FGD, Kofisah M.A. Basic School).

Teachers’ perception of the hygiene status of the school toilets, however, suggest that the school toilets are always clean (hygienic) and over 36 (80%) expressed this view. The assessment results of the observation checklists of conditions of the school toilets (Table

4.3), however, strongly confirmed the pupils’ views on existing conditions of the school toilets.

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Closely linked to the poor hygiene status of the school toilet was the access and adequacy of the school toilets. Pupils views on this issue are expressed in the following quotes:

“…..it is small because I don’t finish easing myself and another person comes to knock”—

(A boy, FGD, Monome D.A. Basic School).

“…Sometimes you get pressed with the faeces but getting there all cubicles are occupied.”— (A girl, FGD, Keta A.M.E Basic School).

“If you go there and the toilet is full you have to wait; if you can’t wait, you have to be shouting “I want to defaecate”—(Male pupil, FGD, in Kofisah M.A. Basic School).

“We queue to use toilet.”—(Female pupil, FGD, Akuffokrom M.A. Basic School).

Perception of over 55% of teachers, however, were incongruent to the pupils’ views on inadequacy of the school toilets (Table 4.3). When demanded explanation to this issue of toilet inadequacy, this was what the District Education Director had to say:

“…when toilet facilities are being put up in the schools they consider the school enrolments; however, no complaint regarding pupils queuing to access the toilet facility or engaging in open defaecation toilets has ever reached my outfit for redress”(District Education Director, IDI, Fanteakwa Education Office).

4.3.2 Privacy and Safety in the School Toilets

Privacy and safety in school toilets was seriously identified by pupils as a key issue influencing their toilet use. Pupils concern and dissatisfaction with the privacy and safety status of the school toilet that supported this views were expressed in the following quotes:

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“I don’t feel like defaecating again when they come and knock the door”—(Male pupil,

FGD, Akuffokrom M.A. Basic School).

“The inner lockers are spoilt as such someone can open the door and see your private parts.”— (Female pupil, FGD, Kofisah M.A. Basic School).

“The doors are not good, so I don’t have enough privacy in the toilet; you can be seen by anyone who comes there.” — (Female pupil, FGD, Kofisah M.A. Basic School).

4.3.3 Smells and Ventilation in School Toilets

Pupils perceived the level of ventilation in the school toilets as very poor. The serverity of poor ventilation in the school toilets are expressed in the following quotes by pupils during the FGDs:

“…The toilet smells and you have to remove your uniforms before defaecating in the toilets—(Male pupil, FGD, Begoro Presby Basic School).

“…When we are asked to go and clean the toilets, we can’t go there because the toilet smells”—(Male pupil, FGD, in Kofisah M.A. Basic School).

“I don’t go there because the scent of the faeces stays in my dress”—(A female pupil,

FGD, Monome Basic School).

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The issue of pupils under five years also using the school toilets was also highlighted extensively throughout the FGDs held with the pupils in all the schools. A key justification raised by discussants in support of this thinking was:

“Pupils under five years using same squat holes as adults; they can fall into the pit”—

(Male pupil, FGD, Kofisah).

“The preschool children also used our toilets and defaecate on the squat holes and make the place dirty”—(Male pupil, FGD, Akatsi Demons 2 Basic School).

This was confirmed by Deputy Municipal Education Director during the in-depth interview with him. He said:

“…Oh, definitely, the preschool children also use the same toilets facilities as the

Primary and the JHS pupils. However, they are supported by Kindergarten attendants; in schools where there are no attendants, the preschool pupils are supported by the teachers to use the toilet facilities”—(Deputy Municipal Education

Director, IDI, Keta Municipal Education Office).

The in-depth interview with the Akatsi South District Education Deputy Director has different view with reference to the issue of preschool children using the school toilets designed for primary and JHS. He said:

“.. the preschool children do not use the same toilet designed for the primary and the JHS. They have their own toilets provided by USAID. In the old schools, however, they were coerced to use same facility with the older pupils.—(District

Education Deputy Director, In-depth interview, Akatsi South District).

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4.3.4 Toilet Maintenance and Provision of Cleaning Logistics

Closely linked to the poor hygiene status of the school toilet was the maintenance of the school toilets. This was another grave concern to discussants during the FGDs. The grave manner in which pupils described their experiences in providing the toilet cleaning logistics are evident in the following narratives:

“…we need nose masks and gloves so we can clean the toilet”—(Female pupil, FGD,

Akuffokrom M.A. Basic School).

“..We need chamber pot for the preschool children, so they don’t make the toilet dirty by defaecating on the floor.”— (Female pupil, FGD Akuffokrom M.A. Basic School).

“We need detergents to clean the toilet”—(Female pupil, FGD Akuffokrom M.A. Basic

School).

“…all we want is that the community should be told not to defaecate on the floor”—

(Female pupil, FGD, Akuffokrom M.A. Basic School).

The perception of teachers on this issues strongly affirmed views expressed by pupils.

When asked about the source(s) of funds for school sanitation and toilets maintenance, this was what the District Deputy Director of Education had to say:

“…funds for toilet maintenance come from the Government of Ghana (GOG) through the

District Assemblies and the GES; this is in the form of capitation grants; but this is irregular. The school heads, through their own initiatives, are also expected to generate funds for ensuring proper cleaning of the toilets in their schools”—(Deputy Education

Director, in-depth interview, Akatsi South District Education Office).

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4.3.5 Community and Rodents Encroachment on School Toilets

The community encroachment into the school toilet system was another serious issues raised by pupils during the FGDs. Their dissatisfaction with the impacts of the community using the school toilet is reflected in the following statements:

“..They make the toilet filthy and full quickly; they also soiled squat holes together with the feet rests; others leave their sanitary pads in the toilet”—(Male pupil, FGD in the

Akuffokrom M.A. Basic School).

“... the ladies threw their wards diapers into the toilet causing the toilet smells badly”—

(Female pupil, FGD in Akuffokrom M.A. Basic School).

“When school closes in the afternoon, we locked the toilet doors; but the town people come and break the padlocks and defaecate in the toilet”—(An 18 year Female pupil, FGD in

Akuffokrom M.A. Basic School).

Concerning the issues of community encroachment into the school toilet and its effects on pupils sustainable toilet use, the responses of majority of the teachers (80%) confirmed this and further indicated that the filthy conditions of the school toilet system is a composite pressure from both community residents and school inmates.

Closely linked with community influence on the school toilets was the presence of rodents in the school toilet premises. The effects of this on pupils’ toilet use and psychological wellbeing were also discussed during the FGDs sections and across all the studied schools.

The psychological experiences (fear and panic) pupils encountered with rodents in the school toilets were expressed in the following by discussants: 106

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“When I go to the toilet and see rodents, I don’t feel comfortable and I cannot even ease myself properly”— (Male pupil, FGD, Kofisah M.A. Basic School).

“Sir, they are there paaa; if I see them, I can’t ease myself properly”—(Female pupil,

FGD, Akuffokrom M.A. Basic School).

“….I don’t even visit the toilet again when I see them”— (Female pupil, FGD, Akuffokrom

M.A. Basic School).

“Seeing them made me defaecated on the toilet squat hole”—(Male pupil, FGD, Akatsi

Demons Basic School”).

“I feel so bad so I hurry myself and run away from the toilet”—(Female pupil, FGD in

Kedzi Havedzi A.M.E. Zion Basic School).

4.3.6 Toilet Suitability

Regarding issues of toilets suitability, which relates to appropriateness of the toilet squat holes and toilet location in the school, views of pupils and education directors are seen in the following:

“..Some pupils’ defaecate around the squat holes causing the place to smell”—(Male pupil, Begoro Presby Basic School).

“..it is not good for me because if you don’t take care you will defaecate on the floor and on the squat hole”—(Female pupil, FGD in Kofisah M.A. Basic School).

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“…It is not good because when pre-school children go there, they defaecate around the toilets squat holes, feet rests and clean their anus on the walls”— (Male pupil, FGD,

Kofisah M.A. Basic School).

When asked whether the preschool children also used the same toilet facilities meant for the primary and JHS pupils, this was what the Deputy Municipal Education Director had to say:

“Yes!, they use the same toilet facility; however, the norm is that they have attendants who assisted them to use the toilets; sometimes, they are provided with chamber pots; some preschool children do visit the toilets without assistance which may pose risk; however, no report from any of the schools has ever reached my regarding any casualties; however, new projects are being design by UNICEF to cater for the preschool pupils”—(Deputy

Education Director, in-depth interview, Keta Municipal Education Office).

Again, on the issue of physically challenged pupils also using the toilet facilities meant for the other normal pupils, this is what the Deputy Education Director had to say:

“…they do as they need normal life like others; but per the Act 770 of MLGRD, new toilets facilities are designed to take care of the sanitation needs of physically challenged pupils.

However, at present, the District has no such physically challenged pupils; those who seek school enrolment in the District are normally sent to Akropong which has facility for them.”—(Deputy Education Director, in-depth interview, Akatsi South District Education

Office).

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Regarding the issue of physically challenged pupils also using the same sanitation facilities

(toilets) designed for the non-physically challenged pupils, this was what the Education

Director of Fanteakwa District had to say:

“… in some instances, they needed to be treated like the non-physically challenged pupils to avoid social discrimination within the school system; this has been proved to be very successful in some schools within the district. We are making the effort to ensure that such best practices are extended to other schools in the district where we have physically challenged pupils. He was quick to add that even though this has been the norm in the district, in some cases, they are supported by both teachers and pupils, in certain areas like the sanitation practices”—(Education Director, in-depth interview, Fanteakwa

District Education Office).

Some views of a cross-section of the pupils interviewed on open defaecation Practices

“...open defaecation can bring about diseases to us.”— (Male pupil, IDI, Kofisah M.A.

Basic School).

“It is not good because it destroys the environment.”—(Male pupil, IDI, Kofisah M.A.

Basic School).

“It is not good because we eat the faeces ourselves when we defaecate in the bush;this is because rain water washes the faeces into water bodies and contaminate it and when we drink water from the water bodies, we drink the faeces”—(A female pupil, IDI, Begoro

Presby Basic School).

“When snails are at the place where you defaecate, they would eat the faeces and when we eat the snails, we also eat the faeces.”—(Male pupil, IDI, Kofisah M.A. Basic School).

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“..It is not good because if you finish defaecating and you don’t have any material to clean your anus, you are therefore forced to use leaves and you don’t know whether the leaf is good or bad”—(Female pupil, IDI, Akuffokrom M.A. Basic School).

“Sir, it is true because when flies step on the faeces, and then step on our food, we eat the faeces when we eat the food.”—(Female pupil, IDI, Akatsi Demonstration 2 Basic

School).

“Animals feed on the faeces and eating the animals means eating the faeces.”—(Male pupil, FGD, Akuffokrom M.A. Basic School).

“It is true because the animals there also eat the fresh of the grass so hunting them and eating them make us eat our faeces as well.”—(Male pupil, IDI, Kofisah M.A. Basic

School).

“There is no scent in the bush so I go there; I get some neatness in the bush”—(A female pupil, IDI, Monome, D.A. Basic school).

“Sir, I feel embarrassed and sometimes I can’t even ease myself again.”(Female pupil,

IDI, Oboahu D.A Basic School).

“I feel shy on seeing other pupils in the toilet.”(A female pupil, IDI, Kedzi-Havedzi

A.M.E. Basic School).

“I feel disgraced when teachers see me going to school toilet.”—(Male pupil, IDI,

Akuffokrom M.A. Basic School).

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I don’ feel comfortable in the bush because the farm owner can do me something bad on seeing me.” (Male pupil, IDI, Kofisah M.A. Basic School).

“…I feel scared because I might see a snake which can bit me”. (Male pupil, IDI, Kedzi-

Havedzi A.M.E Zion Basic School).

“I feel comfortable whilst easing myself in the bush instead of in the toilet because the

toilet smells too much.” (Female pupil, IDI, Oboahu D.A. Basic School).

“What make it difficult for me is that if I defaecate in the bush it can give diseases in many ways.” (Male pupil, IDI, Begoro Presby Basic School).

“ I feel scared when all of a sudden someone appeared.” (Female pupil, IDI, Akuffokrom

M.A. Basic School).

“I don’t feel like going there (toilet) because I can get a diseases, and bad smells can be in me.” Male pupil, IDI, Akatsi Demonstration 2 Basic School).

“Defaecating in the bush is not a taboo because visitors had to go there if the community has no toilet.”—(Male pupil, IDI, Akuffokrom M.A. Basic School).

“It is not a taboo because the chief himself also defaecate in the bush— (Male pupil, IDI,

Kofisah M.A. Basic School).

“Even though I have toilet in the house, I feel more comfortable defaecating in the bush than in the toilet”—(Male pupil, IDI, Keta A.M.E Basic School).

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4.4 Socio-Demographic Characteristics of Study Participants The results of socio-demographic characteristics of study participants is presented in Table

4.3 below.

Table 4.3: Socio-Demographic Characteristics of Study Participants

Participants Demographic Frequency (N=400) Percentage (% ) Characteristics Sex Distribution Male 200 50 Female 200 50

Age Distribution(Year) 9—13 183 45 14—18 217 55

Class/Level) Primary 4—6 192 48 JHS 1—3 208 52

Religious Affiliation Christianity 356 89 Muslem 36 9.0 Traditional 8 2.0

Locality Type Rural 200 50 Urban 200 50

Ethnic Affiliation Ga—Dangme 55 13.8 Ewe 216 54.0 Akans (Fante &Asante) 61 15.2 Akuapem 61 15.2 Others (Moshi & Guan) 7 1.7

The sample size was 400 pupils comprising 200 female and 200 male. For better comparison of open defaecation behaviours between the two sex groups and across all the study areas, sex distribution of sample population was 50% females and 50% males. The

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pupils ages ranged between nine and eighteen years. On educational levels of pupils, 192

(48%) were from primary 4-6 grades and 208 (52%) were from Junior High School grades

1-3. With participants’ religion, 356(89%) were Christians whilst the rest comprising 36

(9%) and 8 (2%) belonged to Muslim and Traditional religion respectively. This result suggested that more than two-third of the sample are Christians. The ethnicity distribution of the sample was: 216 (54%) were Ewes, 55 (13.8%) were Ga-Dangme, 61 (15.2%) belonged to Akans (Fate & Asante). The Akuapem were 61 (15.2%). The remaining 7

(1.7%) were from the Moshi and the Guans ethnic groups. This results showed that majority of the study participants were Ewes, thus emphasizing the migratory pattern of the Ewes in the study areas. These results show that out of the sample size of four hundred

(400), 217 (55%) were aged between 14-18 years and 183 (45%) belonged to age group

9-13 years.

4.5 Occurrence and Prevalence of Open Defaecation in the Study Schools With regards to the occurrence of open defaecation behaviours in the first cycle schools the data presented in Table 4.4 (a) below reported on open defaecation practices of pupils by sex groups, locality type, and study schools.

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Table 4.4 (a) Occurrence of Open Defaecation in Study Schools Category Choices Open Defaecation Prevalence in First Cycle Schools Percentage Distributions of Choice Categories in the Sample Practiced Open Frequency Percentage (%) Defaecation Yes 257 64.3 No 143 35.7 Total 400 100

Open Defaecation Frequency by Sex Groups Percentage Distribution of Choice Categories in the Sample by Sex Sex Groups One Time Two Times Three Times Four Times Five Times Total Male Pupils 29 (24.4) 20 (16.8) 35 (29.4) 20 (16.8) 15 (12.6) 119 (100) Female Pupils 23 (16.7) 45 (32.6) 28 (20.3) 16 (11.6) 26 (18.8) 138 (100) Total responses 52 (20.2) 65 (25.3) 63(24.5) 36 (14.0) 41(16.0) 257(100)

Open Defaecation Frequency by Locality Type Percentage Distributions of Choice Categories in the Sample by Locality One Time Two Times Three Times Four Times Five Times Locality Rural 39 (22.3) 38 (21.7) 46 (26.3) 29 (16.6) 23 (13.1) 175 (100) Urban 20 (24.4) 16 (19.5) 21 (25.6) 7 (8.5) 18 (22.0) 82 (100) Total responses 59 (23.0) 54 (21.0) 67(26.1) 36 (14.0) 41 (16.0) 257 (100)

Open Defaecation Frquency by Study Schools Percentage Distributions of Choice Categories in the Sample by Districts Study Schools One Time Two Times Three Times Four Times Five Times Total From Fanteakwa 8 (17.0) 10 (21.3) 13(27.7) 6(12.8) 10 (21.3) 47 (100)

Akatsi South 27 (38.0) 9 (12.7) 12(16.9) 10(14.1) 13 (18.3) 71 (100)

Keta 12 (17.6) 13 (19.1) 17(27.9) 11(16.2) 15 (22.1) 68 (100)

Nsawam-Adoagyiri 12 (16.9) 22 (31.0) 25(35.2) 9(12.7) 3 (4.2) 71 (100)

Total responses 59 (23.0) 54 (21.0) 67(26.1) 36 (14.0) 41 (16.0) 257 (100)

Open Defaecation Frquency by Regions Percentage Distributions of Choice Categories in the Sample,by Regions Regions One Time Two Times Three Times Four Times Five Times Total Eastern 20(5.0) 28(7.0) 35(8.8) 11(2.8) 3(0.8) 97(38.0) Volta 39(9.8) 26(6.5) 32(8.0) 25(6.2) 38(9.8) 160(62.0) Total 59(14.8) 54(13.5) 67(16.8) 36(9.0) 41(10.6) 257(100) Numbers in parenthesis showed percentage frequency distributions.

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Table 4.4 (b) ANOVA Test Result for Frequency of Open Defaecation in the Study Schools

Variables Mean Squares F-Statistics p-values Sex 0.820 3.388 0.003* Locality 0.757 3.463 0.002* Study Schools 4.536 3.770 0.001* Regions 1.420 6.442 0.000*

*Mean difference significant at 0.05 (95%).

The data summarized in Table 4.4 (a) above showed that almost two-thirds of the sample,

257(64.3%) practiced open defaecation whilst the rest 143(35.7%) did not engage in open defaecation. Each of the pupil who practiced open defaecation had at least undertaken one episode of open defaecation behaviour seven days prior to the administration of the questionnaire. Among the female pupils, open defaecation practices is 32.6%, whilst in the male pupils the frequency stands at 29.4% per week. The study also found 8.8% of female pupils to report the highest number of times (5) open defaecation is practiced per week. Open defaecation frequency was observed to be higher in rural study schools

(26.3%) compared to the urban study schools (25.6%). Pooling the data collected from schools within same districts/municipality, open defaecation practice was highest in study schools from Akatsi (38.0%), followed by Nsawam-Adoagyiri (35.2%), Keta (27.9%) and least by Fanteakwa studied schools (27.7%). Analysis of variance (Table 4.4 (b) showed significant difference in open defaecation frequencies between the following: regions

(mean square= 1.420, F=6.442, p<0.05); sex groups (mean square=0.820, F=3.388, p<0.05); locality (mean square=0.752, F=3.463, p< 0.05); Districts (mean square=12.647

F=3.598, p<0.05).

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4.6 Situational Factors That Influence Open Defaecation Behaviour in the Study

Schools

Evidences from the situational assessment results and perception of pupils about the

conditions of their school toilets suggested that the major factors influencing open

defaecation behaviour among pupils in the first cycle schools involved in this study varied

among the sex groups, locality and schools. This section highlights the major situational

factors influencing open defaecation behaviours in the first cycle schools involved in this

study. The data is presented on the bases of sex, locality and study schools (Table 4.5 (a)

below.

Table 4.5 (a): Situational Factors That Influence Open Defaecation Behaviour in the Study Schools

Situational Factors Influencing Open Defaecation Behaviours

Percentage Distribution of Choice Categories in the Sample by Sex Groups Sex Groups Filthy No Pungent Easy Fies in Rodents Other Total toilet privacy scent infection toilet in the + in toilet with premises toilet diseases Male Pupils 46(28.8) 27(16.9) 40(25.0) 15 (9.4) 12(7.5) 19(11.9) 1(0.1) 160 (100) Female Pupils 56(36.6) 22(14.4) 42(27.5) 19(12.4) 5(3.3) 8(5.2) 1(0.1) 153(100) Total 102(32.) 49(15.7) 82(26.2) 34(10.9) 17 (5.4) 27 (8.6) 2(0.1) 313(100)

*Multiple responses allowed + Toilet premises is bushy, no security & safety

Situational Factors Influencing Open Defaecation Behaviours

Percentage Distribution of Choice Categories in the Sample by Locality Filthy No Pungent Easy Flies in Rodents Others+ Total Locality toilet privacy in scent infection school in the toilet with toilet toilet diseases Premises Rural 83(39.3) 34(16.1) 48(22.7) 24(11.4) 6(2.8) 16(7.6) 0(0.0) 211(100) Urban 19(18.6) 15(14.7 34(33.3) 10(9.8) 11(10.8) 11(10.8) 2(2.0) 102(100)

Total 102(100) 49(100) 82(100) 34(100) 17(100) 27(100) 2(100) 313(100)

*Multiple responses allowed. +Toilet premises is bushy, no security & safety

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Table 4.5 (a) Cont’d Situational Factors That Influence Open Defaecation Behaviours

Percentage Distribution of Coice Categories in the Sample by Study Schools Filthy No Pungent Easy Flies in Rodents Others Total Study toilet privacy scent infection toilet in the + Schools inToilet with premise toilet From diseases s Fanteakwa 25(34.) 8(11.1) 20(28.2) 3(4.2) 5(7.0) 8(11.3) 3(4.2) 72 (100) Akatsi South 37(48.) 13(17.1) 18(23.7) 5(6.6) 0(0.00) 3(3.9) 0(0.00) 76(100) Keta 24(28.) 11(13.3) 19(22.9) 12(14.5) 8 (9.6) 9(10.8) 0(0.00) 83(100) Municipal Nsawam- 12(14.) 16(19.5) 24(29.3) 14(17.1) 9 (11.0) 7(8.5) 0(0.00) 82(100) Adoagyiri *Multiple responses allowed. + Toilet premises is bushy, no security & safety

Table 4.5 (b): ANOVA Test Results for Situational Factors That Influence Open Defaecation Behaviour in the Study Schools

Variables Mean Squares F-Statistics p-values

Sex 0.329 1.323 0.239

Locality 0.567 0.853 0.007*

Study Schools 4.166 3.569 0.001*

*Mean difference significant at 0.05 (95%).

The mean scores of factors cited by pupils to be influencing their open defection

behaviours are presented in Table 4.5 (a) above. This results revealed that the two most

important factors influencing open defaecation behaviours in first cycle schools are the

filthyconditions of the school toilets and the pungent scent emanating from the toilet pits.

Female pupils are more influenced by both situational factors compared to their male

counterparts. By locality the data showed that the single most important factor promoting

open defaecation behaviour among the pupils in rural study schools relates to the filthy

conditions of the school toilets and that of the urban setting was the pungent scent from

the toilets pits. Across the study schools, the data followed similar patters portrayed in

locality and sex.

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Analysis of variance showed significant difference between locality (mean square=0.567,

F=2.853, P<0.05) and schools (mean square =4.166, F=3.569, P<0.05). The sex groups

showed no significant difference to report (mean square=0.329, F= 1.323, p>0.05) (Table

4.5 (b).

4.7 Situational Factors that Prevent Open Defaecation in the Study Schools Situational factors that prevent pupils from engaging in open practices by schools, locality

and sex are presented in Table 4.6 (a) below. below. Table 4.6 (a): Situational Factors that Prevent Open Defaecation in the Study Schools Situational Factors Preventing Open Defaecation Percentage Distribution of Choice Categories in the Sample by Schools Study Schools Shamed Punished Loss of social Snake No No safety & Total if seen if seen respect if seen bite privacy in security in From the bush bush Fanteakwa 38(52.8) 6(8.3) 6(8.3) 7(9.7) 9(12.5) 6(8.3) 72(100) Akatsi South 25(44.6) 10(17.9) 11(19.6) 9(16.1) 1(1.8) 0(0.0) 56(100) Keta Municipal 41(46.1) 15(16.9) 17(19.1) 13(14.6) 3(3.4) 0(0.0) 89(100) Nsawam- 13(19.1) 16(23.5) 20(29.4) 9(13.2) 10(14.7) 0(0.0) 68(100) Adoagyiri Total responses 117(41.) 47(16.5) 54(18.9) 38(13.3) 23(8.1) 6(2.1) 285(100) *Multiple responses allowed

Situational Factors Preventing Open Defaecation Percentage Distribution of Choice Categories in the Sample by Locality Shamed if Punished if Loss of Snake bite No privacy No safety & Total Locality seen seen respect if seen in the bush security in bush Rural 70(39.1) 31(17.3) 39(21.8) 16(8.9) 20(11.2) 4(2.2) 179(100) Locality Urban 47(44.3) 16(15.1) 15(14.2) 22(20.8) 3(2.8) 2(1.9) 106(100) Locality Total responses 117(41.1) 47(16.5) 54(18.9) 38(13.3) 23(8.1) 6(2.1) 285(100) *Multiple responses allowed

Situational Factors Preventing Open Defaecation

Percentage Distribution of Choice Categories in the Sample by Sex Shamed if Punished if Loss of Snake bite No privacy No safety & Total Sex seen seen respect if seen in the bush security in bush Groups Male 51(41.1) 24(17.0) 24(17.0) 21(14.9) 16(11.3) 5(3.5) 141(100) Pupils Female 66(45.5) 23(15.9) 30(20.7) 17(11.7) 7(4.8) 2(1.4) 145(100) Pupils

*Multiple responses allowed

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Table 4.6 (b) ANOVA Test Results for Factors Preventing Open Defaecation Practices

Variables Mean Squares F-Statistics p-values Sex 0.519 2.120 0.051* Locality 0.741 3.317 0.004* Study Schools 6.444 5.738 0.000*

*Mean difference significant at 0.05 (95%).

In the study schools, some pupils avoided open defaecation practices and defaecate in the toilets. The data recorded in Table 4.6 (a) above showed that the three most important factors that prevent pupils from engaging in open defaecation behaviours are perceived stigmatization (shame), punishment and loss of respects attached to the open defaecation practice. Among these factors, the influence of shame dominated the study schools from

Fanteakwa community (52.8%), followed by Keta (46.1%) and Akatsi (44.6%) in that order. Perceived punishment (23.5%) and loss of social respect (29.4%) exert greater influence in the study schools from Nsawam-Adoagyiri. Within the rural and urban localities, the stigma of shame largely dominated other factor preventing pupils from open defaecation practices. Indeed, over 39% and 44% of the pupils from urban and rural study schools, respectively, are prevented from open defaecation practices by this factor. In exception of snake bite, the influence of other factors are equally evident in the study schools from rural locality than those in the urban areas.

The data [Table 4.6 (a)] also indicated that the single most important variable preventing the two sex groups from engaging in open defaecation practices relate to perceived stigma

(shame):(female pupils: 45.5% and male pupils: 41.1%). From this result it can be hypothesized that female pupils avoid open defaecation for fear of being stigmatized

(disgraced) and loss of social respect more than it is observed among the male pupils across the study schools. Other two variables which are also preventing pupils from defaecating

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in the open were punishment and loss of respect in both the school and the community.

Interestingly, lack of safety and security were never mentioned among the female group.

Analysis of variance (Table 4.6 (b) showed significant difference between the mean scores for factors preventing open defaecation practices between the following: localities (mean square = 0.0.741, F = 3.317, p<0.05); study schools (mean square = 6.444, F=5.738, p<0.05) and sex (mean square =0.519, F=2.120, p<0.05).

4.8 Behavioural Factors Influencing Open Defaecation Practices

4.8.1 Attitudes and Open Defaecation Behaviour

The data presented in Tables 4.7, 4.8 and 4.9 below described the percentage distribution of attitudinal factors influencing open defaecation behaviours in the study schools.

Table 4.7: Pupils Awareness of Effect of Open Defaecation Behaviour by Study Schools

Pupils Study Schools

Variable Choice Study schools Study schools Study schools Study schools from Category Categories from from from Nsawam-Adoagyiri Fanteakwa Akatsi Keta

Percentage Distribution of Choice Categories in Sample

Harmful 86 84 94 76 Effect of open defaecation Beneficial 4 4 3 4 behaviour Neutral 10 12 3 20

Total 100 100 100 100

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Table 4.8: Pupils Perception of Open Defaecation Behaviour by Study Schools

Study schools Study schools Study schools Study from Fanteakwa from from schools Akatsi Keta from Nsawam- Adoagyiri Variable Category Choice Percentage Distribution of Choice Categories in Sample Category Effect of open Bad practice 91 82 95 91 defaecation Good practice 6 5 0 4 Neutral 3 13 4 5 Total 100 100 100 100

Tables 4.9 and 4.10: Pupils Knowledge of Environmental and Health Effects of Open Defaecation Behavious

Table 4.9: Pupils Knowledge of Environmental Table 4.10: Pupils Knowledge of Health Effect of Effect of Open Defaecation Behaviour Open Defaecation Behaviour

Category Frequency Percentage Category Percentage

Choices Response Frequency (%)

Undesirable 208 52 Unlikely 212 53

effect

Desirable effects 172 43 Don’t know 48 12

Don’t know 20 5 Likely 140 35

Total 400 100 Total 400 100

Table 4.11: Pupils General Knowledge of Open Defaecation Practices

Variable Category Choice Category Frequency Percentage (%)

Bad practice 359 89.8 Effect of open defaecation behaviours Don’t know 27 6.9

Good practice 14 0.4

Total responses 400 100

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The result in Table 4.7 showed that study schools from Keta hold the highest awareness

(94%) about the negative effect of open defaecation behaviour. The study also measured pupils’ perception of effect of open defaecation behaviour on the environment. This characteristics was investigated among pupils with two items in five category choices each. In both items pupils were asked to indicate whether “open defaecation causes any significant risk to the environment”. The five category choices were collapsed into three category choices—bad effect, good effect, or don’t know.

The result in Table 4.8 suggested that pupils have high level of perception of bad effect of open defaecation behaviour and the level of perception vary slightly from one study area to another with schools from Keta recording the highest perception (95%) of bad effect followed closely by both Nsawam-Adoagyiri and Fanteakwa with (91%) each and Akatsi

(82%) being the least. Again, the study measured pupils’ knowledge of environmental and health risks of open defaecation behaviour.

Tables 4.9 and 4.10 respectively described the results of the analysis of environmental and health effect of open defaecation behaviour. In Table 4.9, the result showed that more than half (52%) of the pupils have good knowledge about the negative effect of open defaecation behaviour on the environment. In Table 4.11, the result indicated that the overall knowledge level of pupils on health risks of open defaecation was, however, low

(53%). Data in Table 4.9 also shows that over 89% of the pupils have adequate knowledge of the negative consequences of open defaecation pracices.

4.8.2 Subjective Norm and Open Defaecation Behaviours

The data presented in Table 4.12 and 4.13 below described the frequency and percentage distribution of influence of subjective norms variables on pupils open defaecation practice.

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Table 4.12: Influence of Role Model on Open Defaecation Behaviour

I defaecate in the open place because people whose opinion I take also do it. Percentage Distribution of Choice Category in the sample by Study Schools Study schools Strongly Disagree Don’t Know Agree Strongly Total from: disagree agree (%) Fanteakwa 50 10 5 33 2 100 Akatsi 61 7 8 20 4 100 Keta 69 9 6 15 1 100 Nsawam-Adoagyiri 47 6 10 25 12 100

I defaecate in the open place because people whose opinion I take also do it. Percentage Distribution of Choice Category in the sample by locality Locality Strongly Disagree Don’t Know Agree Strongly Total disagree agree Rural 113(56.5) 40(20.0) 10 (8.5) 27 (13.5) 10(5.0) 200(100) Urban 90(45.0) 52(26.0) 22(11.0) 19(4.0) 17(9.0) 200(100)

I defaecate in the open place because people whose opinion I take also do it. Sex Groups Percentage Distribution of Choice Category in the sample by sex Strongly Disagree Don’t Know Agree Strongly Total disagree agree Male Pupils 97 (48.5) 50 (25.0) 11 (5.5) 19 (9.5) 23 (11.5) 200 (100) Female Pupils 115(57.5) 42 (21.0) 4 (2.0) 25 (12.5) 14 (7.0) 200 (100)

I defaecate in the open place because people whose opinion I take also do it. Percentage Distribution of Choice Category in the sample by age Age (Year) Strongly disagree Disagree Don’t Know Agree Strongly Total agree 9-13 76 (41.5) 14 (7.7) 4 (2.2) 59 (32.2) 30 (16.4) 183 (100) 14-18 92 (42.4) 51 (23.5) 7 (3.2) 46 (21.2) 21 (9.7) 217 (100)

Note: Figures in parentheses show percentage influence of variables in sample. Figures outside parentheses show the frequency distributions of variables in sample.

The data presented in Table 4.12 above described the percentage influence of role models on pupils’ open defaecation behaviour by school, locality, sex and age. It is evident from the data that role model has insignificant positive influence on pupils open defaecation practices across all the study schools. In the case of rural-urban divides, the data portrayed similar trend observed across the study schools. However, the influence of role models on pupils’ open defaecation practices is more noticeable in rural locality (13.5%) than it is observed in the urban locality (4.0%). By sex, the data followed similar patterns of

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influence of role models on pupils open defaecation practices observed in the rural-urban localities. The influence was high with pupils in 9-13 aged group than it was observed in

14-18 aged group pupils.

Table 4.13: Influence of Social Injunction on Open Defaecation Behaviour

People who are important to me think that I should defaecate in the open

Percentage Distribution of Choice Category in the sample by schools Study Schools Strongly Disagree Don’t Know Agree Strongly Agree Total from: Disagree Fanteakwa 43 33 5 12 7 100 Akatsi 39 25 18 13 5 100 Keta 55 17 6 15 7 100 Nsawam- 39 10 11 35 5 100 Adoagyiri

People who are important to me think that I should defaecate in the open

Percentage Distribution of Choice Category in the sample by locality Locality Strongly Disagree Don’t Know Agree Strongly Total disagree agree Rural 77 (38.5) 61 (30.5) 18 (9.0) 39 (19.5) 15 (7.5) 200 (100) Urban 84 (42.0) 54 (27.0) 13 (6.5) 36 (18.0) 13 (6.5) 200 (100)

Descriptive Norm Influence (social injunctions)

People who are important to me think that I should defaecate in the open Percentage Distribution of Choice Category in the sample by sex Sex Groups Strongly Disagree Don’t Know Agree Strongly Total disagree agree Male Pupils 32 (16.0) 91 (45.5) 16 (8.0) 47 (43.5) 19 (18.5) 200 (100) Female Pupils 89 (44.5) 57 (28.5) 10 (5.0) 33 (16.5) 11 (5.5) 200 (100)

Descriptive Norm Influence (social injunctions) People who are important to me think that I should defaecate in the open Percentage Distribution of Choice Category in the sample by age Age (Year) Strongly Disagree Don’t Know Agree Strongly Total Disagree Agree 9-13 54 (29.5) 33 (18.0) 17 (9.3) 44 (24.0) 35 (19.1) 183 (100) 14-18 83 (38.2) 46 (21.2) 14 (6.5) 47 (21.7) 27 (12.4) 217 (100)

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The data presented in Table 4.13 above described the percentage influence of descriptive norm (social injunctions) on pupils’ open defaecation practices by study schools, locality, sex, and age. The data showed that all study schools are less influenced by descriptive norms. Nevertheless, study schools from the Nsawam-Adoagyiri ar mostly influenced by social injunctions compared to other study schools. On locality basis, it is evident that social injunctions has greater influence on pupils’ open defaecation practices in the rural locality than it is witnessed in the urban locality. By sex, the data indicated that male pupils are more influenced by social injunctions than it is observed in the female pupils.

4.8.3 Influence of Perceived Behavioural Control (PBC) on Pupils Open Defaecation

Behaviour

The predictor variables included on the PBC measuring scale were (i) perceived confidence, and (ii) intrinsic motivation). The study measured and reported the frequency and percentage distribution of influence of these variables on pupils open defaecation behaviours. The analysis results were presented in Table 4.14 below on the basis of schools, localities, sex and age.

Table 4. 14: Influence of Perceived Confidence on Open Defaecation Behaviour

For me to defaecate in the open is….. Percentage Distribution of Choice Category in Sample by schools Study Very Difficult Don’t Know Easy Very easy Total schools difficult from: Fanteakwa 49 16 11 23 1 100 Akatsi 29 9 5 52 5 100 Keta 17 6 6 61 10 100 Nsawam- 33 7 4 55 1 100 Adoagyiri

For me to defaecate in the open is….. Percentage Distribution of Choice Category in Sample by locality Locality Very Difficult Don’t Know Easy Very easy Total difficult Rural 19(9.5) 71(35.5) 13(6.5) 89(44.5) 8(4.0) 200(100) Urban 42(21.0) 70(35.0) 3(1.5) 68(34.0) 17(8.5) 200(100)

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Table 4.14 (Cont’d) For me to defaecate in the open is… Sex Groups Percentage Distribution of Choice Category in Sample by sex Very Difficult Don’t Know Easy Very easy Total difficult Male pupils 34 (17.0) 51 (25.5) 7 (3.5) 98 (48.5) 10 (5.0) 200 (100)

Female 58 (28.0) 25 (12.5) 12 (6.0) 89 (44.5) 16 (8.0) 200 (100) pupils

For me to defaecate in the open is… Percentage Distribution of Choice Category in Sample by age Age (Year) Very Difficult Don’t Know Easy Very easy Total difficult 9-13 43 (23.5) 32 (17.5) 11 (6.0) 85 (46.4) 12 (6.6) 183 (100) 14-18 75(34.6) 69 (31.8) 9 (4.1) 56 (25.8) 8 (3.7) 217 (100)

The data presented in Table 4.14 above indicated that open defaecation behaviours among pupils in the study schools from both Keta and Nsawam-Adoagyiri are largely influenced by their perceived confidence. Indeed, 61 % and 55% of pupils from the Keta and

Nsawam-Adoagyiri, respectively, indicated this. Within the rural-urban localities the data showed that pupils’ defaecate in the open because they found it easy to engage in it. Indeed, majority of the pupils (44.5%) and (34%) from the rural and urban localities, respectively, reported this. Though the data displayed this trend, it is generally evident that more pupils

(21.0%) found it very difficult to defaecate in the open in the urban locality than it is observed in the rural locality (9.5%). This result revealed that between the rural-urban divides, pupils are less influenced by their confidence to engage in open defaecation practices. Analysis of variance showed significant difference in pupils confident to engage in open defaecation between two localities (means square= 17.616, F=3.588, p<0.05).

Within the sex groups the data showed that male pupils are more influenced by their confidence to defaecate in the open than it is observed among the female pupils. Certainly,

98(48.5%) and 89(44.5%) of the male and female pupils, respectively, indicated this. The data further revealed that more pupils in the lower age group (9-13) (46.4%) showed more confidence in defaecating in the open place compared to those in the 14-18 age group

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(25.8%). Analysis of variance showed significance difference among the mean scores for the PBC (confidence) variable among study schools (F=7.543; p<0.05); localities (F=

8.202; p<0.05. Sex of respondents showed no significant difference to report.

4.9 Influence of Cultural Factors on Open Defaecation Behaviour Four cultural variables that could influence sanitation behaviours were assessed. They include superstitions, taboos, traditional value, and traditional norms. The analysis results of the assessment is presented in Tables 4.15, 4.16 and 4.17 below.

Table 4.15: Influence of Superstitions on Open Defaecation Behaviour

Shared toilets are associated with evil spirits and therefore should be avoided. Percentage Distribution of Choice Category in the sample Study Strongly Disagree Don’t Know Agree Strongly Total Schools disagree agree (%) From: Fanteakwa 58 24 11 5 2 100 Akatsi 36 35 18 7 4 100 Keta 68 14 5 13 0 100 Nsawam- 44 26 12 10 8 100 Adoagyiri

Shared toilets are associated with evil spirits and therefore should be avoided. Percentage Distribution of Choice Category in the sample by locality Locality Strongly Disagree Don’t Know Agree Strongly Total disagree agree Rural 119 25 13 32 11 200 Urban 92 31 17 41 19 200

Shared toilets are associated with evil spirits and therefore should be avoided. Sex Groups Percentage Distribution of Choice Category in the sample by sex Strongly Disagree Don’t Know Agree Strongly Total disagree agree Male Pupils 89 (57.0) 57 (23.5) 15 (7.5) 28 (14.0) 11(5.5) 200 Female 111(55.5) 43 (21.5) 14 (7.0) 19 (9.5) 13(6.5) 200 Pupils

Shared toilets are associated with evil spirits and therefore should be avoided. Percentage Distribution of Choice Category in the sample by age Age Strongly disagree Disagree Don’t Know Agree Strongly Total (Year) agree 9-13 92(50.3) 31(16.9) 22 (12.0) 32 (17.5) 6 (3.3) 183 14-18 114(52.5) 58(26.7) 24 (11.1) 13 (6.0 ) 8 (3.7) 217

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Table 4.16: Influence of Taboos on Open Defaecation Behaviour

Defaecating in an enclosed place (inside toilet) is a taboo. Percentage Distribution of Choice Category in the sample Study Schools Strongly Disagree Don’t Know Agree Strongly Total (%) From: disagree agree Fanteakwa 68 27 1 3 1 100 Akatsi 45 25 10 14 5 100 Keta 74 9 2 9 6 100 Nsawam-Adoagyiri 55 27 10 4 4 100

Percentage Distribution of Choice Category in the sample by locality Locality Strongly Disagree Don’t Know Agree Strongly Total disagree agree Rural 42 (21.0) 109 (54.5) 18 (9.0) 22 (11.5) 9 (4.5) 200 Urban 32 (16.0) 123 (61.5) 9 (4.5) 17 (8.5) 19 (9.5) 200

Defaecating in an enclosed place (inside toilet) is a taboo. Sex Groups Percentage Distribution of Choice Category in the sample by sex Strongly Disagree Don’t Know Agree Strongly Total disagree agree Male Pupils 40 (20.0) 97 (48.5) 15 (7.5) 28 (14.0) 20 (10.0) 200 Female 16 (8.0) 112 (56.0) 32 (16.0 ) 24 (12.0) 16 (8.0) 200 Pupils

Defaecating in an enclosed place (inside toilet) is a taboo. Percentage Distribution of Choice Category in the sample by age Age Strongly disagree Disagree Don’t Know Agree Strongly Total (%) (Year) agree 9-13 104 (56.8) 43 (23.5) 7 (3.8) 19 10 (5.5) 183(100) (10.4) 14-18 138 (63.6) 45 (20.7) 16 (7.4) 12 (5.5) 6 (2.8) 217(100)

Table 4. 17 (a): Influence of Traditional Norms on Open Defaecation Behaviour

Defaecating outside toilet signifies continuation of ancestral ways of life Percentage Distribution of Choice Category in the sample Study Strongly Disagree Don’t Know Agree Strongly Total (%) Schools disagree agree From: Fanteakwa 54 16 8 14 8 100 Akatsi 48 22 5 13 12 100 Keta 55 18 2 17 8 100 Nsawam- 54 23 12 5 6 100 Adoagyiri

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Table 4.17 (a) (Cont’d) Defaecating outside toilet signifies continuation of ancestral ways of life Percentage Distribution of Choice Category in the sample by locality Locality Strongly Disagree Don’t Know Agree Strongly agree Total (%) disagree Rural 44 (22.0) 93 (46.5) 16 (8.0) 36 (18.0) 11 (5.5) 200(100) Urban 77 (38.5) 59 (29.5) 30 (15.5) 26 (18.0) 8 (4.0) 200(100)

Defaecating outside toilet signifies continuation of ancestral ways of life Sex Percentage Distribution of Choice Category in the sample by sex Groups Strongly Disagree Don’t Know Agree Strongly agree Total (%) disagree Male 28 (14.0) 96 (48.0) 21 (10.5) 43 (21.5) 12 (6.0) 200(100) Pupils Female 19 (9.5) 112 (56.0) 33 (16.5) 28 (14.0) 8 (4.0) 200(100) Pupils ` Defaecating outside toilet signifies continuation of ancestral ways of life Percentage Distribution of Choice Category in the sample by age Age Strongly disagree Disagree Don’t Know Agree Strongly agree Total (%) (Year) 9-13 100 (54.6) 32 (17.5) 8 (4.4) 26 (14.2) 17 (9.3) 183(100) 14-18 111 (51.2) 47 (21.7) 19 (8.8) 25 (10.6) 15 (9.3) 217(100)

Table 4.17 (b): ANOVA Test Results for Cultural Factors Influencing Open Defaecation Behaviours in the Study School Variables Mean Squares F-Statistics p-values Sex 0.198 0.776 0.801 Locality 0.266 1.187 0.231 Study Schools 1.516 1.240 0.1813

Age 7.567 1.913 0.003* * Mean difference significant at 0.05 (95%).

The cultural variables considered in this study were taboos, superstitions, traditional norms and traditional values. Across all the study schools superstition has less significant influence on pupils open defaecation behaviours (Table 4.15 above). However, its influence on pupils open defaecation behaviours was more pronounced in the urban localities than in the rural locality (Table 4.15 above). The influence of taboos also showed similar pattern of influence observed in superstitions across all the study schools (Table

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4.16 above). The influence, however, is more witnessed in the urban localities than it was seen in the rural areas [Tables 4.16 above). With regards to effect of traditional norms, greater number of pupils were more influenced in the rural schools than it was observed in the urban schools (Table 4.17 above). It is also obvious that more pupils in the lower age group (9-18) are more influenced by traditional norms than it is observed with pupils in the high age 14-18. (Table 4.17 above).

Analysis of variance showed significancant difference between the mean scores for the cultural factors and age (mean square 7.567, F=1.913, p<0.003). The mean scores for other variables showed no significant difference to report (Table 4.17(b).)

4.10 Bivariate Test on Dependent and Independent Variables As shown in the Table 4.18 below, some independent variables showed significant associations with the dependent variables. This provided bases for making valid inferences and drawing valid conclusions from the analyses.

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Table 4.18: Bivariate Test Result for Dependent and Independent Variables

Dependent Variables Items Reliability

Independent Variables Open Defaecation Open Defaecation Cronbach’s Intention Behaviour Alpha value

2 2 ᵡ p-values ᵡ Values p-values Pupils Demographic Characteristics .85

Sex 1.264 0.867 19.671 0.003*

Settings 4.394 0.355 20.087 0.003* Age 17.678 0.798 44.082 0.830 Education 17.701 0.818 43.841 0.173 Ethnicity 39.067 0.334 20.087 0.025* Religion 5.646 0.687 10.158 0.602

Behavioural Factors Influencing Open Defecation

Attitude (Pooled) 242.050 0.037* 270.053 0.042* .87 Knowledge of open defaecation risk 33.975 0.085 61.384 0.005* Awareness of open defaecation risk 61.663 0.005* 43.931 0.008* Perceived comfort/convenience from toilet use 54.014 0.000* 54.014 0.000* Perceived privacy in school toilet 66.315 0.006* 79.451 0.047* Perceived benefits of open defaecation 79.451 0.047* 68.437 0.001**

Subjective Norm (pooled) 81.965 0.000* 0.111 0.026* .85

Descriptive norm (social injunctions) 38.041 0.009* 42.943 0.072 Perceived influence of role model 47.065 0.000* 37.593 0.038* Perceived motivation (extrinsic value) 40.223 0.005* 23.997 0.772

Perceived Behavioural Control (Pooled ) 70.263 0.001* 351.650 0.001** .84 Perceived confidence 44.249 0.000* 24.132 0.000* Perceived Motivation (intrinsic value) 0.168 0.001** 0.126 0.014*

Cultural Factors 33.510 0.004* 0.143 0.004* .88

Perceived influence of Taboos 39.572 0.006* 39.370 0.028 Perceived influence of traditional norms 36.387 0.003* 40.431 0.019* Perceived influence of superstition 31.68.4 0.011* 60.422 0.000* Perceived influence of traditional value 38.398 0.001** 23.332 0.500

*Independent variables which show significant associations/correlations with dependent variables (open defaecation intention & open defaecation behaviour. Association/correlation is significant at 0.05 level (two-tailed) and 0.001 level (one-tailed).

From the data in Table 4.18 above, it is evident that significant association exist between the following dependent and independents variables: open defaecation behaviour has fairly

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strong association with pooled effect of all the five variables on attitude measurement scale at (ᵡ2 =270.053, p<0.05). All the individual variables on attitude measurement scale also showed significant association with both satisfied intention and open defaecation behaviour. Knowledge of open defaecation risk, however, showed no significant association with open defaecation intention (ᵡ2 == 33.975, p= 0.085).

Pooled effect of subjective norm variables produced significant association with satisfied intention (ᵡ2 = 81.965, p<0.05). Only role model on subjective norm measurement scale showed significant association with open defaecation behaviour at (ᵡ2 =37.593; p<0.05).

Pooled effect of the two variables on PBC measurement scale produced significant association with both satisfied intention and open defaecation behaviour. Both variables in their on perceived behavioural control measurement scale, in their individual state, also generated significant association with open defaecation behaviour. Pooled effect of all the variables on cultural measuring scale have significant association with satisfied intention

(ᵡ2 =33.510, p = 0.004), and significantly correlated with open defaecation behaviour (r=

0.143, p< 0.05).

The Cronbach’s alpha values for reliability and consistency of items on all the measurement scales used in the data collection were also reported alongside bivariate results (Table 4.18). The alpha values for all dimensions exceeded the 0.60 lower limit of acceptability (Hair et al., 2006) and therefore indicated that the scales were internally consistent and reliable in all cases and provided a good empirical basis for analyzing the data from the questionnaire within the analytical process postulated by the conceptual framework using the SEM path model.

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4.11 Effect of Behavioural Factors on Open Defaecation Behaviours Although significant associations were observed between some dependent and independent variables, it was necessary to examine further, the effects of these independent factors on dependent variables. So, SEM path analysis of the independent and dependent variables was conducted to provide an empirical basis on which to make assumptions on the data. The results of the analyses are presented in Tables 4.19 and 4.20 below.

Table 4.19: Coefficient Results for Effect of Behavioural Factors on Open Defaecation Practices

SEM Behavioural Impact Dependent Standardized S.E. t- p-value Path Factors Variables Effect Size (r) statistics

Models

M2 Pupils satisfied -----> OD 0.58 0.132 44.101 0.000* intention behaviour

Pupils perceived -----> OD -0.06 -0.321 -3.052 0.002* behavioural behaviour control *All coefficients significant at p< 0.05.; OD = Open defaecation; M2 = SEM path model 2

Table 4.20: Coefficient Results for Effect of Behavioural Factors on Open Defaecation Intention SEM Behavioural Impact Antecedent Standardized S.E. t- p- Path Factors Dependent Effect Size (r) statistics value Models Variable

Pupils attitude ------> OD 0.708 0.665 10.177 0.000* intention

M1 Pupils subjective ------> OD 0.035 0.272 0.917 0.359 norm intention

Pupils perceived ------> OD -0.114 0.321 -2.961 0.003* behavioural intention control

*All coefficients significant at p< 0.05. OD=Open defaecation M1 = SEM path model 1

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4.11.1 Effect of Attitude on Open Defaecation Behaviour

Behavioural factors included on the pupils’ attitude measurement scale were perceived knowledge, awareness of open defaecation risks, perceived convenience, privacy and benefits of open defaecation. These factors were subjected to SEM path analysis using variables on pupils’ open defaecation intention as proximal antecedent dependent to actual open defaecation. The result of these analyses is presented in Table 4.20 above. This result produced an effect size of 0.708, indicating that 71% of variance in pupils’ intention to engage in open defaecation behaviour was due to the pooled effects of behavioural factors included on the pupils attitudes measurement scale (standardized effect = 0.708; S.E. =

0.665; t = 10.77; p<0.05).

4.11.2 Effect of Subjective Norm on Open Defaecation Intention

The effect size of subjective norm on pupils intention to defaecate in the open was also predicted by regressing data collected on their self-reported subjective norm against data gathered on their intention to defaecate in the open using SEM model. Behavioural factors

(variables) included on subjective norm scale were descriptive norm (social injunction), perceived influence of role model and perceived motivation (extrinsic value). In this analysis, the intention was used as proximal dependent variable to open defaecation behaviour. The SEM path result produced is presented in Table 4.20 above. This result produced standardized effect size of 0.035, p>0.05, indicating that variables included on pupils subject norm measuring scale explains 4% of variance in pupils’ intention to engage in open defaecation behaviour but with no significance effect to report (standardized effect

=0.035; S.E. =0.272; t=0.917; p>0.05). This result suggested that in their combined form, the variables included on the subjective norm measurement scale (descriptive norm,

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perceived role model and perceived motivation) plays insignificant role in the pupils’ intention to defaecate in the open.

4.11.3 Effect of Perceived Behavioural Control (PBC) on Open Defaecation

Practices

Behavioural factors included on PBC measuring scale were perceived confidence and intrinsic motivation. When data collected on these was regressed against pupils open defaecation behaviour directly and indirectly using SEM path analysis (M1), the results produced is shown in Tables 4.19 and 4.20 above. These results showed inverse correlation between the two variables in both cases: direct measure (Table 4.19) (standardized effect

= -0.06, t =-3.052, p < 0.05) and indirect measure (Table 4.20) (standardized effect = -

0.114, t = 2.961, p < 0.05). This result suggested that predictor variables included on the

PBC measurement scale (perceived confidence and perceived extrinsic motivation) might not possibly be responsible for the pupils open defaecation behaviour in the first cycle schools covered by the study. These results, however, suggested that for every single unit of increase in pupils confidence and motivation, open defaecation behaviour intention and actual open defaecation decreases by 0.06% and 0.11% respectively.

4.11.4 Aggregate Effect of Behavioural Factors on Open Defaecation Intention and

Open Defaecation Behaviour

The aggregate effect size of behavioural factors on pupils satisfied open defaecation intention and actual open defaecation behaviour was also estimated using the SEM path analysis (M4). The coefficience results produced is presented in Table 4.21 below.

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Table 4.21: Aggregate Effect of Behavioural Factors on Intention and Open Defaecation Behaviour Behavioural Factors SEM Path Pooled effect Pooled effect Pooled effect size Pooled effect Model size of size of of behavioural size of behavioural behavioural behavioural Dependent factors on factors factors on factors on Variables subjective norm on PBC OD intention measuring attitude measuring measuring Scale measuring scale scale scale

OD 0.035 -0.114 0.708 (71%) --- Intention M4 OD 0.02 -0.129 0.821(82%) 0.58 (58%) Note: All coefficients significant at p< 0.05 and were derived from SEM path SEM Analyses (1-tailed). The Behavioural variables considered included: attitudes, subjective norm and Perceived behavioural control (PCB). OD = Open defaecation. M4= SEM path model 4

The aggregate effect sizes of behavioural factors—attitude, subjective norm and perceived behavioural control—on pupils’open defaecation intention and the actual open defaecation behaviour were also estimated using the SEM path analysis method. The results produced are presented in Table 4.21. These results showed that the behavioural factors included on the three behavioural measurement scales (attitudes, subjective norm and perceived behavioural control) together explained 58% of variance in pupils open defaecation behaviour. Within this aggregate effect size, behavioural factors on attitude measurement scale explained over 82% of the variance of pupils open defaecation behaviour and 71% of pupils’ intention to engage in open defaecation behaviour. The effect sizes of behavioural factors presented on subjective norm and PBC measurement scales on pupils’ intention of open defaecation behaviour were 2% and 4%, respectively. Also, subjective norm and PBC produced effect sizes of 2% and -13%, respectively, on pupils’ actual open defaecation behaviour. These results showed that behavioural factors (predictor variables) included on pupils’ attitude measuring scale constituted the most significant factors contributing largely to open defaecation behaviours observed among pupils.

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4.11.5 Effect of Individual Behavioural Factors on Intention & Open Defaecation

Behaviours

The effect of individual behavioural factors on attitude measurement scale on pupils’ open defaecation behaviour were estimated using variables on pupils’ intention as proximal antecedent dependent variables to actual open defaecation behaviour. The results produced the effect sizes highlighted in Table 4.22 and Table 4.23 below.

Table 4.22: Effect of Individual Behavioural Factors on Open Defaecation Intention

SEM Behavioural Factors Impact Dependent Standardized S.E. t- P- Path (Attitudes) Variables Effect Size (r) statistics value Model Perceived privacy in  OD 0.018 0.029 0.365 0.715 school toilets Intention Perceived Comfort/  OD 0.081 0.039 1.619 0.106 convenience from Intention toilet use M8 Awareness of open  OD -0.044 0.051 -0.884 0.377 defaecation risks Intention Perceived knowledge  OD -0.016 0.049 -0.329 0.743 of open defaecation Intention risk

Perceived benefits of  OD -0.033 0.050 -0.653 0.514 open defaecation Intention *All coefficients significant at p<0.05 M8= SEM path model 8

Table 4.23: Effect of Individual Behavioural Factors on Open Defaecation Practices

SEM Behavioural Factors Impact Dependent Standardized S.E. t-statistics P- Path (Attitudes) Variables Effect Size value Model (r) Perceived privacy in  OD -0.06 0.022 -1.212 0.226 school toilets Perceived Comfort/  OD 0.116 0.029 2.347 0.019* convenience from toilet M9 use Perceived awareness of  O D -0.028 0.038 -0.558 0.577 open defaecation risks Perceived knowledge  OD 0.073 0.037 1.483 0.138 of open defaecation risks Perceived benefit of  OD -0.019 0.038 -0.391 0.696 open defaecation *All coefficients significant at p<0.05 OD = Open defaecation. M9= SEM path model 9.

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The results detailed in Table 4.22 above on effect of behavioural factors on pupils’ open defaecation intention showed no significant effect to report. Perceived comfort/convenience), however, produced significant positive effect size on pupils’open defaecation behaviour: standardized effect = 0.116, p<0.05. (Table 4.23 above).

4.11.6 Interaction Effect of Behavioural Factors on Open Defaecation Practices

The interaction effect sizes of behavioural factors on pupils open defaecation behaviour were also estimated using SEM path analysis (M12). In this analysis, behavioural factors on attitude measurement scale were interacted with behavioural factors on subjective norm and PBC measurement scales. The behavioural factors on subjective norm measurement scale were also interacted with behavioural factors on PBC measurement scale. The results produced are presented in Table 4.24 below.

Table 4.24: Interaction Effect of Behavioural Factors on Open Defaecation Practices

Interaction Effect Size of Behavioural Factors on Attitude & PBC Measuring Scales on Pupils Open Defaecation Behaviour SEM Path Independent Impact Dependent Standardized S.E. t- P- Model Variables Variables Effect Size (r) statistics value

Attitude ⁂ ----> OD 0.363 0.132 44.101 0.002* Subjective norm

Attitudes ⁂ PBC ----> OD 0.390 0.112 36.824 0.000* M12

PCB ⁂ Subjective ----> OD 0.608 0.112 36.824 0.000* norm ⁂=interaction =All coefficient significant at p<0.05. M12= SEM path model 12. OD=open defaecation

These results in Table 4.24 above indicated the following effect sizes: behavioural factors on attitude measurement scale interacting with subjective norm (standardized effect =

0.363; p = 0.002); attitude interacting with PBC (standardized effect = 0.39; p<0.05); and subjective norm interacting with PBC (standardized effect = 0.608; p<0.05). The data in

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Table 4.24 above suggested that the open defaecation behaviour observed among the

pupils in the study schools was also largely due to interacting effect of behavioural factors

on subjective norm and PBC variables. The effect size of interaction of behavioural factors

on PBC and subjective norm measurement scales produced the greatest standardized

significant effect size of 0.608 (61%); p<0.05).

4.12 Moderating Effect of Cultural Factors on Open Defaecation Behaviour Moderating effect size of cultural factors on pupils open defaecation behaviour is

presented in Table 4.25 below.

Table 4.25: Coefficient Results for Pooled Effect of Cultural Factors on Open Defaecation Intention and Open Defaecation Behaviour

SEM Independent Impact Dependent Standardized S.E. t- p-value Path Variables Variables Effect Size (r) statis Model tics Pooled cultural factors ------> OD 0.63 0.653 9.25 0.000* M3 Intention Pooled cultural factors -----> OD 0.23 0.252 3.87 0.021* Behaviour

*All coefficients significant at p< 0.05. M3= SEM path model 3.

Cultural variables included on the cultural measurement scales in this study were perceived taboos, traditional values, superstitions and traditional norms. Pooled effect size of these variables which showed statistically significant associated with pupils’ open defaecation intention and actual open defaecation behaviours at bivariate analyses stage were subjected to SEM path analysis (M3) to estimate their mean effect sizes on pupils’ open defaecation behaviour. The results produced were statistically significant (Table 4.25 above), suggesting that cultural factors included on cultural measurement scale explained 63% of variance in occurrence of open defaecation among pupils (standardized effect = 0.63; S.E = 0.653; t =

925; p<0.05).

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Similarly, behavioural factors included on pupils’ satisfied open defaecation intention measurement scale was also statistically significance when subjected to same SEM path analysis M3) the results produced is presented in Table 4.25. (standardized effect = 0.23;

S.E = 0.252; t = 3.87; p<0.05). This result suggests that 23% of the variance in pupils open defaecation behaviour was explained by pupils’ satisfied intention with open defaecation behaviour. This finding presupposes that in terms of pupils’ satisfied intention to engage in open defaecation behaviour, cultural factors (taboos, superstitions, traditional norms and knowledge of traditional values) in their pooled state have strong statistically significant positive impacts on pupils’ intention to defaecate in the open.

4.12.1 Effect of Individual Cultural Factors on Open Defaecation Intention and

Open Defaecation Behaviour

The effect sizes of individual cultural factors considered in this study on pupils’ open defaecation intention and open defaecation behaviour were also estimated using the SEM path analysis. The results of the path analysis are presented in Tables 4.26 and 4.27 below.

Table 4.26: Coefficient Results for Effect of Individual Cultural Factors on Open Defaecation Behaviour

SEM Independent Impact Dependent Standardized S.E. t- P- Path Variables Variables Effect Size (r) statistics values Model Perceived influence ----> OD 0.462 0.115 33.406 0.00 M6 of taboos behaviour Perceived influence -----> OD 0.425 0.105 41.541 0.00 of traditional norms behaviour Perceived influence -----> OD 0.728 0.180 59.933 0.00 of superstition behaviour *All coefficients significant at p< 0.05. M6= SEM path model 6. OD= open defaecation

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Table 4. 27 : Effect of Individual Cultural Variables on Open Defaecation Intention

Independent Impact Dependent Standardized S.E. t- P- variables Variables Effect Size (r) statistics values Perceived influence -----> OD Intention 0.012 0.090 0.247 0.805 of traditional values

M7 Perceived influence -----> OD Intention 0.138 0.034 2.814 0.005* of superstition Perceived influence -----> OD Intention 0.077 0.059 1.566 0.117 of tradional norms Perceived influence -----> OD Intention -0.098 0.054 -1.980 0.048* of taboos *All coefficients significant at p<0.05 OD =open defaecation M7= SEM path model 7.

The data presented in Table 4.26 above showed that all the predictor variables included on the cultural measurement scales, which showed significant association with open defaecation behaviour at bivariate stage, yield significant mean effect size with pupils open defaecation behaviours, with superstition producing the largest mean effect size

(standardized effect= 0.728; p<0.05) which is statistically significant. Also, both taboos and superstition yielded statistically significant effect sizes with pupils’ intention to engage in open defaecation behaviours (Table 4. 27) (Taboos: standardized effect = -0.098; p<0.05); superstition: standardized effect = 0.138; p<0.05. Other predictor variables on the cultural measurement scale yielded no significant effect size with pupils’ satisfied open defaecation intention to report.

4.13 Interacting Effect of Behavioural and Cultural Factors on Open Defaecation

Behaviour

The interaction effect size of behavioural and cultural factors included on both cultural and behavioural measurement scales on pupils’ satisfied open defaecation intention was also determined in a SEM path analysis (M5) with the aid of AMOS software version 24 141

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(Arbuckle, 1997). In this analysis, cultural factors found to have significant associations with pupils’ open defaecation behaviour at bivariate analysis stage were used as proximal antecedent indicator to open defaecation behaviour.

The behavioural factors included on attitude, subjective norm and PBC measurement scales were used as independent variables. The combined effect sizes of all the independent variables on pupils’ open behaviours were estimated (M5) using SEM path analysis. The result obtained is presented in Table 4.28 below.

Table 4.28: Coefficient Result for Interacting Effect of Behavioural & Cultural Variables on Open Defaecation Behaviour

SEM Independent Moderati Dependent Standardized S.E. t- p- Path Variables ng Variables Effect size (r) statistics value Model Effects Size

Behavioural factors ⁂ -----> OD behaviour 0.682 0.125 6.58 0.000* Cultural factors Subjective norm ⁂ -----> OD behaviour 0.117 0.285 3.02 0.003*

Cultural factors M5 Perceived behavioural

⁂ -----> OD behaviour 0.001 0.336 0.026 0.979 control Cultural factors

Pooled culture factors -----> OD behaviour 0.585 0.205 5.020 0.000*

⁂ =Interaction *All coefficients significant at < 0.05 . OD= open defaecation. M5= SEM path model 5.

This result presented in Table 4.28 above showed significance interacting effect sizes between the following: (behavioural factors on attitude scale interacting with cultural factors on culture measurement scale: standardized effect= 0.682; p<0.05); behavioural factors on subjective norm scale interacting with culture factors: standardized effect =

0.117; p<0.05); behavioural factors on perceived behavioural control measurement scale

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interacting with culture factors, however, produced no significant effect size to report. The variance explained by these aggregate interacting effects of the three behavioural variables with cultural factors was (59% (0.585). By statistics, these results indicated that cultural factors significantly moderate pupils’ behaviours to engaging the open defaecation practices.

4.14 Moderating Effect of Demographic Variables on Open Defaecation

Behaviours

The moderating effect of demographic variables on pupils’ open defaecation behaviours are presented in Table 4.29 below.

Table 4. 29: Moderating Effect Size of Demographic Variables on Open Defaecation Behaviour

SEM Path Independent Impact Dependent Standardized S.E.(t-values) P-value Model Variables Effect Size(r) Variables

Gender -----> OD -0.028 0.198 (-0.566) 0.571

M13 Age -----> OD -0.026 0.057 (-0.522) 0.602

Education -----> OD -0.038 0.046 (-0.761) 0.447

Locality -----> OD 0.101 0.188 (2.033) 0.042*

*All coefficients significant at p<0.05; [t-values are in parenthesis] OD open defaecation. M13= SEM path model 13.

The data in Table 4.29 on moderating effect size of demographic variables on pupils open defaecation behaviour showed that only locality produces statistically significant effect size with pupils’ open defaecation behaviour (standardized mean positive effect size=

0.101; p<0.05). All other variables produced no significant effect size on pupils open defaecation behaviour to report. 143

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4.15 Summary of Path Coefficients Estimated For the Dependent and Independent Variables

Presented in Table 4.30 is summary of SEM path coefficients for the dependent and independent variables.

Table 4.30: Summary of Path Coefficients Estimated For the Dependent and Independent Variables

Variables Relationship Antecedent/Dependent Standardized Effect Size S.E t-statistics p- Variables (r) values Path Coefficients Estimated for Effect Size of Behavioural Factors on Open Defaecation Practices

Perceived privacy of OD ------> Open Defaecation -0.06 0.022 -1.212 0.226

Perceived comfort of OD ------> Open Defaecation 0.116 0.029 2.347 0.019*

Awareness of OD risks ------> Open Defaecation -0.028 0.038 -0.558 0.577

Knowledge of OD risks ------> Open Defaecation 0.073 0.037 1.483 0.138

Perceived benefit of OD ------> Open Defaecation -0.019 0.038 -0.391 0.696

Path Coefficients Estimated for Interaction Effect Size of Behavioural Factors (Attitude, Subjective Norm & PBC) on Open Defaecation Practice

Attitude ⁂ Subjective norm ----> Open Defaecation 0.363 0.132 44.101 0.002*

Attitudes ⁂ PBC ----> Open Defaecation 0.390 0.112 36.824 0.000*

PCB ⁂ Subjective norm ---> Open Defaecation 0.608 0.112 36.824 0.000* Path Coefficients Estimated for Effect Size of Behavioural Factors on Open Defaecation Intention

Attitude(pooled ) ------> OD intention 0.708 0.665 10.177 0.000*

Subjective norm (polled) ------> OD intention 0.035 0.272 0.917 0.359

PBC (pooled) ------> OD intention -0.114 0.321 -2.961 0.003*

Confidence ------> OD intention 0.060 0.024 0.512 0.008*

Motivation ------> OD intention 0.010 0.332 0.351 0.004

Descriptive Norm ------> OD intention 0.432 0.321 2.328 --

Role model ------> OD intention 0.537 0.152 0.043 0.867 Path Coefficient Estimated for Effect Size of Individual Behavioural Factors on Pupils Open Defaecation Intention

Perceived privacy of OD ------> OD Intention 0.018 0.029 0.365 0.715

Perceived comfort of OD ------> OD Intention 0.081 0.039 1.619 0.106

Awareness of OD risks ------> OD Intention -0.044 0.051 0.884 0.377

Knowledge of OD risks ------> OD Intention -0.016 0.049 0.329 0.743

Perceived benefit of OD ------> OD Intention -0.033 0.050 0.653 0.514

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Table 4.30 (Cont’d) Path Coefficients Estimated for Effect Size of Intention and Perceived Behavioural Control on Open Defaecation

Intention Formation -----> Open Defaecation 0.58 0.132 44.101 0.000*

PBC (pooled) -----> Open Defaecation -0.06 0.321 -3.052 0.002*

Confidence -----> Open Defaecation 0.130 0.043 0.451 0.001*

Motivation -----> Open Defaecation 0.031 0.054 0.834 0.521

Descriptive norm ------> Open defaecation 0.025 0.340 3.231 --

Role model ------> Open defaecation 0.046 0.551 2.739 0.056

Coefficience significant at 0.05; OD=open defaecation; PBC=perceived behavioural control; ⁂=interaction

Independent variables Impacts Dependent Standardized S.E. t- p-values Cultural Factors variables Effect Size startistics Taboos -----> Open defaecation 0.462 0.115 33.406 0.00

Traditional norms -----> Open defaecation 0.425 0.105 41.541 0.00

Superstitions -----> Open defaecation 0.728 0.180 59.933 0.00

Traditional values -----> Open defaecation 0.012 0.090 0.247 0.805 intention

Superstitions -----> Open defaecation 0.138 0.034 2.814 0.005 intention

Traditional norms -----> Open defaecation 0.077 0.059 1.566 0.117 intention

Taboos -----> Open defaecation -0.098 0.054 -1.980 0.048 intention

Coefficient Results For Interaction Effect Of Behavioural And Cultural Factors On Open Defaecation Behaviour

Attitudes ⁂ Cultural Factors -----> Open Defaecation 0.682 0.125 6.58 0.000* Subjective norm ⁂ cultural Factors -----> Open Defaecation 0.117 0.285 3.02 0.003*

PBC ⁂cultural factors -----> Open Defaecation 0.001 0.336 0.026 0.979

Culture factors (pooled) -----> Open Defaecation 0.585 0.205 5.020 0.000*

Table 4. 2: Moderating Effect of Demographic Variables on Pupils Open Defaecation Behaviours Gender -----> Open Defaecation -0.028 0.198 -0.566 0.571 Age -----> Open Defaecation -0.021 0.057 -0.522 0.602 Education -----> Open Defaecation -0.038 0.046 -0.761 0.447 Locality -----> Open Defaecation 0.101 0.188 2.033 0.042

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4.16 Results of Policy Documents Review on School Toilets Provisions The policy documents review process compared the technical requirements of the school toilets in the MLGRD 2010 Revised Sanitation Policy Framework with what was observed from the fields. The reviewed results are presented in ten columns in Table 4.32 below.

These results revealed that all the toilets construction standards outlined in the policy framework in areas of type of vent pipes, number of vent pipes in relation to toilet capacity, diameters and heights of vent pipes were followed. Nonetheless, the toilets were without technical challenges. The major challenges associated with the school toilets which were discovered during the review process were related to squat hole and feet rests sizes with reference to sex and age, and number of squat holes in relation to the school enrolment

(often referred to as pupils-toilet-ratio).

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Table 4. 32: Results of Policy Documents Review on School Toilets Provisions in First Cycle Schools

Columns 2 Columns3 Columns 4 Columns 5 Columns 6 Columns 7 Columns 8 Columns 9 Columns 10

Name of School Present Number of Toilet Squat Squat Holes Type of Vent Pipe Number of Diameter of Vent Pipes Height of Vent Pipe Localities Toilet Type School Holes (s) Dimensions/Size (cm) Vent Pipes (cm) Above Pit (cm) Rural/Urban Enrolment Reco’d Observed Reco’d Observed Rec’d Observed Reco’d Observed Reco’d Observed Reco’d Observed Kofisah M/A Primary 7 Rural 170 5 (2) 4 25 25 PVC PVC 7 ( 1 spoilt ) 15 15 60 60 Kofisah M/A JHS KVIP Rural 81 Akuffokrom M/A Primary Urban 178 25 25 PVC PVC 7 7 15 15 60 60 KVIP 4 (2) 7 Akuffokrom M/A JHS Urban 40 25 25 PVC PVC 7 15 15 60 60 Begoro Presby Primary Urban KVIP 208 8 25 24 PVC PVC 6 6 15 15 60 60 Begoro Presby JHS Urban Pit 67 5 (2) 2 25 30 NIL NIL 6 15 15 60 60 Oboaho D/A Primary 173 Rural 25 24 PVC PVC 6 6 15 15 60 60 Oboaho D/A JHS KVIP 5 (2) 6 Rural 55 25 24 PVC PVC 6 6 15 15 60 60

Akatsi Demons 2 Primary 6 Urban 499 4 25 22 PVC PVC 5 15 15 60 60 11 (2) (1 spoilt) Akatsi Demons JHS KVIP 6 Urban 54 PVC PVC 15 15 60 60 Monome D/A Primary Rural KVIP 171 3 (2) 3 25 30 NIL NIL 3 NIL 15 15 60 60 Monome D/A JHS Rural KVIP 66 2 25 24 PVC PVC 3 Kedzi—Havedzi A.M. E. Primary Rural 132 25 24 PVC PVC 5 5 15 15 60 60

4 (2) 4 Kedzi—Havedzi A.M. E. JHS KVIP Rural 84 25 24 PVC PVC 15 15 15 60 60

Keta A.M.E Primary Urban 152 KVIP 25 24 PVC PVC 4 4 15 15 60 60 6 (2) 4(1) Keta A.M.E JHS Urban 77 25 24 PVC PVC 15 60 60 Note: Number of toilet squat holes for teachers are in parentheses in column 5; Reco’d =recommended

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Table 4. 33: Pupil-Toilet Ratio in the Study Schools and its Bad Effect on Pupils Toilet use

Year Studied Schools from Eastern Region Studied Schools from Volta Region

Kofisah M.A Akuffokrom M.A. Begoro Presby Oboaho D.A Akatsi Demons Monome D.A Basic Kedzi-Havedzi Keta A.M.E

Basic school Basic School Basic School Basic School Basic School School A.M.E Basic School Basic School

Enrolment Enrolment Enrolment Enrolment Enrolment Enrolment Enrolment Enrolment

Acc’ble Not Acc’ble Not Acc’ble Not Acc’be Not Acc’ble Not Acc’ble Not Acc’ble Not Acc’ble Not

Acc’ble Acc’ble Acc’ble Acc’ble Acc’ble Acc’ble Acc’ble Acc’ble

2010 175 — 139 — 141 — 68 — 397 — 154 — 148 — 155 —

2011 187 (12) 151 12 154 13 87 19 491 14 169 15 160 12 162 7

2012 211 24(36) 164 11(23) 158 4(17) 92 5(24) 513 22(36) 186 17(32) 178 18(30) 173 11(18)

2013 215 4(40) 177 7(30 170 12(29) 105 13(37) 521 8(44) 197 11(43) 187 9(39) 185 13(31)

2014 224 9(49) 196 19(49 162 8(37) 114 5(42) 527 6(50) 213 16(59) 191 4(43) 197 12(43)

2015 236 15(64) 203 17(66) 160 2(39) 125 11(53) 546 9(59) 224 11(70) 202 11(54) 212 15(58)

2016 251 5(69) 218 15(81) 175 15(54) 128 3(56) 553 7(66) 237 13(83) 216 14(68) 229 17(75)

Excess 69 81 54 56 66 83 68 75

2017 Nsawam—Adoagyiri Municipal =150 Fanteakwa District= 110 Akatsi South District = 149 Keta Municipal = 143

2017 Eastern Region =260 Volta Region= 292

Note: Acc’ble =Accessible

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4.16.1 Toilet Suitability

This result presented in Table 4.32 above showed that some of the KVIPs used in studies schools have squat holes with either smaller or bigger dimensions compared to the prescribed dimensions in the 2010 revised sanitation policy framework.

4.16.2 Pupil-Toilet Ratio

The results presented in Table 4.33 described the current states of pupil-toilet-ratios in the studied schools within the periods 2010-2016. These results showed that the current pupil- toilet ratio in the schools are high compared to what policy recommended. For example, in 2010 the toilet in Kofisah M.A basic school was constructed to serve a population of

175 pupils (Table 4.33). In 2011, the school enrolment increased to 187 from 175 indicating that 12 pupils in 2011 were without toilet. This number of pupils without toilet facility has increased to 224 in 2014 indicating an excess of 49 pupils with no toilet facility.

In 2016, study schools in the Eastern and Volta regions have the following number of pupils without toilets. Eastern-260, Volta-292 (Table 4.33). These results indicated that the pupil-toilet ratio continued to increase annually with increase in school enrolments suggesting that toilet facilities used in the study schools were inadequate causing pupils to queue before accessing the facility. These results confirmed the qualitative data obtained from the FGDs and checklist observation.

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CHAPTER FIVE

DISCUSSIONS

5.1 Socio-demographic Characteristics of Study Participants

Out of the 400 participants, 55% were aged between 14-18 years and 45% were in the age range group of 9-13 years. Regarding their educational background, 48% were in primary class 4-6 and 52% were in Junior High School forms 1-3. With participants’ religion, 89% were christians whilst the rest comprising 9% and 2% belonged to Muslim and Traditional religion respectively. This result suggests that more than two-thirds of the study participants were christians. The ethnicity distribution of the participants was: 54% Ewes,

13.8% of Ga-Dangme extraction, 15.2% belonged to Akans ethnic group. The Akuapem were 15.2%. The remaining 1.7% were from the Moshi and the Guans ethnic groups.

This result showed that majority of the study participants were Ewes, thus emphasizing the migratory pattern of the Ewes in the study areas. These findings underscored the importance of differences in ethnicity in understanding cultural and behavioural factors that influence open defaecation practices in schools.

5.2 Conditions and Usage of Toilet Facilities in the First Cycle Schools

5.2.1 Hygiene and Access in School Toilets

Studies (Jenkins & Scott, 2007; Appiah & Oduro-Kwarteng, 2011) have identified some technical drivers associated with school toilets which affect their regular usage These include design and construction, mechanisms to desludge excreta, siting of facilities and user behaviour relating to convenience and prestige (Jenkins & Scott, 2007; MLGRD,

2010b; Appiah & Oduro Kwarteng, 2011). They demonstrated that where one or combination of these factors do not meet the defaecation preference of toilet users, the

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facility is either misused or abandoned. Encouraging millions of school children to use toilets that are likely to be taken further into adulthood will contribute towards achieving the 2030 SDG 6 target 2 of United Nations General Assembly.

The results of this study, however, revealed that pupils were unable to use the school toilets because of the health barriers associated with them. They perceived the school toilets as unhygienic and therefore associated with diseases. This, they attributed to both lack of adequate funds to maintain the toilet facilities and inappropriate design and construction of the facilities. Studies demonstrated that when toilet maintenance system breaks down, the facility becomes unpleasant to use (Schaub-Jones et al., 2006). The present study’s result is also consistent with a number of school based sanitation studies in some countries.

For example, a study (Vernon et al., 2003) in Sweden and United Kingdom demonstrated that schoolchildren avoided defaecating in toilet because the toilets were too filthy.

In Ghana, a study conducted by WSMP (2008) to determine the factors contributing to high incidence of open defaecation behaviours among pupils found absence of clean toilets and lack of adequate privacy to be responsible. The low interest in toilet use by pupils reveals by this study may also be attributed to the fact that the toilet is used by large population of pupils but were poorly maintained. Studies by Cairncross & Feachem (1993) showed that if toilets are not kept clean they may be determined and become a focus for disease transmission and pupils will prefer not to use them. This underscores the importance of providing sex and age based sanitation facilities to schools. As shown in this study, the provision of sex and age based sanitation facility backed by adequate education on proper use of toilet can significantly help reduce the unhygienic conditions of toilets used in the first cycle schools. From the equity perspective, improving access to

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adequate toilet facility is necessary for pupils’ dignity, privacy and safety. Nevertheless, efforts to increase access to improved school toilets should be accompanied by schemes to promote appropriate use of the toilet facilities (Kema et al., 2012). Previous studies

(WHO/UNICEF, 2015 & Kema et al., 2012) have reported that adequate toilets encourages pupils to attend schools, particularly girls. An increase in girls’ enrolment have been credited to providing separate sanitary facilities for girls.

5.2.2 Privacy, Safety and Ventilation in the School Toilets

The present study identified absence of adequate privacy associated with the school toilet system as serious drive contributing significantly to pupils open defaecation behaviours.

The influence of inadequate privacy in toilets and its negative effect on toilet use have been documented in several studies (WATSAN, 2006 & WASH, 2012). For example, a study in Ghana (Gyekye, 2012) reported that absence of appropriate toilets that provide adequate privacy in schools for girls is a major reason parents keep their daughters from attending school. This suggests that adolescent girls attending school during menstruation require girl appropriate toilets, water supply for washing and receptacles for discarded sanitary pads (Kirk, Jackie & Marni Sommer, 2006). Without appropriate toilet facilities, adolescent girls may be unable to remain comfortably in class. In support of this assertion, one school-based study (WHO/UNICEF, 2013) in Ethiopia revealed that over 50% of girls missing between one and four days of school per month is due to lack of appropriate toilet that address their menstruation challenges. Integrating privacy in intervention programs to motivate pupils in the first cycle schools to use toilet may be considered a precursor towards achievement of target two (2) of the 2030 SDG six (6).

For adequate safety for potential toilet users, policy documents on school toilet provision recommend that toilet doors should be well fitted and lockable from inside (MLGRD,

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2010; Zomerplaag & Mooijman, 2005). This study, however, discovered that about 62.5% of the school toilet doors were not lockable from inside as most of the locks were out of order and therefore cannot protect potential users from all forms of harassment and to provide users with adequate privacy (See checklist Observation results at page 95). This situation according to Franceys et al., (1992) could result not only in rape and sexual violence but also lead to toilet avoidance by users.

Bad scent generated from the school toilet as a result of poor ventilation constitutes another key driver associated with the school toilets. This may be attributed to absence of desludgment of faecal matter from the toilet pits. The effect of scent on human behaviour have been reported in several studies and found to have two major behavioural effects: avoidance or approach (Fulbright et al., 1998). Pleasant scents produced approach whilst unpleasant scents produced avoidance and both leave lasting effects on the person’s liking or disliking of a person, place, or thing (Fulbright et al., 1998). Curtis and Biran

(2001) have argued that a mere universal human disgust of faeces, and one might add, of its smell, may reflect ancient biological predispositions to avoid potential sources of diseases.

The present study also revealed that school toilets in two of the eight study schools were located at distances of 25.2m and 22m from the closest classrooms as against the recommended distance of 30m (Adams et al., 2009). The influence of inappropriate toilet location on sustainable toilet use has been documented in several studies (Franceys et al.,

1992; & Adams et al., 2009; Curtis & Biran, 2001). They demonstrated that when toilets are located on the school compound where anybody within the school premises can see anyone entering or leaving the toilets, the location of such toilets, in most cases, are

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perceived as psychologically inappropriate and significantly affects the toilet use (Adams et al., 2009). Going to open defaecation sites, usually referred to as “free range’ is therefore preferred among pupils, particularly the girls as they could not be seen (Adams et al.,

2009). Provision of toilets that appeal to pupils’ defaecation preference and creating a supportive environment for all girls to be able to manage their menstrual challenges hygienically, safely, in privacy and with dignity could be one of the targeted ways of reducing open defaecation practices and school dropouts’ rates found to be associated with the open defaecation phenomenon. Lack of adequate privacy associated with the school toilets as a result of inappropriate location of toilets can therefore be a strong psychological barrier that inhibits pupils, particularly girls, from using the facility (Adams et al., 2009).

Besides, toilets that are sited close to the classrooms do not only allow bad scent from the toilet pits to the classroom to interfere with learning, cognitive functioning, decision making and assimilation of concepts, but it also reduces contact teaching and learning hours since teachers and pupils had to battle with the bad smell amidst teaching and learning respectively.

A study found that bad scent interferes with the enjoyment of activities (Krishna, 2011), causes stress and anxiety (Smeets et al, 2008), nausea, headache, tightening of the chest or other allergic reactions such as frustration mood induction (Epple & Herz, 1999; Herz et al., 2005; Cameron, 2007). This study strongly recommends that a formative study is conducted in the first cycle schools to determine the negative effects of bad odour on human health and learning in order to address this situation in the school system.

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5.2.3 Community and Rodents Encroachment on the School Toilets

Another key factor revealed by the present study as responsible for pupils open defaecation behaviours is community encroachment on the school toilets. The community encroachment increased pressure on toilet use and resulted in filthy conditions of the school toilet and making daily cleaning very difficult. This finding confirmed what was reported in a study by Gyekye (2012) that lack of communal toilet facilities can result in community members encroaching into any readily available toilet facilities and increasing their daily maintenance costs and cleaning burden. The community encroachment on the school toilets has resulted in low toilet use among the pupils. This assertion was confirmed by teachers. They reported that the greatest source of pressures on the school toilets system was lack of toilet facilities in the communities. Absence of community toilets has caused residents to resort to the use of the school toilet thus increasing pressure on the facility.

Though the school authorities may have been successful in preventing school toilet use by residents or ensuring that they make proper use of the facility, it had more often turned into conflicts situations between the school authorities and the community residents. In

Akuffokrom M.A. Basic School for instance, the conflict had resulted in transfer of a teacher from the school in 2011 due to constant threats from the residents). In the absence of communal toilet facilities, this conflicts between the school and the community will continue and thus increases the open defaecation prevalence among the pupils. This situation was, however, identified to be absent in schools where the communities had toilet facilities nearst to the schools. For example, in Oboaho D.A. Basic school in the Fanteakwa

District, the community encroachment on the school toilet was virtually absent because the community had toilet facility. This suggested that when CLTS programmes, which operates on principle of “shock” and “shame” psychological foundation, are extended to

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such communities without toilet facilities, it will help address the conflicts between the school and the community and thus increases toilet use among the pupils.

It is worth noting that a key trigger to discourage traditional open defaecation behaviour and encourage toilet use among pupils in the first cycle schools is around the notion that

“community desist from using the school toilets”. This result indicated that future interventions would benefit by ensuring that when schools are provided with toilet facilities, the community in which the schools are located should also be motivated to construct their own toilet through CLTS program and awareness creation.

Studies (Berkowitz et al., 2004; Rogers, 2003) showed that in places where toilet provision in schools experienced some success, open defaecation remains a continuing problem due to exogenous (external) factors. Effecting sustained toilet use among pupils and in the first cycle schools requires inputs at many levels: appropriate infrastructure provision, ensuring a positive contextual environment, and provision of enablers of the behavioural factors and elimination of barriers must all come together to achieve lasting change. This means that any intervention strategies should target communities in which the sampling points

(school) are located by increasing access to credit with easy terms that could be accessed by households to construct their own toilet facilities.

Closely linked to the community encroachment on the school toilet system is invasion of school toilet premises by rodents. This constitutes another major barrier and threats revealed by checklist assessment results and this is contributing significantly to the pupils’ open defaecation behaviours. The risk of rodents in dwelling places has been documented in various studies (Gratz, 1994). Dangerous rodents such as snakes, lizards, wall gecko,

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spiders, mouse, rats, cockroaches, and houseflies, caused myriad of psychological stress ranging from fear and panic and sometimes health hazards to humans. The conditions of school facilities such as school toilets are therefore a strong determinant of open defaecation behaviour and invariably affects absenteeism (Barnham, 2004 & Alexander et al., 2014). The importance of rodents’ prevention through good hygiene, management and exclusion practices should be emphasized. Teachers as well as the pupils in charge of hygiene in the school have the day to day responsibility of ensuring a rodent management programme is maintained. Nevertheless, research is strongly needed to understand the health and psychological implications of presence of rodents in the school toilet premises and their impacts on pupils’ toilet use and learning.

5.2.4 Technology Drives

The inappropriateness of school toilets’ squat holes was found in this study as an emerging drive preventing pupils from using the faclities. According to Zomerplaag & Mooijman

(2005), children under five years require toilet of different squat hole dimensions than do older children and adults; and specific features need to be taken into account to make the toilet easy, safe and comfortable to use. For example, the squatting holes in a KVIP toilet need to be smaller, and footrests may need to be closer together for younger children thus making it safer, secure and risky free for use by children (Zomerplaag & Mooijman, 2005).

The result of this study, however, revealed that most of the KVIP toilets facilities used in the study schools have squat holes being either larger or smaller than toilet provision policy recommended. In Begoro basic school for example, the squat holes of the KVIP used by

JHS was 30cm in diameter as against the 25cm dimension recommended in the Ghana’s environmental Sanitation policy framework (MLGRD, 2010). Similar observation was made in Kofisah Primary and JHS where the squat holes of the school toilet have smaller

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dimensions compared to what policy recommended. Larger squat holes may cause fear of falling into the squat holes when using the toilets, and smaller squat holes may make it difficult for toilet users to direct the faecal matter into the squat holes, thus resulting in soiling the squat holes areas with faeces and making the toilet filthy and unhygienic. Since school pupils are often powerless to bring improvement in these aspects of their lives, they are largely affected more than the adults.

For sustainable toilets use in the first cycle schools, the provision of pupil-friendly and appealing toilets that compete with the current practice of open defaecation where pupils give fondness to easy access without waiting time, fresh air and adequate privacy is very crucial. This is a wakeup call for sanitation stakeholders and policy makers including

MOE, GES, School Management Committees (SMCs), Parent Teacher Associations

(PTAs), as well as MMDAs in Ghana to ensure that proper and adequate sanitation toilets are provided in the first cycle schools. To this effect, this study strongly suggests a holistic assessment regime of conditions of toilet systems currently used in the first cycle schools and enhance their convenience and comfortability.

5.3 Pupils and Teachers Assessment of Conditions and Usage of School Toilets Encouraging millions of school children to use toilets that are likely to be taken further into adulthood will contribute towards achieving the 2030 SDG six (6) target two (2) of

United Nations General Assembly (UNGA). The results of this study, however, revealed that pupils were unable to use the school toilets because they perceived the school toilets as unhygienic and therefore associated with diseases. The result is consistent with a number of school based sanitation studies in some countries. For example, a study (Vernon et al., 2003) in Sweden and United Kingdom demonstrated that schoolchildren avoided defaecating in toilets because the toilets were too filthy and were perceived to be associated

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with diseases. In Ghana, a study conducted by WSMP (2008) to determine the factors contributing to high incidence of open defaecation behaviours among pupils found absence of clean toilets to be responsible. The low interest in toilet use by pupils revealed by the results of the present study may be attributed to the fact that the school toilets are used by large number of pupils coupled with poor maintenance. Studies (Cairncross & Feachem,

1993) showed that if toilets are not kept clean they may become a focus for disease transmission and pupils will prefer not to use them.

Furthermore, bad scent has also been reported in this study as another key factor associated with the toilet facilities used in the study schools. This was attributed to absence of desludgment of faecal matter from the toilet pits. The influence of bad scent on toilet use has been reported in various studies (Nuzhat & Mohammed, 2006; Vernon et al., 2003;

Lundblad, 2005; Bell & Bell, 2007; Vlahos, 2007; Zaltman, 2003). Bad scent has two major behavioural effects: avoidance or approach (Fulbright et al., 1998). Pleasant scents produced approach whilst unpleasant scents produce avoidance and both leave lasting effects on the person’s liking or disliking of a person, place, or thing (Fulbright et al.,

1998). Curtis and Biran (2001) have argued that a mere universal human disgust of faeces and its bad smell may reflect ancient biological predispositions to avoid potential sources of diseases. These findings emphasized the influence of attitudinal and superstitious beliefs that bad scent are permeable to the body and cause diseases (Craig, 2002; Knudsen et al.,

2008). This means that creating the necessary awareness and education about the negative consequences of open defaecation on health and learning as well as the environment can go a long way to reduce open defaecation behaviours observed among the pupils. One ways this can be done effectively is through the social media platform. According to 2010

PHC, about 78% of Ghanaian used mobile phones (GSS, 2012). Using this broad based

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social media can largely help disseminate information on consequences of open defaecation on health and the environment to these proportion of the populace found to be using phones.

Another similar community-based qualitative study conducted within Sweden communities where the study schools were located found a reluctance across all ethnic minorities to use enclosed toilets, as it was perceived that "dirty air" within the toilets premises could penetrate the body and make people sick (Rheinländer et al., 2010). The present study also found bad smells from the toilets as barrier to toilet use by pupils in the study schools. This was revealed in the quantitative study and supported by the results of the qualitative study. Pupils discussed experiences they had, challenges they faced, frustrations and difficulties they had using the school toilets due to the bad scent they produce. Furthermore, many of the pupils who defaecated in the open noted that they were unable to use the school toilets due to the bad scent they produce. For example, pupils from

Akatsi Demonstration 2 and Akuffokrom Municipal Assembly Basic Schools (M.A) believed that a key disadvantage of using a toilet is the unpleasant scent they generate.

Given these negative perceptions of the pupils regarding their school toilets, open defaecators would describe their behaviour as a more pleasant, convenient and comfortable experiences. This result underscored the importance of provision of user preference and appealing school toilets if pupils are to use them sustainably. A study by Sidibe (2007) showed that provision of user preference sanitation facilities do not only ensure adequate and sustainable use of the facilities, but it also produces positive hygiene behaviours, including correct use and maintenance of facilities by users

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Similarly, the results of the assessment of conditions of the school toilets showed that pupils perceived community encroachment on the school toilets as another key factor responsible for their inability to use the school toilets. The community encroachment has increased pressure on toilet use and resulted in filthy conditions of the school toilets and making daily cleaning very difficult. This finding confirmed what was reported in a study by Gyekye (2012) that lack of communal toilet facilities can result in community members encroaching into any readily available toilet facilities and increasing their daily maintenance costs and cleaning burden. The community encroachment on the school toilets has resulted in low toilet use among the pupils. Indeed, 80% of the teachers confirmed this views expressed by pupils. They reported that the greatest source of pressures on the school toilets system was lack of toilet facilities in the communities.

Absence of community toilets has caused residents to resort to the use of the school toilet thus increasing pressure on the facility.

Though the school authorities may have been successful in preventing community residents from using the school toilets or ensuring that they make proper use of the facility, it had more often turned into conflicts situations between the school authorities and the community residents. In Akuffokrom Municipal Assembly Basic School for instance, the conflict had resulted in transfer of a teacher from the school in 2011 due to constant threats from the community residents. This situation was, however, reported to be absent in schools where the communities had toilet facilities. For example, in Oboaho District

Assembly (D.A) Basic school in the Fanteakwa District, the study found that the community encroachment on the school toilet was virtually absent because the community had communal toilet facility. This suggests that when CLTS programmes, which operates on principle of “shock” and “shame” psychological foundation, are extended to such

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communities without toilet facilities, it will help address the conflicts between the school and the community and thus increases sustainable toilet use among the pupils.

It is worth noting that a key trigger to discourage traditional open defaecation behavior and encourage toilet use by pupils in the first cycle schools is around the notion that

“community desist from using the school toilets”. Future interventions would benefit by ensuring that when schools are provided with toilet facilities, the community in which the schools are located should also be motivated to construct their own toilet through community led total sanitation (CLTS) program and awareness creation. Studies

(Berkowitz et al., 2004; Rogers, 2003) showed that in places where toilet provision in schools experienced some success, open defaecation remains a continuing problem due to exogenous (external) factors. Ensuring sustainable toilet use among pupils in the first cycle schools requires inputs at many levels: appropriate infrastructure provision, ensuring a positive contextual environment, and provision of enablers of the behavioural factors and elimination of barriers must all come together to achieve lasting change. This study therefore strongly suggested that any intervention strategies should target communities in which the school are located by increasing access to credit with easy terms that could be accessed by households to construct their own toilet facilities.

5.4 Occurrence and Frequency of Open Defaecation Behaviour in the Study Schools The result of this study revealed that open defaecation behaviour among the pupils in the first cycle schools involved in the study is 64.8%, and this varies across the sex groups and localities. Among the female pupils, the open defaecation frequency reported in this study was 32.6% per week, whilst in the male pupils’ the frequency is 29.4% per week. These figures are not shocking but described the reality in the schools. This frequency may be attributed to the shared toilet facilities used in the schools. A study (Günther et al., 2011)

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showed that when large population share same facility, the facility in most cases is misused and poorly maintained. These findings also supported by results of a study by Adams et al., (2009) to evaluate WASH needs in Nepal public schools. The study found that the school toilets were not adequately maintained and this situation had resulted in open defaecation behaviours among the pupils. The prevalent level of open defaecation in

Ghana stands at 23% (WAG, 2013). The high open defaecation practices among female pupils (32.6%) revealed by quantitative results of this study and supported by result of the qualitative study may also be attributed to the absence of washrooms, sanitary towel and disposal facilities in the school toilets.

The effect of absence of sanitary facilities on toilet use by female pupils, particularly during their menstrual periods have been reported in various studies (Planned Parenthood

Ghana (PPG), 2007; Adams et al., 2009). For example, in some cultures defaecation should be followed by body washing, and school toilets that do not provide these facilities are in most cases avoided by pupils belonging to such cultural identity and girls have been found to be largely affected when in their menstrual periods (menarche periods). This result further supported the findings of another similar study that determine the role of several actors in promoting in-school hygiene and sanitation practices Planned

Parenthood, Ghana (PPG) (2007). The study found that absence of hand washing kits in school toilets resulted in traditional open defaecation practices among the girls and subsequently culminating in girls’ absenteeism from school. It can therefore be posited that when school toilet facilities have wash and changing rooms attached to them it would help increase female pupils’ toilet use and reduce their absenteeism from schools.

The problems of open defaecation in the first cycle schools therefore need to be treated as a national issue else Ghana’s vision of achieving the sustainable development goal (SDG)

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six (6) target two (2) by 2030 will be illusion. This study therefore strongly underscores the importance of providing professional development training for science education teachers and School Health Education Programs (SHEP) coordinators who are frequently responsible for ensuring safe school sanitation and health in the first cycle schools. The training is also essential for ensuring that teachers replicate evidence-based sanitation programs with fidelity. Once they are made aware of the synergy between the two, they are far more amenable to open defaecation behaviour prevention programs not only in the schools but also in the communities in which they teach.

There is also the need for schools to partner with community-based NGOs and local health and sanitation agencies and departments to hold in-person or online professional development sanitation courses for teachers and head teachers to equip them with health and academic issues which are directly or indirectly related to open defaecation behaviours. Study (Adams et al., 2009) showed that schools that have established this linkage have experienced great success in ensuring delivery of good sanitation services and programs to the school children and reduction not only in open defaecation behaviours but also other associated anti-social behaviours such as school absenteeism, and school dropout rates, particularly for the girls.

With regards to the open defaecation practices across rural and urban localities the result of the present study revealed that open defaecation practices observed between rural and urban studied schools are 26.3% and 25.6%, respectively. This suggests that open defaecation practices in the rural study schools is little above that of the urban schools and this may be attributed to the filthy conditions of toilet facilities used in the rural schools.

This finding is consistent with a number of school based sanitation studies in some

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countries. For example, a study (Vernon et al., 2003) in Sweden and United Kingdom demonstrated that schoolchildren avoided defaecating in toilet because the toilets were too filthy.

The high open defaecation practices recorded by this study between rural and urban schools may also be attributed to the built environment and political ecology of the two localities. Large land space exists in rural areas due to dispersed settlement types and houses resulting from low population density. The availability of land space facilitates physical activities as open defaecation. This, however, is not the case in urban centres where settlement types is largely nucleated due to high population density and which results in reduced land space and open defaecation. Land space is a component of built environment and therefore a determinant of open defaecation behaviours. The relationship between the built environment and open defaecation is also seen in relation to time. For example, the time individual spends to get to open defaecation site compared to the time taken to reach the communal toilet is a function of preference and choice. Even though other factors come to play, the smaller the time spend in getting to open defaecation site the more preferred choice that open defaecation site will be compared to the community toilet. Just as preferences have a role in determining a person’s open defaecation habits, so is the built environment which has the potential to influence open defaecation behaviour in each of these localities. Studies (Hawkins et al., 2013) have also established that access to toilets is much lower in rural areas than in urban localities due to an absence of toilet facilities or few available facilities serving larger numbers of people.

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5.5 Situational Factors That Influence Pupils’ Open Defaecation Behaviour in

Schools

Previous studies have identified filthy toilets as one of the factors hindering toilet use by school pupils (Vernon et al, 2003 & Lundblad, 2005) since dirty school sanitation facilities are associated with increased bacterial pathogens (Aiello, 2008) and with increased incidence of diarrhea and vomiting (Spears, 2014). The results of this study showed that the three most important situational contexts within which pupils in first cycle schools express their open defaecation behaviours centered on filthy conditions of the school toilets, the bad scent emanating from the toilet pits, and lack of adequate privacy in the school toilets. Study showed that one of the obstacles to toilet use is that individual generally perceived the toilets as smelly, dark, small, enclosed spaces that need to be emptied (Vernon, Lundblad, 2003).

Filthy toilet had been linked to toilet inadequacy which, in the school system results from high pupil-toilet ratio (Mendes & Lynch (1976). Studies (Walker, 2010; Crompton, 1999) reported that inadequate sanitation is important for school-aged children, who experience over 2.8 billion cases of diarrhoea annually, and bear much of the burden of soil transmitted helminth morbidity. Inadequate sanitation also leads to stunted growth

(Spears, 2013); diarrheal illness (Fewtrell et al., 2005; Cairncross et al., 2010) and even death (Bartram et al., 2010). It was reported in another study in India that 600,000 under- five children succumbed to diarrhoea, pneumonia and other diseases directly linked to inadequate hygiene practices (UNICEF, 2010). These consequences associated with unclean school toilets are largely enough to cause pupils to engage in open defaecation behaviours.

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Bad scent has also been reported in this study as another key factor associated with the toilet facilities used in the first cycle schools. The influence of bad scent on toilet use has been reported in various studies (Nuzhat et al., 2006; Vernon et al., 2003; Lundblad,

2005; Bell & Bell, 2007; Vlahos, 2007; & Zaltman, 2003). For example, one previous studies have identified smelly toilets as a significant factor playing a role on whether pupils will use the toilet or not (Vernon et al., 2003). Younger children, especially, felt uncomfortable using toilets in such conditions (Nuzhat et al., (2006). Another study

(Lundblad, 2005) among Swedish school children aged between 6-16 years on toilet use habits discovered that they were influenced by their perceptions of pungent scent associated with the schools.

Conversely, similar findings were reported in a qualitative study in Senegal where good smell was a great driver for sustainable toilet compliance behaviour among school children

(Sidibe, 2007). These findings underscore the importance of offering appealing school toilets if pupils are expected to use them sustainably. This shows clear indication that the open defaecation behaviours observed among the pupils was as a result of their dissatisfaction with bad odours associated with school toilet facilities available to them.

Absence of regular maintenance and cleaning are the major reasons accounting for this.

This study strongly suggests that a separate budget be allocated to allow the school to maintain the toilets and keep them hygienic and appealing for the pupils. Also, teachers need to acknowledge the importance of offering clean and appealing school toilets for supporting good pupils’ sanitation behaviour and encouraging toilet use. Another implication of this finding is that technological innovation must pay much attention to improving level of ventilation in school toilets by either increasing the number of vent

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pipes or the dimeters of vent pipes fitted to the toilets to enhance adequate in and outflow of fresh and polluted air respectively within the toilet premises.

This study also revealed that the open defaecation behaviour observed among the pupils was due to lack of adequate privacy associated with the school toilets. Adequate privacy in toilet facilities are essential ingredients for sustainable toilet use. Previous study

(OECD, 2005)showed that girls in developing countries report missing classes, particularly when they are menstruating, in order to ensure privacy in a communal toilet.

Young people seeking privacy outside the school building may encounter snakes or other dangers (IRC, 2005; Scott, 2010; WASH, 2011). Privacy in school toilets was therefore identified as a key barrier to toilet use by pupils and their dissatisfaction with the privacy status of the school toilet was expressed in various dissatisfaction manners. Studies

(Vernon et al., 2003) showed that privacy is important for children, not just as a requirement for using the toilet, but as personal space. Similarly, people associated pleasure, privacy and comfort with open defaecation and those who defaecate outside toilets, despite having access to toilets, cited the same reasons (Clasen et al., (2014).

5.6 Factors that Prevent Open Defaecation Behaviour in the Study Schools Evidences from the results of the present study indicated that fear of being disgraced

(shame and embarrassment) and loss of social respects from peers, the schools and the community constituted the major factors preventing pupils from engaging in open defaecation behaviours. This is a lifesaving, appropriate and social cohesion behaviour which can be used to discourage open defaecators in the school from their acceptable behaviour. An important issue is whether shame, or the propensity to feel shame, is differentiated by sex. Tangney & Dearing (2002) found that across a range of samples,

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from school children to adults, female respondents reported greater shame and guilt than men consistently. Nevertheless, more research is needed to establish whether self- conscious emotions such as shame are differentiated along sex lines. A study by Giddens,

(1991) showed that shame is negative side of an individual’s motivational scheme’ and plays an important role in self-regulation in its capacity to establish or modify a person’s behaviour and thoughts (Tangney et al., 1995; Williams, 1993) and can generates a higher likelihood of pro-social behaviour. Brown and Marshall’s (2001), in confirmation of this argued out that the greater the extent to which an individual anticipates they will face setbacks or failure with a goal, and this failure can be attributed to internal, stable, and global causes, the more likely shame avoidance behaviour is elicited. Conversely, the greater the setbacks individuals experience in carrying out tasks, the higher the potential for shame to be provoked and the more likely that goal commitment will be reduced

(Sorotzkin, 1985). Similar studies (Janis & Mann, 1977) also reported that individuals may avoid seeking negative feedback for action because they see it as ego-threatening.

Another study by Gough (1998) showed that punishment is essential in good behaviour development. He further argued that the ultimate goal of character development occurs when each person reaches the point where doing “good” becomes automatic or habitual.

It is therefore essential that teachers should ensure that the basic sanitation rules and regulations are followed and that logical consequences are set and kept in a no hostile way.

Teachers should mean what they say and say it without shaming of the pupils. Verbal abuse is no less damaging than physical punishment. As with other disciplinary techniques, teachers should refrain from hurting the pupils’ sanitation preferences by instilling shame, guilt, and loss of trust.

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5.7 Pupils’ Awareness and Perception of Health and Environmental Risk of Open

Defaecation Behaviour

The awareness and perception of health risks of open defaecation behaviour has been documented in various studies (Madeleen, 2000; Hathi et al., 2014; & Spears et al., 2014).

The results of the present study revealed that the greater number of pupils are unaware of the health risk associated with open defaecation practices. This finding indicates that pupils’ awareness of faecal-oral transmission routes was low. This is very dangerous because school environments are high populated and any outbreak of faeco-oral diseases such as typhoid, cholera, diarrhoea, hepatitis, trachoma can easily spread among the school population and cause high health impacts. This finding buttressed earlier study by Hathi et al., (2014); Spears et al., (2014) who found that pathogens are more easily transmitted in high population density environments and thus increases the public health risks and human capital costs.

In Ghana, the first cycle schools have high population density environments and if traditional open defaecation is practiced in such a highly populated environment, it can result in spread of faeco-oral diseases, thus increasing out-patient population and its associated health and social costs. Similarly, an outbreak of diseases in the school can also extend to the homes, and the community. Study by Aiello et al., (2008) showed that infections which children contract in schools will lead to infections in up to half of their household members and that 88% of diarrheal diseases are caused by inadequate sanitation and inappropriate hygiene (WHO, 2008). They further stressed that the consequences of open defaecation for infant mortality and child height are worse where population density is high compared to where it is low (Aiello et al., (2008). A study by Spears (2012 a) reported that even very modest improvements in open defaecation rates in rural India have

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statistically detectable effects on infant mortality, child height, and child cognitive achievement.

The bad effects of open defaecation on health and the environment as discussed above has placed the open defaecation behaviour in the first cycle schools at certain pedestrian level that merits public attention. The feasibility of ending open defaecation in Ghana in general and in the first cycle schools in particular, as crafted in the post 2015 SDG six (6) target two (2) largely depend on the ability of sanitation policymakers within the GES, MOE and

MMDAs to confront the traditional open defaecation behaviour challenges with strong political will and increased budgetary allocations. It also worth noting that provision of toilet facilities to first cycle schools is not enough to substantially reduce the current rate of open defaecation behaviour (64.3%) observed among the pupils.

The behavioural and cultural factors discovered by this study and which are generating strong open defaecation behavioural intention and consequently open defaecation behaviour in first cycle school pupils must equally be addressed. For example, the open defaecation behavioural norms which are held more strongly by open defaecators serve as barrier to pupils toilet use in the first cycle schools.

It is worth noting also that in situations where residents of a given community, families members, neighbours and peers defaecate in the open, this behaviour later becomes part of the local culture and perceived as a common way of life and consequently forms part of one’s daily routine. Indeed, the present study’s results suggest that more than half of pupils in sampled schools would still be defaecating in the open. This is an awaking call for the sanitation policy makers and the teachers.

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Teachers in the first cycle schools must increase their sanitation and health education in their classrooms teaching and learning contexts to motivate and promote proper toilet use among the pupils and in the school. This will also form a base from which health and hygiene promotion can be introduced.

All interventions should, however, look at pupils’ sanitation behaviours, and where needed, reinforce existing positive sanitation behaviour while trying to modify or change behaviour that favours open defaecation and increase disease transmission. For sanitation policy makers, they must ensure that toilet provided for the school children are appropriate to their age, meet their cultural and defaecation behavioural preferences. This can be done by involving them in every aspect of the toilet type selection and construction process.

Involving children in the process would offer hope for sustainability, because as the children grow, they will continue to implement better sanitation practices and influence their own children and community to do the same.

Again, in order to have a sustainable toilet use in the first cycle schools, the school toilets must be compatible with local setting and cultural beliefs systems of the pupils. Study showed that raising awareness and improving environmental knowledge among school pupils helps encourage sustainable toilet use (MDWS, 2011).

5.8 Results of Policy Document Review on Toilet Provision in First Cycle Schools

This section discusses school toilet provision policy framework showing important correlations between different indicators related to the results of the present study.

According to policy requirement the number of toilets for every school depends on the

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school enrolment. A maximum of 50 pupils using one squat hole is recommended (CWSA,

2008).

The results of the present study revealed that the average number of pupils is often higher than even the 50 pupils per drop hole in both rural and urban schools. None of the eight studied schools had increased the number of its toilet squat holes since the toilets were constructed in 2010, suggesting that they were barely managing to keep up with the rise in pupil-toilet ratio due to increasing school enrolment. Inadequate sanitation in schools jeopardize not only pupils’ health but also their school attendance and learning. Girls in particular are largely affected and likely to be kept out of school. Aside this, the toilet provision and management policy framework also stipulates that changing room for adolescent girls and female teachers in each toilet block for girls is highly acceptable. This ensures adequate privacy and convenient for the female sex group

(MLGRD, 2010 & CWSA, 2008). The present study, however, found that these facilities were virtually absent in seven out of the eight school toilets the study covered. This suggests that most girls, particularly the adolescent, may not be conveniently placed in using the toilets during their menstrual periods and may often absent themselves from classes. It worth nothing that good school attendance was important because it is linked to pupils’ academic high attainment and achiement of future career prospects.

Toilets for children should be appropriately sized to ensure that children are comfortable and feel safe in the use of the toilet. Foot rests for squatting units should be appropriately sized and positioned according to user’s age and sex. The results of this study, however, revealed that pupils under five years—preschool pupils—also used the same toilet with squat holes designed for those above five years. This implies that pre-school pupils can

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easily fall into the pit since the facility is not appropriately designed for them. On the other hand, it is likely toilets with squat holes dimensions of 22cm instead of the recommended

25cm were purposely constructed to cater for all aged groups of pupils in the school.

Technically, this may not function well because in the course of trying to satisfy one category of pupils in the school system can result in punishing the others. Reduction in squat hole size by 3 cm can cause the “young adult”—pupils in the primary and JHS streams—soil the squat holes and probably the feet rests with faeces. This was evident from the checklist observation assessment results and the focus group discussion (FGD) sections.

The results of the policy review indicated that the KVIPs in the schools must be desludge every two years. However, the results of this study showed that none of the toilets had ever seen any desludgment since they were constructed for the past five years. This has increased the concentration of odour in the toilet premises. These findings are in concomitant with previous assessment of school sanitation and hygiene education programs in Vietnam where it was reported that overcrowding resulting from high pupil- toilet ratio added to the offensive odour at school toilet since children did not have time and materials to clean toilets with water after use (Nguyen, 2006). This was supported by findings from the qualitative component of this study where pupils queued to access the school toilets and also provided their own toilet cleaning materials. In situations where they could not provide such cleaning logistics, the toilets were left uncleaned. This condition could further enhance their open defaecation behaviours.

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5.9 Behavioural Factors Influencing Open Defaecation in the First Cycle Schools 5.9.1 Effect of Attitudes on Open Defaecation Intentions

Behavioural factors influencing pupils’ open defaecation practices may stems from their attitudes. Attitude refers to the degree to which the person has a positive or negative evaluation of a behaviour (Ajzen, 1988) and have been reported in many studies to correlate significantly with intentions (Ajzen, 1985; Armitage & Conner, 2001; Smith et al., 2008; Eagly & Chaiken, 1993; Fazio, 1990).

The direct positive mean effect of attitude on pupils intention to engage in open defaecation reported in this study was 0.708 with p<0.05. This suggests that behavioural variables included on attitude measurement scales (perceived knowledge and awareness of open defaecation risks, perceived comfort/convenience of using school toilets, perceived level of privacy in the school toilet and perceived benefits of open defaecation) accounted for 71% of variance in pupils’ satisfied intention to engage in open defaecation.

This further indicated that pupils in the study schools hold higher favourable attitudes toward open defaecation intention. Earlier studies (Kim & Hunter, 1993) showed that individual with high attitude towards environmental behaviour had significantly large effect size attitude on intention. This suggested that the high mean positive effect size of pupils’ attitudes on their open defaecation intention found in this study may originate from the parents, siblings, peer group, family situations and conditions of the school toilets.

The result of this study revealed that some of the communities within which the pupils come from have no toilet facilities and therefore defaecate in the open. Due to absence of toilet in the community, pupils may model these open defaecation behaviours during off- school hours from parents, siblings, peers and community members and practice it in the

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school when they evaluate it to be more convenient than toilet use. This finding agreed with the Social Learning Theory (Bandura, 1977) which postulated that observational learning, and the resulting imitation, are fundamental processes within socialization process. The socialization process involves values and beliefs (attitudes) formation from what they observe, hear and listen to from interactions with their environment—family, peers, community and mass media. A study by Tronick & Beeghly (2011) also reported that the socialization process helps children develop a sense of self which determines their behaviour. In support of this assertion, Kerr et al., (2012) argued that parental attitudes and behaviours have greater influence on their children’s behaviours. The theory demonstrated that individuals with high attitude towards specific behavioural intention are generally susceptible and self-conscious to perform the behaviour (Petty & Krosnick,

1995); and perhaps more likely to intend to perform the behaviour based on positive evaluation of the behaviour outcome. Put in another perspective, if the perceived advantages of performing the behaviour outweigh its perceived disadvantages, individuals are likely to form a favourable attitude toward the behaviour. Conversely, if, on balance, the perceived disadvantages outweigh the perceived advantages, a negative attitude is likely to be formed.

This draws attention to the importance of open defaecation behaviours among adults especially in the rural communities and how these may affect pupils’ defaecation preferences. For example, if pupils had a good experience with open defaecation in the home, or communities where they come from, and when this behaviour develops into habits and supported by social norms and values, the pupils will tend to hold much more preference and desire to engage in it even when they are in schools. One serious consequence of this is that if the open defaecation behaviour modeling intention occurs

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during the pupils’ formative period of development, this can develop into habits and consequently attitude. Once attitudes are formed and experiences are acquired through learning and practice, it works into their attitudinal beliefs and value systems. Values according to Lusk & Oliver (1974) refer to a person’s stable life goals, reﬂecting what is most important to him, suggesting that the values a person holds can influence his or her defaecation preferences and behaviour. For example, a person who values open defaecation may hold high preference for it rather than defaecating in toilet.

Changing the open defaecation behaviours in pupils require addressing the pupils attitudes since their attitude was found to be contributing significantly to their open defaecation behaviours. To do this there is the need to address the cognitive and emotional components of the pupils by providing them with information on the risks associated with open defaecation behaviours.

Also, to be able to influence pupils’ attitudes, there is a need for strategies that are directed to more personal and interpersonal formative experiences. This can help appeal to the emotion and cognitive process of the pupils towards reorganization of their thoughts and consequent attitudinal change.

Nevertheless, it is worth nothing that changing attitude takes time because strong attitudes involve issues of personal relevance and values and are held with great conviction (Petty

& Krosnick, 1995; Raden, 1985). As a result, they are assumed to be persistent over time and be resistant to attack, to influence perceptions and judgments, and to guide overt behaviour (Krosnick & Petty, 1995).

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Although an active concern is still important in predicting an intention to end open defaecation behaviour, the major behavioural predictors of intention is the acceptance of the norm to stop open defaecation behaviour. It is therefore important for teachers not to expect to change pupils’ open defaecation attitudes quickly. They need to understand that attitude change takes time and should not set unrealistic expectations for rapid change

(Moore, 2003). A study by Disinger et al., (2001) showed that children are more open to accepting influences on their attitudes than they are open to accepting influences on their behaviours. The implication of this to classroom teachers who want to shift pupils from open defaecation behaviours to toilets use is that their strategies must appeal to pupils’ attitudes rather their behaviours. Attitudinal changes among children was found to be easier to achieve than changes in behaviour through conventional educational strategies of influence (Disinger et al., (2001). Intensive attitudinal campaigns can gain demonstrable success in a relatively short time. Their success can be reinforced by intrinsic motivation and not by sanitation bye-laws, school rules and regulations, or social pressure (Disinger et al., (2001). According to social constructivism, attitudes are socially constructed, and individuals need to be involved in their learning processes (Novack, 1993; Gergen &

Gergen, 1986).

The present study therefore strongly suggested that more effective influence on pupils’ attitudes can be achieved through constructivist approaches that actively involve pupils by relating to their closest and immediate circles. This implies that teachers in the first cycle schools must be seen as guides—helping pupils to construct their own sanitation behaviours and attitudes—rather than being instructors—directing pupils to acquire lay down sanitation attitudes. Nevertheless, strategies designed to address pupils attitudinal change must be planned within the general context of compelling situational drivers,

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particularly those associated with the school toilets, pushing pupils to engage in open defaecation practices.

5.9.2 Effect of Subjective Norm Behaviour on Open Defaecation Intentions

Evidences from a plethora of studies showed that human behaviour is guided not only by attitudes (Fishbein & & Ajzen, 2010; Ajzen & Fishbein, 1974; Godin, & Kok, 1996;

Fazio, Russell, 1990) perceived behavioural control (Bandura, 1986), perceived barriers

(Janz & Becker, 1984), and risk assessments (Weinstein, 1989) but also by perceptions about others’ beliefs (Ajzen & Fishbein, 1980) and behaviours (Fishbein & Ajzen, 1975).

This constitutes individual subjective norm which refers to “the person’s perception that most people who are important to him or her think he/she should or should not perform the specific behaviour in question” (Fishbein & Ajzen, 1975). This suggested that the behavioural factors influencing pupils’ open defaecation practices may have strong root cause from their subjective norm belief system.

The result of this study, however, revealed that subjective norm has less significant effect size of 0.035 (4%) on pupils intention towards open defaecate behaviour (r=0.035; SE=

0.272; t= 0.917; p>0.05). This means that in aggregation, behavioural factors included in subjective norm measurement scales (descriptive norm, extrinsic motivation and role models influence) play less significance role in influencing pupils’ intention towards open defaecation behaviour. This result is consistent with discussions in the literature reviewed.

For a wide range of behaviours, the correlation of prediction of intentions from subjective norms ranges from 0.34 to 0.42 (Albarrac´ ın et al., 2001; Armitage & Conner, 2001;

Godin & Kok, 1996; Hagger et al., 2002b; Sheeran & Taylor, 1999). One possible theoretical explanation put forwards to explain this proposition is that an individual under

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social influence will try to conform to the expectations of others (Shen et al., 2006). When individual evaluates the social influence to be positive, the behaviour is executed (Ajzen

& Fishbein, 1980; Fishbein & Ajzen, 1975). In contrast, where it is unfavourable individual tends to avoid executing any intended action (Ajzen & Fishbein, 1980).

Nevertheless, the low mean effect size of variables included on the subjective norm measurement scales on pupils satisfied open defaecation intention (0.04, p> 0.05) reported in this study is on the lower side compared to what was reported in theoretical literature reviewed (0.34) (Armitage & Conner, 2001). This may be ascribed to multiples of different personality factors simultaneously affecting pupils open defaecation behaviour intention.

First, the pupils used in this study (9-18 years) are mainly adolescents and who are unlikely to hold high and stable behavioural intention towards open defaecation behaviour since their intentions, particularly those relating to behaviours that are considered negative and therefore checked by social pressure from significant others such as parents, teachers, peers to engage or not engage in the behaviour. Their intentions are also likely to be influenced by exogenous factors like culture, which might have accounted for the low mean positive effect size of predictor variables included on the subjective norm measurement scale on pupils open defaecation intention reported in this study. This finding also supports for peer cluster theory (Oetting & Beauvais’s,1987) which postulates that adolescents tend to cluster around like-minded others who engage in similar behaviours.

According to the theory, an individual under social influence such as the peer group will try to conform to the expectations of the group behaviour (Shen et al., 2006). For example, in a peer group where members engage in open defaecation behaviour, this behaviour will be the group norm and every member of the group will conform to.

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Again, it is worth noting that in a given family all important family matters are discussed in the family as they work together to achieve a common family goals (Oetting &

Beauvais’s,1987). The more supportive the subjective norms from the family, the higher the intention to engage in a given behaviour. If the target behaviour is more attractive to the individual, the intention will be higher. Conversely, if family members perform the target behaviour—open defaecation as in this case—the younger generation within that family will model such behaviour. This is done in two ways: first, they make assessments about advantages and disadvantages that are likely to result and then gauge the acceptability of the behaviours, and make comparisons between themselves and others whom they perceive to be engaging in those behaviours; second, the more attractive and beneficial the target behaviour is to the individuals, the higher the intention generated towards execution of the behaviour. This view supports earlier findings by Shapero (1975) who found that exogenous factors such as family culture and friends influence individuals to exhibit a given behaviour. Therefore in making choices humans are adept at rationalizing the negative outcomes of their choices (Festinger, 2005).

It is evident from the present study that one reason for the low performance of behavioural variables included on subjective norm measurement scale to pupils open defaecation behaviour was the presence of imbedded personality moderators. Future researchers employing the Theory of Planned Behaviour (TPB) to investigate influence of subjective norm on open defaecation intention should account for the possible moderators of the subjective norm for more accuracy in this area. As Ajzen (2002) pointed out, the low variability mean response to subjective norm may be motivated by an obvious reason comprising important persons within the individual immediate environment. In the school

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system, these important personalities include the school authorities (teachers and head teachers) who may approve desirable behaviours and disapprove undesirable behaviours.

Another theoretical explanation to the low mean effect size (influence) of behavioural variables included on the subjective norm measurement scale on pupils open defaecation behaviour intention reported in this study is evident in the social norms approach theory

(Miller & McFarland, 1991; Toch & Klofas, 1984). This theory posits that individual behaviour is influenced by wrong perceptions of other members of the social groups such as families, peer groups and the school system think and act (Miller & McFarland, 1991;

Toch & Klofas, 1984). For instance, an individual may overestimate the permissiveness of peer behaviour with respect to open defaecation or underestimate the extent to which peers engage in healthy behaviour. The theory predicts that overestimations of problem behaviour will increase these problem behaviours while underestimations of healthy behaviours will discourage individuals from engaging in them (Linkenbach & Perkins,

2003B). Thus, correcting misperceptions and superstitions that open defaecation promotes good ventilation; accumulation of faeces at a place brings bad luck; children‘s faeces are not harmful; losing one’s respect for sharing toilet with others; fear of losing one’s unborn children in the case of pregnant women; of group norms is likely to result in decreased open defaecation behaviour or increased healthy behaviours such as toilet use. On the contrary, highlighting the negative consequences of open defaecation behaviour will discourage individuals from engaging in it. Subjective norm variables included in the subjective norm measuring scale are therefore less important constructs in this study, as the result shows that they weakly correlated with the pupils’ intention to engage in open defaecation behaviour.

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These findings have significant implications for teachers in the first cycle schools and sanitation policy makers trying to end open defaecation in Ghana. There is the need for policy programmes to highlight and strengthen awareness programmes and interventions measures that aim at changing pupils’ open defaecation behavioural attitudes more than the subjective norm. Nevertheless, any intervention measures to address pupils open defaecation behaviours must take into consideration the individual psychological variables separately rather than in aggregation. This is because in this study it was discovered that behavioural factors included in attitudes and subjective norm measurement scales working in aggregation tend to increases pupils open defaecation behaviours rather than slowing it.

For example, interacting behavioural factors on subjective norm measuring scale with those on attitude and PBC measurement scales produced effect sizes of 36%, and 39% respectively. However, the individual effect sizes of behavioural factors on subjective norm and PBC were (-0.114, p<0.05 and -0.06, p<0.05 respectively.

Finally, the conditions of the school toilet environment is another essential ingredient that can motivate and attract pupils to use the toilet and shun open defaecation behaviours. First of all, the toilet must be accessible and of quality that contributes to pupils defaecation preferences. If pupils perceived the toilet premises and its environs as neither safe nor conducive, it will be difficult for them to use it. Findings from the present study showed that pupils perceived the school toilets as unhygienic and unsafe, and therefore avoid their use. This finding confirmed earlier study (Becker, 1974) which found that a person’s perceived risk of contracting an illness and the perceived severity of its consequences are likely to trigger development of healthy practice behaviour. The low variability mean effect size of behavioural factors included on subjective norm measuring may be motivated

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by obvious reasons comprising school authorities (teachers and headterchers) to approve desirable behaviours and disapprove undesirable behaviours.

5.9.3 Effect of Perceived Behavioural Control (PBC) on Open Defaecation

Behaviours

The behavioural factors influencing pupils’ open defaecation practices may stem from pupils PBC belief system. The PBC is the perceived ease or difficult of performing a behaviour under different situations when the behaviour may go beyond one’s controllable aspects of predicting behaviour directly or through intention (Ajzen, 1991).

Behavioural factors (variables) included on PBC measuring scale were perceived confidence and intrinsic motivation. A study by Ajzen (2005) showed that people’s behaviours are strongly influenced by their confidence in their ability to perform them.

Given a sufficient degree of actual control over behaviour, people transform their intention into action when the opportunity arises to do so. This further suggested that behavioural control can have a direct effect on behaviour itself, in addition to the indirect effect mediated by intention (Ajzen, 2005).

Findings from the present study confirmed both assertions. This study found that PBC inversely influences pupils open defaecation behaviour and intention both directly (6%; p<0.05) and indirectly (-11%; p<0.05) via intention. This suggests that PBC has inverse mean moderating effect size (influence) on both pupils’ open defaecation intention and actual open defaecation behaviour.

This finding was comparable to what was reported by one earlier study (Smith & Kirby,

2008) which found no or limited effect of PBC on both intention and behaviour. Armitage

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and Conner (2001) similarly reported that across 63 applications of TPB, PBC-intentions accounted for 27% of variance in behaviour. The attitude towards behaviour can override the effect of self-efficacy (Ajzen, 2002), as reported in this study. For example, if a person has strong subjective knowledge about open defaecation behaviour, the person will have higher confidence in the ability to engage in that behaviour. This further suggested that the mediating mean effect of PBC on intention will be weaker when individual has high subjective knowledge about the behaviour. The present study, however, reported low mean effect size of subjective knowledge (4%) on pupils open defaecation intention and this might have accounted for the low mean effect size of PBC (11%; p<0.05) on pupils open defaecation intentions. These findings therefore confirmed this observation. According to

Ajzen (2002), PBC deals with situations when people may lack complete volitional control over the behaviour of interest. Individuals who believe that they have the skills and other resources needed to perform the behaviour or overcome barriers are likely to develop a strong sense of self-efficacy or PBC, whereas people who believe that they lack the requisite resources are likely to have a much weaker sense of personal agency (Ajzen,

2002).

The low mean effect size of PBC (6%; p<0.05) on pupils open defaecation behaviour, as reported by this study, may be attributed to the conditions (nature) of the school system as pupils’ self-efficacy to engage in open defaecation behaviour is largely limited by school rules and regulations governing sanitation behavioural intentions including the open defaecation behaviour. This implies that the school toilet system may lack adequate comfortability, privacy and security, and personal defaecation preferences. This might have accounted for high intention of pupils (58%) to engage in open defaecation behaviour. One theoretical explanation to this is found in social cognitive theory which

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posits that individuals do not simply respond to situational influences, but rather they actively seek and interpret information (Nevid, 2009), prior to the execution of the behaviour. The more favourable the evaluation outcome, the stronger the PBC towards performing the perceived behaviour (Nevid, 2009). In context of open defaecation behaviour, besides this inherent factor, studies confirmed the influence of other variables, such as socio-demographic variables (Phuah et al., 2012), health awareness (First &

Brozina, 2009; Salleh et al., 2010); and reference knowledge (Amran & Nee, 2012; Saleki et al., Seydsaleki & Rahimi, 2012).

Again, the behavioural achievement of PBC depends upon confidence and accuracy of perceptions. The low level of self-efficacy of pupils to engage in open defaecation practices as reported in this study may be ascribed to their low level of knowledge and perception about effects of open defaecation behaviours. For example, if an individual perceive low accuracy of perception, PBC may not be realistic with respect to little information (Ajzen, 1991). A study by Yzer (2012) reported that when moderation effects of PBC on behaviour intention is weak, PBC is likely to affect the behaviour directly; he further explained that the actual control of individual over his or her environment does not guarantee that the performance of the behaviour will occur in a specific situation. By this,

Yzer (2012) means that an individual cannot engage in any behaviour for which he or she does not have the required skills and resources to execute. He concluded that situational factors are likely barriers to enhancing the behaviour performance (Yzer, 2012).

Another study by Cheung et al., (1999) also reported that PBC moderates control beliefs to promote or inhibit the performance of the behaviour. Self-efficacy therefore has greater influence over individual ability to learn, their motivation and their performance, as people

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will often attempt to learn and perform only those task for which they believe they will be successful (Lunenburg, 2011). In the context of open defaecation behaviour, studies confirmed the influence of a number of factors, such as previous experiences related to the open defaecation behaviour, convenience perceptions, perceived monetary barriers, perceived time barriers, and other factors, that increase or decrease the perceived level of feasibility of open defaecation behaviour—these variables constituted situational factors.

Evidence from the results of the present study, however, indicated that the open defaecation behaviours observed among the pupils in the first schools are largely influenced by behavioural factors emanating from their attitudinal belief systems with minimal contributions from pupils PBC belief system. The current results therefore provided some support for the role of situational factors in influencing open defaecation behaviours.

5.9.4 Effect of Intention on Open Defaecation Behaviours

Behavioural intentions are self-instructions to execute particular behaviours (Triandis,

1980). Previous studies on intention-behaviour relations (Armitage & Conner, 2001;

Godin & Kok, 1996; Randall & Wolff, 1994; Shephered et al., 1988; Sheeran, 2002) showed that intentions have strong associations with environmental behaviours.

Finding from present study revealed that the mean positive effect size of intention on pupils open defaecation behaviours was 0.58 (variance-58%). This mean effect size is comparable to what was reported in some previous studies (Fishbein & Ajzen, 1975;

Gollwitzer, 1993; Triandis, 1977). Authors of these studies found mean intention- behaviour correlation of 0.47 (47%). Similar studies have also reported mean behaviour-

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intention correlation of 0.53 (variance-53%) (Notani, 1998; Shepherd et al., (1988); 0.45

(45%) (Randall & Wolff, 1994); and as high as 0.62 (variance-62%) (van den Putte, 1993).

The mean correlation of open defaecation intention and actual open defaecation behaviour itself discovered in this study may be attributed to the direct result of personal influences and situational factors with the later assuming a more significant role in motivating open defaecation behaviour among pupils and in the first cycle schools. These situational factors emanate from the conditions of the school toilets and which include: filthy toilet; pungent odour from the toilet pits; inadequate toilet drop holes with reference to the school enrolment; lack of adequate privacy in the school toilets; presence of fearful rodents in the toilet premises; and inappropriate toilet squat holes sizes. This result agreed with some earlier studies (Jenkins & Scott 2007; MLGRD 2010b; Appiah & Oduro-Kwarteng, 2011) which reported that when toilet facilities lack user preference the facility is discarded by beneficiaries. This suggests that the open defaecation behaviour observed among the pupils and in the first cycle schools involved in the study was the direct result of interaction between pupils open defaecation preferences and the situational factors associated with the conditions (nature) of the school toilet and this works through their intentions. Andrews et al., (2003) examined the relationship between behavioural intention and subsequent behaviour among children aged between 5 and 9 year and found that intention to engage in any environmental behaviour increases with age. This suggests that pupils aged between

9 and 18 years, as the case in this study, will be better informed about intention towards environmental behaviours. In earlier study intention has been shown to be the most important factor in predicting behaviour, suggesting that behaviours are often linked with one’s personal motivation (Godin, & Kok, 1995).

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The high mean positive correlation of 0.58 (variance of 58%) between behavioural intention and open defaecation behaviour reported in this study has some relevant implication for policy makers and sanitation stakeholders—MMDAs, GES, MOE,

MLGRD—whose objectives aim at ending open defaecation in Ghana and elsewhere as emphasized in the post 2015 sustainable development goal six (6) target two (2). This study strongly suggests that it is important to present information on health and environmental risks of open defaecation behaviour to pupils to help shape their attitudes towards the elimination of the open defaecation behaviours. Whilst doing this there is the need to stress subjective norms or opinions that reject the open defaecation behaviour.

Thus, from the view point and perspective of the present study, intention of pupils in first cycle schools has positive significant impact on their open defaecation behaviours. The theoretical significance of these findings resides in the fact that several important conceptual frameworks in social and health psychology propose that changing behavioural intentions can bring about behaviour change (Ajzen, 1991; Bandura, 1989; Carver &

Scheier, 1998; Gibbons et al., 1998; Heckhausen & Gollwitzer, 1987; Locke & Latham,

1990; Triandis, 1980). These findings suggested that the next decade of research on behavioural factors influencing open defaecation practices should concentrate more on the pupils’ attitudes, intention, and situational factors as postulated by the theoretical frameworks of this study.

5.9.5 Effect of Aggregate Behavioural Factors on Open Defaecation Practices

The mean aggregate effect of behavioural factors included on attitudes, subjective norm and perceived behavioural control (PBC) measurement scales on pupils open defaecation behaviour reported in this study was 58%, a correlation coefficience of 0.58 (S.E. =0.132;

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t= -2.961; p<0.05). This finding is consistent with previous studies which found mean correlation ranging between 0.45 and 0.60 (Beck & Ajzen, 1991; Ajzen, 1985; Armitage

& Conner, 2001; Chatzisarantis et al., 2004).

Within the aggregate effects, behavioural attitude largely accounted for over two-thirds

(82%) of the variance of pupils open defaecation behaviour and 71% of pupils’ intention to engage in open defaecation behaviour. This high positive effect size might have resulted from the application of the mixed methods in data collection. Studies (Olsen, 2004;

Alexander, 2001; Blaikie, 1991; Shih, 1998) showed that combining two methods help overcome the weaknesses or intrinsic biases and the challenges that come from single method studies.

The influence of subjective norm within the aggregate effect size on pupils overall open defaecation behaviour and behavioural intention was r =0.02 (2%); p<0.05 and r =

0.035(4%); p<0.05) respectively. These findings were on the low side compared to what was reported in previous study. For example, a study by Armitage (2001) reported that the average contribution of subjective norm-intention correlation was 0.34 (34%). These variations may be attributed to the average age difference of the sample population involved in present study (9-18 years) compared to the previous studies (above 20-60 years). Studies showed that humans have mindreading belief systems which helps them reason about how beliefs might inﬂuence individual actions, interpersonal communications, and conducts, and the belief system of children is low compared to the adults (Apperly, et al., 2006). Thus, developing intention towards specific environmental objects may be limited in children compared to adults (Apperly, et al., 2006).

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Similar results were also reported in related studies (Armitage & Conner, 2001) which found low correlation values of intention .39 (variance of 39%) for aggregate mean effect of attitudes, subjective norms and PBC on behaviour. Perceived behavioural control (PBC) accounted for 27% of variance in behaviour across 63 applications. In aggregate effects, the results of this study show that the behavioural factors (variables) included on attitude measuring scale constituted the most significant factors contributing to open defaecation behaviours reported among the pupils in the study schools.

The evidence of attitudes causing a particular behaviour has been provided by Ajzen

(1988); Eagly & Chaiken (1993); Fazio (1990). The present study confirmed this assertion and therefore suggests that any intervention measures design to help change open defaecation behaviours discovered among the pupils must largely address pupils’ attitudes amidst other competing variables affecting open defaecation decision process of individual pupils. In addition to this, the confidence with which an attitude is held towards satisfied open defaecation intention and the situational factors including normative constraints, inducements and the individual vested interests in the open defaecation behaviour must be equally addressed if positive open defaecation behaviour change is to be achieved.

5.9.6 Interaction Effect of Behavioural Factors on Open Defaecation Practices

The results of this study revealed that when behavioural variables included on subjective norm measurement scale were interacted with variables on PBC measuring scales, together they produced mean effect size of 0.608 (variance, 61%) with p<0.05. Similarly, when behavioural variables included on subjective norm and attitude measurement scales were interacted, a mean positive effect size of 0.363 (or 36% variance) was produced with probability value of 0.002. This meant that the open defaecation behaviour observed

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among pupils in the first cycle schools involved in this study may be attributed to the interacting effects of composite behavioural factors.

This high mean combined effect size of PBC and subjective norm on pupils open defaecation behaviour reported in this study has strong implication for policy makers and sanitation stakeholders (MLGRD, MMDAs, GES, PTAs, SMCs, etc), and teachers and parents whose objectives aim at ending open defaecation in Ghana and elsewhere as emphasized in the post 2015 Sustainable Development Goal six (6) target two (2). This suggests that in designing intervention strategies to address open defaecation behaviour change, the behavioural factors included on the three psychological measurement scales, which were found to be influencing open defaecation behaviours in the schools, must be integrated to produce greater effect size on open defaecation behaviour change. Teachers and parents’ disagreement on pupils present and future open defaecation behaviours could contribute significantly to pupils lower intentions to defaecate in the open. Another useful preventive strategy could be raising the awareness of pupils who defaecate in the open, on the pernicious influence of their open defaecation behaviours on their health, schooling, and the environment. Helping pupils who defaecate in the open to desist, could have a positive impact on preventing open defaecation intention and initiation.

5.10 Cultural Factors and Open Defaecation Behaviours

5.10.1 Effect of Pooled Cultural Factors on Open Defaecation Behaviours

Every home is a miniature society, contains all the societal value systems and serves as nursery that nurtures all cultural values (Berger & Thompson, 1998). Thus cultural factors play significant role in the perception, habits, and behaviour of individuals. Dukor (2010) reported that when cultural values are enacted and assimilated, they become a form of law or guide to the group this moderate their life activities. The results of the present study

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showed that the pooled cultural variables (taboos, superstitions, traditions values and traditional norms) considered in this study produced mean positive effect size of 63% on pupils open defaecation behaviour. This large mean positive effect size may be attributed to the influence of families, peers, and communities. One previous study (Berger &

Thompson, 1998) demonstrated that throughout existence, an individual behaviour is influenced by his/her environment—family, friends, peers, mass media and the school— and more importantly the cultural environment that teaches him/her values, preferences as well as common behaviours to their own culture. This finding from the present study is also comparable to a study conducted by WSP (2012) to determine the cultural factors influencing open defaecation behaviour in rural settings in Ghana, Burkina Faso, Mali, and

Nigeria. They found that taboos and values constituted major cultural factors influencing open defaecation behaviour among study participants.

Many cases of cultural tolerance for the handling of faeces are associated with superstitious beliefs and are common in countries such as China, India and Ghana (Van der Geest, 1998; Ramaswamy, 2005; Esrey et.al, 1998; Hart‐Davis, 2008). Studies (WB,

2010) in Krishnagiri, Pudukottai and Salem Districts reported that people avoided toilet use because they believed it was unhygienic and culturally wrong to have toilets near their houses. The study also reported that they belief that using toilets was culturally unacceptable (WB, 2010) and they are perceptually adapted to open defaecation (WB,

2010). A similar study in Sierra Leone (Mehta & Bongartz, 2009) also demonstrated that people belief that one should not sit over someone else’s faeces because it will lead to bad luck; and an initiated individuals should not sit over the shit of a non-initiate. Reported in another previous study in Kampala also asserted that people believe that pregnant women should not use the toilet because of fear of the death of the foetus (WB, 2010).

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The increasing cultural diversity of pupils in the first cycle schools must be seriously considered when designing a school toilet that competes with values pupils placed on open defaecation. It is only toilet facilities that are culturally designed can appeal to pupils’ defaecation preferences and consequently motivate them to use them. The results of the present study indicates that pupils have different cultural reasons for avoiding toilet use or defaecating in the open. This was evident during the FGDs and in-depth interview with open defaecators. For example, a discussant from Kofisah M.A basic school said that “he avoided toilet use because of fear of being possessed by evil spirit”. Another discussant from Kofisah M.A. Basic School also explained: “I defaecate in the open because the chief of my community also does it”.

These behavioural experiences showed that cultural factors do contribute to open defaecation among pupils in the first cycle schools; and these factors, however, vary from pupils to pupils, and from locality to locality depending on their cultural backgrounds. This meant that teachers in the first cycle schools must know that the pupils they teach come from families with different cultural background and can be more or less influenced by parental sanitation behaviours. As a consequence, it is important that teachers collaborate with parents to instil in pupils positive attitudes that will help them avoid open defaecation behaviour. They must develop sanitation activities that can promote development of proenvironmental sanitation behaviour in the pupils they teach. A study (Senge et al.,

1994) suggests that teachers should be producers of environment that allow pupils to learn good sanitation behaviours as much as possible.

The result of the present study futher revealed that the studied schools admitted pupils from adjoining communities and these communities lacked toilet facilities and therefore

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practice the traditional open defaecation. This suggested that the open defaecation behaviours observed among the pupils are true reflection of community norm. For instance, in one of the FGDs, one discussant from Kofisah M.A Basic School explained:

“I defaecate in the bush because it is not a taboo since the chief of the community also does it”. Since culture is acquired through observation and learning the open defaecation behaviour observed among the pupils was as a result of what they are exposed to in the communities they come from. One previous study (Tomasello et al., 1993) reported that when people, particularly children begin to understand full-fledged intentional action of adults—including the rudiments of the way adults make rational decisions in choosing action plans for achieving their goals in particular real life situational contexts and selectively attending to goal-relevant aspects of the situation, this kind of understanding leads to some powerful forms of cultural learning, especially imitative learning in which the observer must perform a means-ends analysis of the actor’s behaviour and say in effect

“When I have the same goal I can use the same means. This suggested that goal-achieving actions parents exhibit in homes are emulated by children and thus has significant influence on their behaviours.

A study (Treven & Treven, 2001) found that the conscious behaviour of most individual is acquired through learning and interacting with other members of his or her culture suggesting that culture is learned from the people individuals interact with as they are socialized and the home is the custodian of cultural value system. For instance, the home initiates the child into his or her value system and the cultural norms such as sanitation behaviours. Through this attitudes are acquired. In his study to determine how attitudes, which determines human behaviour, are acquired by children born to a particular culture,

Lewis (1969) found that such attitudes are acquired through learning and this learning is

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coordinated by social norms and customary rules of behaviour. He further stated that once a particular way of doing things becomes established as a norm, it continues in force because individuals prefer to conform to the norms given the expectation that others are going to conform. This suggested that social norms (Ajzen & Fishbein, 1980), cultural traditions, and family customs influence and shape individuals attitudes towards environmental behaviours. For example, if the dominant culture propagates open defaecation behaviour-lifestyle that is acceptable, open defaecation is more likely to occur.

Nevertheless, it must be indicated that other confounding predictor variable such as genetic traits, which were beyond the scope of this study, may also account for the persistent open defaecation behaviours of pupils in the first cycle schools.

5.10.2 Effect of Individual Cultural Factors on Open Defaecation Behaviours

Regarding the individual cultural variables included on the cultural measurement scale, all the variables in their individual state yielded statistically significant positive effect on pupils’ open defaecation behaviours:(perceived influence of taboos: standardized mean effect = 0.462, p = 000; traditional norms: standardized mean effect = 0.425, p<0.05; traditional values:standardized mean effect = 0.276, p<0.05; and superstition: standardized mean effect= 0.728, p<0.05).

This result suggested that 46% of the variance in pupils open defaecation behaviour was due to the influence of taboos. Taboo is a prohibition of certain social action which may cause violation of some norms commonly held by all in the society or which may call the wrath of a supernatural punishment believed by members of the society (Jejeebhoy, Shah,

& Puri, 2003). The influence of taboos on intention and actual open defaecation behaviours have been documented in some previous studies (Fawcett, 2008; Ramanantsoa, 2004 &

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Jewitt (2011). For example, Jewitt (2011), in a study to determine cultural factors influencing open defaecation behaviours reported taboos surrounding human excrements as significant cultural factors endorsing open defaecation behaviours.

Previoues studies (Black and Fawcett, 2008; Ramanantsoa, 2004) in Madagascar to determine the cultural factors influencing open defaecation behaviours also reported that it is taboo to store sewerage underground for fear of contaminating the dead; and putting one person’s faeces on top of another’s both of which exclude the use of drop and store systems.

Open defecation is culturally encouraged in Idoma communities as it is a taboo to defaecate in toilets, and many older people still refuse to defaecate in any sort of enclosed environment (WA, 2008). Among the Idoma communities, husbands do not allow their wives or daughters to share toilets with them, and will generally refuse to pay to build toilets for the use of female family members (WA, 2008). Another study conducted in rural communities in Ghana, Burkina Faso, Mali, and Nigeria to find out the cultural factors reinforcing open defaecation practices revealed that the practice of open defaecation was surrounded by taboos (WA, 2008).

Traditional examples of influence of taboos on open defaecation have been observed in some communities in Sierra Leone. It is a belief among the Kampalans that pregnant women should not defaecate in toilet because of fear of the death of the foetus (WA, 2008).

More so, in other communities it is a taboo to share toilets among some members of the family. A good example is demonstrated among the Luo in Kenya, Uganda and Tanzania.

In these countries, it is taboo for in-laws to share a toilet (Devine, 2010). The belief is that

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you will be cursed if you undress in the same space as your in—laws. Similar beliefs have also been reported among pregnant women where it is believed that pregnant women may lose their fertility if they use pit latrines (Caldwell, 1993). Furthermore, it is a common belief in some parts of Uganda that if children’s excreta is disposed in a pit latrine they would not grow up to be healthy (Caldwell, 1993). Among the Malian and Idoma people in Nigeria, open defaecation is seen as an ancestral practice passed down through generations (WA, 2008). Open defecation is culturally encouraged in Idoma communities as it is a taboo to defaecate in a building or super structure, and many older people still refuse to defaecate in any sort of enclosed environment (WA, 2008). Knowledge of these belief systems can influence the intention of school pupils to indulge in open defaecation behaviours when they are enrolled in the school system. Studies (Parke, 2002) have demonstrated that most sanitation behaviours pupils’ exhibit in the school have root causes from the home. The implication of this to the sanitation stakeholders including MMDAs,

GES, MOE, NGOs and the Government is that any intervention that seeks to change open defecation behaviours and encourage toilet use in any setting can be successful when specific culture underlying open defaecation practices and behaviours of those engaged in it are adequately addressed.

Superstition refers to belief about action that may lead to good or bad luck (Rabiei et al.,

2013). Superstitions in the present study produced positive effect size of 0.728, p<0.05) on pupils intention to engage in open defaecation behaviours. This suggested that 73% of the variance of pupils intention to defaecate in the open is explained by pupils superstious beliefs. This finding is consistent with some earlier studies. For example, a study by WA

(2008) to determine the cultural factors that reinforced open defaecation practice in four

West African countries—Burkina Faso, Ghana, Mali, and Nigeria revealed that the

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practice of open defaecation was surrounded by superstitious beliefs particular to many of the ethno-linguistic groups who live there. For example, a study by WA (2008) in Ghana demonstrated that fear of being possessed by demons and losing one’s magical powers constituted leading cause of open defaecation behaviour seen across all the study areas.

Nearly half of the respondents’ in Tamale believed that public toilets are surrounded by evil spirits and therefore should be avoided, with a significant group of respondents in the

Wa East district believing that latrine use will strip the user of their magical powers.

Traditional norms are conventions that shape and regulates human environmental behaviour (Bicchieri, 2006; Sugden, 1986; Coleman 1990). The results of the present study revealed that 43% of variance of pupils’ open defaecation behaviours was due to influence of traditional norms. Studies (Parke, 2002) showed that most sanitation behaviours pupils’ exhibit in the school have root causes from the home. For example, open defaecation has been seen as traditional legacy of ancestors handed over to the younger generation and therefore must be continued. In most Ghanaian communities as some traditional norms continue to prevent people from toilet use thus slowing down the efforts towards ending open defaecation behaviours in the country. One previous study (WSP/WB, 2013) reported that open defaecation is common behaviour in some cultures and it is sustained through local cultural norms throughout the global environment. In some regions such as India and

East Java, open defaecation is a social norm and practiced since childhood and strongly nurtured by designated sites allocated for it (WSP/WB, 2013).

The impact of traditional norms on safe excreta disposal has also been identified in a study by Devine (2010). He discovered that people imitate others (defaecating indiscriminately) thinking that it is good practice. These traditional norms continued to prevent people from toilet use and thus increasing sanitation challenges in the global,

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Africa and Ghana. There is therefore, the need to thoroughly understand and build on local traditional assumptions if behaviour change in relation to open defaecation is to be successful. Messages to motivate pupils in first cycle schools to use toilet should therefore integrate themes of cultural traditions such as taboos and superstitions and family customs which influence and shape individuals attitudes towards open defaecation behaviours.

5.11 Interacting Effect of Behavioural and Cultural Factors on Open

Defaecation Behaviour

The interaction effect of behavioural and cultural variables included in both cultural and behavioural measurement scales on pupils’ satisfied open defaecation intention produced the following significant effect sizes: (behavioural factors on attitude scale interacting with cultural factors on culture measuring scale (standardized effect size = 0.682; p<0.05); behavioural factors on subjective norm scale interacting with culture factors: standardized effect size = 0.117; p<0.05); behavioural factors on perceived behavioural control measurement scale interacting with culture factors, however, produced no significant effect size to report. The variance explained by these aggregate interacting effects of the three behavioural variables with cultural factors was 59% (0.585). Within the interactions, cultural factors produced the higher effect size when interacted with attitudes (68%). This result suggested that cultural factors significantly moderate pupils’ open defaecation intentions.

This high mean positive interacting effect size of cultural and behavioural factors on pupils open defaecation has strong implication for policy makers and sanitation stakeholders

(MLGRD, MMDAs, GES, PTAs, SMCs, teachers and parents) whose objectives aims at ending open defaecation in Ghana and elsewhere as emphasized in the post 2015

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Sustainable Development Goal six (6) target two (2). Ending open defaecation practices is a vital public-health practice throughout the world and especially in developing countries including Ghana. This means that for effective intervention strategies to address open defaecation behaviour, integrated strategies that combined the behavioural and cultural factors are needed.

5.12 Moderating Effect of Demographic Variables on Open Defaecation Behaviour

Setting as used in this study refers to the two main types of localities—rural and urban.

This categorization was based on population size. Localities with 5,000 or more persons are classified as urban while localities with less than 5,000 persons were classified as rural

(GSS, 2012). Different settings are associated with different cultural meanings, and these differences influence behaviour (Baumeister, 2005; Tomasello, 1999). The influence of localities on human behaviours have been documented in several studies (Baumeister,

2005). The result of this study revealed that locality or setting had statistically significant effect on pupils open defacaetion behaviours (standardized mean positive effect size =

0.101; p<0.05). The high open defaecation frequency recorded by this study between rural and urban schools may be attributed to the built environment and political ecology of the two settings. Large land space exists in rural localities due to dispersed settlement types and houses resulting from low population density. The availability of land space facilitates physical activities such as open defaecation. This, however, is not the case in urban centres where settlement types is largely nucleated due to high population density and which results in reduced land space and physical activities such as open defaecation. Land space is a component of built environment and therefore a determinant of open defaecation behaviours.

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The relationship between the built environment and physical activity such as open defaecation is also seen in relation to time. For example, the time individuals spend to get to open defaecation site compared to the time taken to reach the communal toilet is a function of preference and choice. Even though other factors come to play, the smaller the time spent in getting to open defaecation site the more preferred choice that open defaecation site will be compared to the community toilet. Opportunities to increase open defaecation levels exist in many settings—at home, at work, and at school. Just as preferences have a role in determining a person’s open defaecation habits, so is the built environment which has the potential to influence open defaecation behaviour in each of these settings. Studies have established that access to toilets is much lower in rural areas than in urban centers due to an absence of toilet facilities or few available facilities serving larger numbers of people (Hawkins, et al., 2013).

The present study’s open defaecation prevalence figure reported for rural schools (26.3% per week) included in this study is also comparable to what was reported in a study in India

(WHO/UNICEF/JMP, 2014) which found that India recorded the highest number of people practicing open defaecation globally (GI, 2016) and most of this occur in rural areas where the prevalence rate is estimated at 52% of the population, as opposed to urban areas, where prevalence rate is estimated at 7.5% (GI, 2016). It is worth noting that schools are part of the communities and whatever happens in the school system affects the community and vice versa. The high open defaecation prevalence recorded in this study for rural schools (26.3%) and urban schools (25.6%) are at variance with what was reported in India

(52%) and Tanzania (74%). Most people (9 out of 10) who practiced open defaecation lived in rural areas WHO/UNICEF/JMP, 2014). Seventy-three percent (73%) of urban population share sanitation facility whereas in rural areas the corresponding proportion is

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43% (WHO/UNICEF/JMP, 2014) giving 30% difference point. Instead of sharing the toilet facility, the problem in rural areas is the open defaecation as 33% of the rural population is practicing open defaecation (WSP, 2010). Shared toilet may not be hygienic, convenient and private enough for users (WSMP, 2008).

5.13 Situational Contexts Pupils Expressed Their Open Defaecation Behaviours

A number of studies have documented the effects of situational factors on open defaecation behaviours (UNICEF, 2013; Appiah & Oduro-Kwarteng, 2011); WB, 2010; Spears, 2013;

Cairncross et al., 2010; Bartram et al., 2010; Walker & Black, 2010; Jenkins & Scott,

2007). A study by WSP (2013), for example, indicated that environmental variables such as access to water, perceptions of soil quality, seasonal factors respectively, provide important contextual information for sanitation behaviours. Drawing evidences from the results of the qualitative and quantitative analyses, this study identified five (5) key situational contexts within which open defaecation behaviours are expressed by pupils.

They included: (1) perceived poor hygiene status of school toilet which may result in infections from using the toilets; (2) community encroachment on school toilet; (3) presence of unfriendly rodents in premises of the school toilets; (4) perceived inadequate privacy in the school toilets, and poor safety status of the school toilets; and (5) technology drivers comprising inappropriate toilets’ squat hole sizes, toilet inadequacy and toilet locations within the school premises—which this present study described as new interesting emerging situational variables inducing pupils’ open defaecation behaviours.

These open defaecation determinants have been discussed extensively under the factors that influence satisfied intention and actual open defaecation behaviours in the study schools (page 177).

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Regarding the situational context in which pupils express their open defaecation behaviours, the open defaecation behaviour found among the pupils largely revolved around personal circumstances and physical structure of the school toilets. These results suggested that open defaecation behaviour can be evoked by situational context in which the individual finds him/herself. Thus some situations are likely to evoke open defaecation behaviours. Studies (Ajzen, 1989, 1991, & 2001) demonstrated that behaviours are influenced by both situational and psychological factors and both factors act to shape intentions toward action and behaviour itself. The key situational factors within which pupils expressed their open defaecation behaviours found in this study followed this theoretical evidence from previous studies. For example, the situational factors discovered in this study which are influencing pupils open defaecation behaviours included inappropriate school toilet squat hole sizes, filthy toilet, poor toilet maintenance, bad smells from the toilets, lack of privacy in the school toilet, unfriendly rodents in the school premises, and toilets inadequacy. These factors reflected personal circumstances and technological drive.

The personal circumstances comprised sanitation preference such as convenience, comfortability, privacy, and safety and these largely dependent on the situational factors evidenced in the assessment results of the conditions of the school toilets. This, nevertheless, is high enough to warrant open defaecation behaviours among pupils, as they

(pupils) are at higher risk of acquiring communicable diseases from using the school toilets. This finding suggested that the high open defaecation behaviours reported in this study (64.8%) may continue to increase if these personal circumstances and situational variables are not adequately addressed.

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The technological drivers on the other hand relate to the physical structure and design of the toilet facilitties and consisted of inappropriate squat holes and siting of the toilet in relation to walkways within the school compound. The present study therefore strongly suggested that in formulating sanitation programmes to address open defaecation behaviours among pupils, more attention should be paid to pupils’ attitudes and PBC more than subjective norm. Addressing the norms regarding health behaviour and enforcing school sanitation bye-laws, whilst encouraging motivational factors such as beliefs, attitudes, and values surrounding health behaviours as well as emotional, physical, and social drivers are all significant strategies that could help end open defaecation behaviours observed among pupils in the first cycle schools.

Besides, addressing these situational factors associated with the conditions of the school toilets and which are resonating with open defaecation behaviours is equally important when finding sustainable measures to motivate and encourage pupils to use toilets and avoid open defaecation. Thus, any attempt to end open defaecation behaviour in the first cycle schools in the Eastern and Volta regions must adequately address these twin factors.

The physical school toilet facilities must be made descent and attractive, and incorporate personal sanitation preferences, particularly those relating to age and sex.

5.14 Contributions of the Study to Knowledge

Aside the existing knowledge which the results of this study has confirmed, the study has made a number of original contributions to knowledge as well as expanding the basis for future researchers. These contributions included the following:

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First, the findings of the study revealed that open defaecation behaviour is being reinforced in the first cycle schools. Secondly, regardless of pupils’ high level of knowledge about health and environmental risks associated with the open defaecation behaviours, they perceive nothing wrong with the practice and therefore continue to do it. The open defaecation behaviour is therefore seriously being nurtured in the basic schools and the practice is largely policy and situation-driven.

Finally, most published literature on open defaecation behaviours largely stressed on adults’ attitudinal and behavioural changes as key panacea to ending open defaecation challenges leaving children below eighteen years. It worth noting that it is easier changing the attitudes of children by addressing their behaviours than the adults and more so, children are agent of behaviour change and developing appropriate sanitation behaviour today, such behaviour can be carried into the future. The contribution of this study again, lies in its focusing on unearthing the existing behavioural and cultural belief systems that are informing open defaecation behaviours among pupils aged between 9 and 18 years who are in the first cycle schools.

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CHAPTER SIX

SUMMARY, CONCLUSION AND RECOMMENDATIONS

6.1. Summary and Conclusion

This study has provided both qualitative and quantitative data and information on

behavioural and cultural factors that influence open defaecation behaviours among pupils

in the first cycle schools. It was conducted among pupils aged between nine and eighteen

years, and in Eastern and Volta Regions of Ghana. All the study subjets were in the

Primary and Junior High Schools of education. The majority were Christians (89%), with

the Ewes, Ga-Dangme, Akans, and Moshi ethnic backgrounds constituting the rest in

varying numbers.

6.1.1 Summary In summary, the results of the study point to the following key findings:

1. There is high open defaecation prevalence (64.3%) among the pupils; with female and

male pupils recording 32.6% and 29.4% prevalence respectively. Significantly, more

female pupils than male pupils recorded higher open defaecation prevalence rate across

the study schools and this may be attributed to absence of washrooms and privacy in the

school toilets.

2. The overall knowledge level of risks associated with open defaecation behaviour was

high among the pupils. Also, a greater number (90%) of the pupils from all the eight

study schools were better informed about negative effects of open defaecation

behaviours. The awareness of health risks associated with open defaecation behaviour

was, however, low among the greater number of pupils (53%) and across the study

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schools. Nevertheless, the awareness levels of negative effect of open defaecation

behaviour on the environment was fairly high among the greater number of pupils

(52%).

3. The situational threats preventing pupils from sustainable toilet use as the study’s results

revealed included high pupil-toilet ratio, inappropriate squat hole sizes, lack of funds for

toilet maintenance resulting in poor hygiene and inadequate ventilation in the school

toilets, lack of adequate privacy, presence of unfriendly rodents in the school toilets

causing psychological discomfort to pupils during toilet use; others are lack of

desludging of faecal sludge from the school toilets resulting in bad smells in the toilet

premises; and unresolved conflicts between the communities and the schools regarding

use of school toilets by the communities.

4. The key behavioural factors influencing pupils open defaecation practices in the study

schools stemmed from pupils subjective norms, perceived behavioural control, and

attitudes, with the latter contributing a more significant positive influence among these

variables. Specific behavioural factors including perceived discomfort, lack of privacy,

associated with the school toilets are the primary drivers behind the attitudinal variables

largely influencing the pupils open defaecation behaviours. The mean effect sizes for

the three variables, however, varied in intensity with those on attitudes measuring scale

exerting the most significant effect size compared to the other two.

5. With regards to cultural factors, taboos and superstitions constituted the major variables

driving pupils open defaecation behaviours. Superstitions, however, was found to be

playing a dominant role among these variables. The cultural factors have also been found

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to be interacting with the behavioural variables included on pupils’ attitudes, subjective norms, perceived behavioural control, and situational factors to exert a substantial mean positive effect sizes on pupils open defaecation behaviours.

6.1.2 Conclusion

The study has provided strong theory-based evidence on behavioural, cultural and

situational factors informing open defaecation practices in the first cycle schools. The

behavioural factors stem from pupils attitudes more than subjective norms and

perceived behavioural control. The behavioural factors, including perceived

discomfort, and lack of privacy associated with the school toilets, were the primary

drivers motivating pupils open defaecation intentions and open defaecation behaviours

in the first cycle schools. The presence of unfriendly pests in premises of the school

toilets, high pupil-toilet ratio, inappropriate squat hole sizes, poor hygiene and

inadequate ventilation in the school toilets constituted the main situational predictors

of open defaecation behaviours in the study schools. The key cultural factors driving

open defaecation behaviours among the pupils included taboos and superstitions. The

contributions of these factors therefore provided holistic understanding of the subject

of open defaecation and upon which some useful recommendations have been made.

6.2 Recommendations

Open defaecation is unacceptable and unhealthy behaviour and its practice must be

discouraged if Ghana is to achieve the target two (2) of the 2030 SDG six (6). There

must be framework of strict punitive measures to discourage open defaecation

behaviours and encourage acceptable sanitation behavioural practices. This must,

however, start with children because it is easier changing their attitudes compared to

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adults. Educating pupils on the dangers associated with open defaecation and the need

to use toilet both at home and at school is very crucial in this 21st century and a pre-

requisite for the realization of the 2030 SDG six (6) target two (2). Based on the major

findings and conclusions of this study, the following recommendations have been made

for consideration by both direct and indirect stakeholders to end open defaecation

practices not only in the first cycle schools but also communities in which the schools

are located.

1. The Ministry of Local Government and Rural Development (MLGRD) must make it a

national policy that existing toilet facilities in the basic schools are upgraded to meet

the standards. The newly constructed school toilets are provided with toilet facilities

whose qualities resonates with the fondness—such as adequate privacy, proper

ventilation, absence of waiting time—pupils attach to open defaecation practices.

2. The Ministry of Health (MOH) must also intensify their health education on the

campaingn consequences of open defaecation behaviours in the basic schools and the

communities in which the schools are located through posters, videos, and television

broadcasting. Creating the necessary awareness and education about the negative

consequences of open defaecation on health and learning, as well as the environment

can go a long way to to reduce open defaecation behaviour observed among the pupils.

These can be done effectively through social media platforms. The adjoining

communities and schools must be equaly covered with these educational campaign.

3. Also, the Ministry of Education (MOE), Ghana Education Service (GES), Teacher

Education Division (TED), and Curriculum Research and Development Division

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(CRDD) must introduce new courses into the curriculum that can help both pupils and

teachers to acquire knowledge and skills in current trends in best sanitation practices.

These courses must also reflect on the colleges of education curriculum so that teachers

they train for the first cycle schools are well equipped with adequate knowledge and

skills of what constitute effective sanitation systems. This information will not only

make the first cycle school teachers better informed about the need to emphasize

positive sanitation behaviours in their classroom teaching and learning activities but it

will also assist them to become better school-community sanitation advocates. They

must also integrate local cultural beliefs systems-taboos and superstations-that relates

to open defaecation practices into school curriculum and ensure that science education

helps pupils give scientific explanations to them. This also underscores the need for

government to build a strong enabling environment through sanitation policy guidelines

coupled with adequate financing arrangement for the sanitation departments of

MMDAs to enable them carry out their mandate not only to the communities but also

the schools within the communities. The monthly government sanitation initiative

programme that aims at ensuring clean and disease free communities should be scaled

up to cover the basic schools so that at least the school toilet facilities are cleaned to

make them attractive, safe and disease-free environment for pupils.

4. There is the need to form first cycle school pupils’ pressure groups to play the role of

attitudinal change agents through advocacy education among peers in the schools with

regards to ensuring proper school sanitation in general and halting open defaecation in

particular, and the need for toilet use. This can also be done by relying on public

demonstrations, discussions and school-wide sanitation promotion clubs as well as

posters, games and stories to illustrate that messages. The MMDAs, SMCs, PTAs as

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well as school authorities have crucial roles to play in this directions. They must ensure

that sanitation policies prioritize collective first cycle school-wide behaviour change

interventions to halt open defaecation behaviours and create demand for toilet use

among the pupils. In addition to these, the school authorities should create zero no-

tolerance for open defaecation in the first cycle schools. This can help publicize the

need and desire in favour of sustainable toilet use on the platform of better health and

better academic work in a better school environment.

5. Again, cultural drivers including taboos, superstitions, and traditional values were

found to be interacting with pupils’ psychological variables to produce strong

preference for open defaecation behaviour among the first cycle school pupils. These

factors worked through intention towards open defaecation behaviour itself.

Intervention programmes that aim at ending open defaecation behaviours in the first

cycle schools must integrate the local cultural beliefs and psychological variables,

particularly attitudes, to exert significant impacts on pupils open defaecation intention

behaviour change. MMDAs, GES, SMCs, PTAs and School authorities has crucial role

to play in this direction.

6. To maintain school sanitation toilets and keep them hygienic and appealing for pupils

a separate budget must be allocated by Government, through the MMDAs to school

authorities to enable them carry out effective cleaning and repairs on the school toilets.

This also points to the government to build a strong enabling environment through

sanitation policy guidance coupled with adequate financing arrangement for the

sanitation departments of MMDAs to enable them carry out their mandate not only to

the communities but also the schools within the communities.

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7. The Community Led Total Sanitation (CLTS) programmes should be extended to all

communities, as a matter of urgency, to enable them halt the open defaecation

behaviours.

8. The presence of rodents in the school toilet premises has also been found to be

contributing significantly to the open defaecation behaviour observed among the school

pupils. Addressing this through annual rodent control regimes could help increase

sustainable toilet use among the pupils. The importance of rodents’ prevention through

good hygiene, management and exclusion practices should be emphasized. Teachers as

well as the pupils in charge of hygiene in the schools have the day to day responsibility

of ensuring a rodent management programme is maintained. Nevertheless, research is

strongly needed to understand the health and psychological implications of presence of

rodents in the school toilet premises and their impacts on pupils toilet use.

9. Ending open defaecation requires concerted efforts, commitment and strong political

will on part of the government through the MMDAs to scale up the CLTS programme

to every community. This can halt the community encroachment into the school

sanitation system. MMDAs through the national government can invest in advocacy

campaigns in schools on ending open defaecation by paying for training of teachers to

deliver effective education against open defaecation.

6.3 Areas for Further Studies

Limited research has been conducted in Ghana to examine how situational variables

associated with school toilets interact with the psychological factors to influence open

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defaecation behaviour. Possible synergistic effects need to be explored to provide a stronger theory based foundation for informing public sanitation policy intervention measures that would address succinctly, the open defaecation behaviour drivers revealed by this study. More importantly, the negative effect of absence of age and sex differentiated squat hole sizes on pupils toilets use, as well as psychological, physical and emotional stress caused by presence of rodents in the school toilets and on pupils’ sustainable toilet use, should be empirically tested in future research as this study did not, obviously, tests the effect of these emerging situational variables in relation to sustainable toilet use. This will better inform future sanitation intervention measures to warrant greater attention if sustainable toilet use by pupils in the first cycle schools is to be achieved.

Also, given the interplay of culture, open defaecation and behaviour, future research should be directed at relating the various elements of observable open defaecation behaviours against contextual factors that resonate with open defaecation behaviours to enhance analytical understanding of the various driving factors of local open defaecation behaviours.

Finally, the study suggests that investigating the open defaecation behaviour in the long-term observations with larger samples for better generalization of the findings will be good . This study’s results therefore provide key foundation for further theory and evidence based intervention research on eliminating open defaecation behaviour in the school systems and the communities.

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APPENDICES

Appendix 1: Questionnaires for Pupils INSTRUCTION: Tick [√] the correct response from each of the alternatives provided for each question. Where necessary, provide, to the best of your knowledge, short responses/answers in the spaces provided.

Part I: Participants Bio-Data and Demographic Characteristics

1. District 1. Fanteakwa 2. Akatsi South 3. Keta Municipal 4. Nsawam-Adoagyiri

2. Region 1. Eastern 2. Volta

3. Gender: 1. Male 2. Female

4. Age (in years)

5. Education (indicate class)

6. Ethnicity 1. Akan 2. Akuapem 3. Asante 4. Ewe 5. Fante 6. Ga 7. Ga-Dangme 8. Guan 9. Others, specify………………………………….

7. Religion 1. Christian 2. Moslem 3. Traditional

8. Settings (This should be based on community’s population).

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1. Rural (community’s population < 5000) 2. Urban (community’s population >5000)

PART II: Participants Open Defaecation Behaviour

Instruction: For item 9 Tick [√] the box below the number that corresponds to your answer. 9. During the last 7 days, on how many days did you defaecate outside toilet? [Go to 10 if the answer is 1 2 3 4 5]. [Go to 11 if the answer is 0 or don’t remember]

5 4 3 2 1 0 Don’t remember

Part III: Situational Factors Instruction: For item 10 Tick √ the box that corresponds to your answer in item 9 above. 10. You have indicated in item 9 that you defaecate outside toilet before. Which of the following prevented you from defaecating in the toilet? (Multiple responses are allowed). 1. Toilet is dirty/filthy 2. Toilet provides no privacy 3. Toilet smells 4. You may easily get infected with diseases 5. Too many flies in the toilet rooms 6. Maggots on the toilet floor 7. Rodents such as lizards, wall gecko, snakes are sometimes found in the toilet 8. Others (specify)……………………………………………………………………

Part IV: General Knowledge, Perception and Awareness of Effects of Open Defaecation

Instruction: For items 11 to 12 draw a circle on only ONE of the FIVE numbers that best describes how you feel about the idea in each box.

11 BOX 1 Defaecating in the open/outside toilet. Very harmful Harmful Don’t know Useful Very Useful 1 2 3 4 5

12 BOX 2: Defaecating in the open/outside toilet. Very bad practice Bad practice Don’t know Good practice Very good practice 1 2 3 4 5

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PART V: Participants Attitudes (Behavioural Belief) Instruction: For item 13 to 22 draw a circle on only ONE of the FIVE numbers that best describes how you feel about each of the ideas in tables 12 to 21. 13 I feel comfortable if I defaecate in the open/outside toilet/bush. More unlikely Unlikely Don’t know Likely More likely 1 2 3 4 5

14 I enjoy adequate privacy if I defaecate in the open/bush. More unlikely Unlikely Don’t know Likely More likely 1 2 3 4 5

15 I defaecate in the open/bush to avoid bad smell from the toilet More unlikely Unlikely Don’t know Likely More likely

1 2 3 4 5

16 If I defaecate in the open/bush, I will be making other people ‘eat my faeces’ More unlikely unlikely Don’t know Likely More likely 1 2 3 4 5

17 Feeling comfortable by defaecating in the open/bush is….. Very undesirable Undesirable Don’t know Desirable Very desirable -2 -1 0 +1 +2

18 Enjoying adequate privacy by defaecating in the bush/outside toilet is….. Very undesirable Undesirable Don’t know Desirable Very desirable -2 -1 0 +1 +2

19 Defaecating in the open/bush causes something bad to the environment. Very undesirable Undesirable Don’t know Desirable Very desirable -2 -1 0 +1 +2

20 Avoiding pageant faecal smell by defaecating in the open/bush is… Very undesirable Undesirable Don’t know Desirable Very desirable -2 -1 0 +1 +2

21 Making other people “eat my faeces” by defaecating in the bush is….. Very undesirable Undesirable Don’t know Desirable Very desirable -2 -1 0 +1 +2

22 Doing something bad to the environment by defaecating in the open/bush is………… Very undesirable Undesirable Don’t know Desirable Very desirable -1 -2 0 +1 +2

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PART VI: Participants Subjective Norm (Social influence)

Instruction: For items 23 to 25, Tick (√) the box that corresponds to your level of agreement with the statements in the table. Items/Response Format

23 People who are important to me think that I should defaecate in the open.

1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

I defaecate in the open/outside toilet because people whose opinion I take also do it.

24 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

25 People I am important to think that I should defaecate in the open.

1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

PART VII: Participants Behavioural Intention Instruction: For items 25 Tick (√) the box that corresponds to your level of agreement with the statements in the table. Item/Response Format

26 I intend to defaecate in the open/outside toilet if I feel dissatisfied with the school toilet.

1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

PART VIII: Participants Perceived Behavioural Control (PBC) Instruction: For items 30 to31 draw a circle on only ONE of the seven numbers that best describes how you feel about each of the idea in the box below.

27 For me to defaecate in the open/bush is… Very difficult Difficult Don’t know Easy Very easy 1 2 3 4 5

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28. What makes it difficult for you to defaecate in the open/bush 1. I will feel ashamed if people see me. 2. I will be punished 3. I will lose my respect in the school and community 4. Snake may bite me in the bush 5. I will not get enough privacy in the bush 6. Others (specify)…………………………………….…………………………………

29 Whether I defaecate in the open/outside toilet is entirely up to me. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

PART IX: Cultural Factors Associated with Open Defaecation

Instruction: For items 30 to 39, Tick (√) the box that corresponds to your level of agreement with the statements in the boxes 1 to 10.

30. What is your level of agreement about the idea in box 1?

BOX 1: Faeces are not things to be kept in homes/in a room built in the house. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

31. What is your level of agreement about the idea in the box 2?

BOX 2: Defaecating in toilet causes one to be possessed by evil spirits. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

32. What is your level of agreement about the idea in box 3?

BOX 3: Shared toilets are associated with evil spirits and therefore should be avoided. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

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33. What is your level of agreement about the idea in box4?

BOX 4: Defaecating in an enclosed place (inside toilet) is a taboo. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

34 What is your level of agreement about the idea in box 5?

BOX 5: Children can defaecate in the open since their faeces are considered harmless. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

35. What is your level of agreement about the idea in box 6?

BOX 6: Defaecating in the open (bush, beach) signifies continuation of ancestors’ way of life. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

36. What is your level of agreement about the idea in the box 7?

BOX 7 Contact with human faeces is unacceptable 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

37. What is your level of agreement about the idea in box 8?

BOX 8: Using same toilet with people in other houses causes one to lose his/her social status. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

38. What is your level of agreement about the idea in box9?

BOX 9: Defaecating in public toilet causes one to lose his or her magical powers. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

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39. What is your level of agreement about the idea in box 10?

BOX 10: Girls who are in their menstrual periods are not supposed to defaecate in toilet. 1. Strongly disagree 2. Disagree 3. Don’t know 4. Agree 5. Strongly agree

End of Questionnaire

Thank You

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Appendix 2: Questionnaires for Teachers, Head Teachers and SHEP Coordinators PART I: Soci-Demographic Characteristics of Respondents Instruction: Tick [√] the appropriate response from the alternatives provided. Where appropriate, write in the space provided. 1. Name of School:……………………………………………………………………………....

2. Municipal/District: Nsawam-Adoagyiri Fanteakwa Akatsi South Keta Municipal 3. Region: Volta Eastern

4. Gender: Female Male 5. Qualification/Designation……………...... ………………………………

PART II: Conditions of the School Toilets 6. Tell us about the school toilet facility with respect to the following: (a) Toilet type:………………………………………………………………………… (b) Accessibility (easy to locate/reach)………………………………………….Yes/No. (c) Adequacy (Example: number of squat holes enough for all pupils)…………Yes/No. (d) Pupils queue to use the toilet during peak hours ………………….Yes/No/Sometimes. (e) Frequency of use by pupils… …………………../(Daily/Weekly/Monthly/Not used). (f) Privacy for both sexes (cubicle doors lockable from inside etc.)……………Yes/No. (g) Appropriateness (Example: squat holes----well sized for all age groups?)……Yes/No. (h) Hygiene status (cleanliness) of the school toilet…………….... (Always clean/Always filthy/Sometimes clean/Sometimes filthy. Others, specify……………….…………… (i) Maintenance schedule (Example: how often is cleaning, dislodging, repair work is done?).[Daily/weekly/monthly/yearly. Others, specify……………………..……… (j) Who provides funds/logistics for the toilet maintenance? (Give name)……………… (k) When was the last time this fund/logistics was provided?…………………………… (l) Community influence (Example: Community using school toilet) Yes/No. If the answer is Yes, how does this affect sanitation in the school toilet? Please specify………………………………………………………………………………… 7. Do the boys and the girls use the same toilet cubicles? Yes/No. If yes, give reason...... 8. Do pupils less than five years use the same school toilet? Yes/No. If no, where do they defaecate? ……………………………………………………………………….. 9. In your view, what is the responsibility of the pupils regarding cleaning of school toilet? 10. What challenge(s) does the school face in ensuring proper use of the school toilet by pupils?………………………………………………………………………………… 11. What do you think can be done to address the challenge(s)?......

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Appendix 3: Focus Group Discussion Guide for Pupils Part I: Participants Awareness, Perception and Knowledge of Open Defaecation

Question Questions Follow-Up Item Number Probe to find out participants 1 Tell us what you believe is good about defaecating in perception on open defaecation. open/bush/outside toilet. 2 Probe to find out participants Tell us what you believe is bad about defaecating in the knowledge on consequences of open/bush/outside toilet. open defaecation.

3 Tell us how you feel if you defaecate outside toilet? Probe to find out if it is pleasant/unpleasant.

4 Defaecating in the open/bush/outside toilet make you Probe to find out participants “eat your own faeces and that of others”. What do you knowledge about negative say about this statement? effects of open defaecation?

Part II: Measuring Participants Subjective Norm

5 Tell us how you feel If your friends or teachers saw you What makes you feel so? going to school toilet to defaecate? 6 Tell us how people who are important to you feel if they Probe further if response is “they see you defaecate in the open/outside toilet? will feel good “or “bad”.

Part III: Measuring Participants Perceived Behavioural Control

7 What is your level of confidence if you chose to defaecate in Probe to find out if participants the open/outside toilet? [higher/low]. have confidence to defaecate outside toilet/in open.

8 What conditions will make it difficult for you to defaecate in the open/outside toilet? 9 What other issues come to mind when you think about Could you tell us a little more defaecating in the open/outside latrine? about?

10 Tell us how you feel anytime you intend visiting the school What make you feel that way? toilet to defaecate?[Good/Bad] 11 Tell us how you feel about the number of rooms/cubicles in What make you feel that way? the school toilet?[Satisfied/Not satisfied] 12 Tell us how you feel about the size of the squat holes of the Probe to find out participants’ school toilet?[Too small/ too big/normal]. perception about squat holes sizes.

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13 Tell us how you feel about the space between the toilet’s foot Probe to find out participants rests? [Too wide/too close/normal]. perception about space between feet rests. 14 Tell us how you feel about the location/distance of the toilet What makes you feel that way? from your school/classroom? [Satisfied/Not satisfied] 15 Tell us how you feel about the cleanliness of the school toilet? (Faeces/urine/anal cleaning materials etc on toilet What make you feel that way? floor).[Satisfied/Not satisfied]. 16 Tell us how you feel about the privacy status of the school toilet? (e.g. cubicle doors are in good condition/bad Would you explain further? conditions, lockable/not lockable whilst one is inside). [Satisfied/Not satisfied]. 17 Tell us how satisfied are you with comfortability of the Would you explain further? school toilet?(All user preference conditions are provided by the toilet.) 18 Tell us how often desludging & repairs work is done on What makes you feel that way? school toilet.[Daily/weekly/monthly/yearly/not done at all.] 19 Tell us how you feel about the type of anal cleansing What make you feel that way? materials used in the school toilet? 20 Have you ever observed/seen rodents (e.g. lizards, wall Probe to find out the gecko, cockroaches, ants, snake mouse, flies, maggots etc) in presence/absence of rodents in the school toilet premises before? Yes/No. the school toilet? Would you give an example? 21 Give us some examples of the rodents you have ever seen in the toilet premises before. 22 Tell us how you feel when you see/come across rodents in Probe to find out what makes the toilet room? them feel that way?

23 Tell us one thing you dislike about the school toilet? Probe to find out reason(s) for their responses. 24 Tell us one thing you like about the school toilet? Probe to find out reason(s) for their response(s). 25 Tell us how satisfied are you with the community also using What makes you feel that way? same toilet as the school? (Satisfied/ Not satisfied). 26 If you are being asked to clean/wash/scrub the school toilet, What makes you feel that way? tell us how you feel? (Bad/good/happy/unhappy.) 27 Who supplies the materials such as soap, detergents, brush, water etc for cleaning the school toilet? 28 Are there taboos surrounding defaecation and faecal If yes, probe participants to give disposal in this Community? Yes/No. an example?

29 Are there anything else, you will like to share with us about Probe to find out participants open defaecation? knowledge on open defaecation.

End of Focus Group Discussion

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Appendix 4: In-depth Interview Guide for Municipal/District Education Directors

PART I: IDI PARTICIPANTS

Instruction: Tick [√] the appropriate response from the alternatives provided. Where appropriate, write in the space provided. [To be completed by the interviewer].

4. Municipal/District: Nsawam-Adoagyiri Fanteakwa Akatsi South Keta Municipal 5. Region: Volta Eastern 4. Gender: Female Male

5. Qualification/Designation………………...... ………………………………

PART II: To Be Responded To By Interviewees.

6. Tell us about the school toilet facility with respect to the following: (a) Who ensures that toilet construction specifications are strictly adhered to by the contractors? [Examples: Squat hole size, space between foot rests, number and type of vent pipes, vent pipe diameter etc…………………………………………………………………………… (b) What criteria are used to determine the number of toilet cubicles in a given school?…………………………………………………………………………………… (c) How often is dislodging of faecal matter from the toilet done?......

(d) Who is responsible for dislodgement of the faecal matter? …………………………… (e) Who provides funds/logistics for toilet maintenance?………………………………… (f) When was the last time this fund/logistics was provided to schools in your Municipal or District?………………………………………………………………………… 7. Do the pre-school pupils also use the same school toilet? Yes/No. If no, where do they defaecate?………………………………………………………………………………… 8. Do the physically challenged pupils also use the same toilet? Yes/No. If no, where do they defaecate?…………………………………………………………………………………

9. Has any of the schools reported to your outfit any form of challenge(s) they face in ensuring proper use and maintenance of the school toilet? Example: squat holes too small/too big/foot rest too close/too wide/toilet provides no privacy/pupils queuing to use the toilet/community using the toilet/ rodents invading the toilet etc.. ………………… 10. If the response to 9 is Yes, what did your outfit do to address the challenge(s)?...... 11. Are there anything else, you will like to share with us about sanitation system in the first cycle (basic) schools?......

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Appendix 5: Checklist Observation Guide Item Response Number Criteria Format Field Notes (Characteristics of Interest) Yes No A Toilet Location and Accessibility 1 Toilet is accessible to all pupils/users. 2 Toilet is accessible to physically challenged pupils. 3 Pupils use the toilet at specific school hours 4 Toilet key is placed at accessible point for all pupils. B Toilet Apartments 5 Toilet apartment for both sexes are in same block. 6 Toilet has washroom attached to it 7 Toilet for the girls has changing room attached to it. 8 Toilet has urinal compartment 9 The school has separate toilet for Pre-school pupils. 10 The school has separate toilet for Primary pupils. 11 The school has separate toilet for JHS pupils. 12 The school has separate toilet for Teachers. 13 The pre-school, primary & JHS use the same toilet facility. C Hygiene Status of the School Toilet 14 Faeces present on toilet floor. 15 Faeces present on toilet squat holes. 16 Faeces present on toilet foot rest. 17 Faeces around toilet premises. 18 Maggots present on toilet floor. 19 Urine present on toilet floor/squat holes/foot rests. 20 Anal cleaning materials packed in safe container(s). D Toilet Maintenance and Cleaning 21 Teachers supervise the cleaning of the toilet. 22 Pupils provide their own cleaning materials. 23 Pupils protect themselves from infections while cleaning

the toilet (e.g. wear nose masks, hand gloves etc).

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24 School has waste disposal bins in the toilet. 25 Anal cleaning materials present on toilet floor. 26 Regular repair work is carried on the toilet.

E Pupils-Toilet Ratio & Pressure on use of School Toilet 27 Based on boys’ enrolment, the number of toilet cubicles for boys is adequate. 28 Based on girls’ enrolment, the number of toilet cubicles for girls is adequate. 29 Pupils queue to use the toilet. F Scent and Ventilation in School Toilets 30 Toilet produces heat through the squat holes. 31 Toilet provide adequate ventilation to all users. 32 Scent from the toilet gets to the classrooms. G Privacy and Safety Status of the School Toilet. 33 Toilet entrance is positioned away from the school compound. 34 Toilet is locked during classes hours. 35 Toilet doors is locked during off—school hours. 36 Toilet has door (s) to every cubicle 37 Toilet provides adequate privacy to pupils/users. 38 Toilet cubicle doors are in good shape. 39 Toilet cubicle doors have inner locks. H Presence of Rodents in Toilet Premises 40 Rodents in toilet premises. 41 Toilet premises is weedy. 42 Toilet is safe for all users irrespective of age and sex. I Community Encroachment on School Toilets 43 Community also uses the school toilet. J Technology Drives 44 Toilet squat holes are appropriate for pupils age and sex. 45 Toilet feet rests are appropriate for pupils’ age. 46 Toilet location is psychologically appropriate for pupils. 47 Toilets have Recommended number of vent pipes 48 Toilets vent pipes have appropriate dimensions. 49 Toilets have appropriate height of vent pipes.

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Appendix 6: Some Relevant Field Images

Interview Session with a Pupil on Open Defaecation

Interview Session with Deputy Education Director

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Condition of School Toilet-Akuffokrom

Researcher Having Informal Discussions with SHEP Coordinator Coordinator-Akuffokrom

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SHEP Coordinator Filling in Questionnaire Guide-Akuffokrom

Researcher On Tour with SHEP Coordinator to School Toilet-Akuffokrom

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Researcher Having Informal Discussions with SHEP Coordinator-Begoro

Researcher Observing Conditions of SchoolSchool Toilet

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Researcher administering Questionnaire-Akatsi

Condition of School Toilet-Begoro

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Researcher Inspecting Conditions of School Toilet Doors

Resercher measurining the squat hole size

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Reseracrer inspecting the school toilet conditions

Researcher Inspecting Conditions of School Toilet

Female Pupils FGDs Section

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Rodent (Lizard) on School Toilet Premises-Kedzi-Havedzi

Male Pupils FGD Session

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Researcher Measuring the Distance of School Toilet from School Comound

Researcher measuring Toilet squat hole size-Begoro

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Researcher Inpecting School Toilet Door-Begoro

Research at Akatsi South District Health Directorate-Discuss Sanitation Issues With Stakeholders

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Researcher Returning from Administration of Research Instruments-Keta

Pupils Had To Remove Their Uniform Before Using Toilets

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Appendix 7: Ethical Certificate of Study Approval

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Appendix 8: School Entry Protocol

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