Health aspects of sanitation among Eastern Cape ( EC ) rural communities , South Africa

Curationis 29(2): 41-47 A descriptive study was conducted to determine the health aspects of sanitation among rural communities of the EC. A purposive sample of 145 villagers was drawn from 14 villages selected through systematic random sampling. Of these, 71 were male and 74 were female. The 145 participants were divided into 14 groups (M = 10 participants) by community and randomly assigned to 14 community-based trained facilitators. Each facilitator administered Dunker’s (2001) KAP tool for hygiene to the assigned group. The responses from all the groups were collated and analysed. Communities’ health was generally not considered good (78.6%) because of limited clean water, lack of money to treat water and unhealthy food. The prevalence of diseases in the last 6 months, included: skin diseases, worms, eye infections, diarrhoea, bilharzias and malaria; the perceived causes of diseases were mainly related to poor sanitation and the suggested disease prevention methods were sanitation improvement related. Institutional capacity was generally lacking as more than 50% of the communities did not have sanitation committees and environmental health officers (98.3%); health (64.3%) and water (57.1 %)committees. The results have implications for policy-makers, programme planners, academics and practitioners in the field of water and sanitation in terms of policy and programme formulation, curriculum development, and service delivery.


Curationis May 2006
financial and health burden on poor families (Tumwine, Thomson, Katui-Katua, Mujwanhuzi, Johnstone & Porras, 2003: 107).For example, an estimated 10 0 0 0 people die every day from water and san itatio n related diseases and thousands more suffer from a range of debilitating illnesses (Tladi et.al. 2002:17).Hemson (2003Hemson ( :3 & 2004:14) :14) reports that inadequate sanitation has an acute effect on child mortality rates in South Africa i.e. child mortality is twice as high for those households which do not piped w ater and four times high for those households which do not have flush to ile ts.The im pact o f inadequate sanitation on the health of the community and others downstream, is extremely serious as witnessed by the 1.5 million cases annually of diarrhoea in children under the age of 5 and the cholera outbreaks (DWAF, 1996: 40).Other health problem s associated with in ad eq u ate san itatio n are typhoid, bilharzias, malaria, cholera, worms, eye infections, skin diseases and increased risk for bacteria, infections and disease for people with reduced immune systems due to HIV/AIDS (DWAF, 1996: 39;DWAF, 2004: 19);Tladi et. al. 2002: 17).
The current study explores the health aspects of sanitation, such as health status of communities; the prevalence, in cidence, causes, p rev en tio n and treatment of diseases as well as available institutional capacity to deal with the diseases; among 14 rural communities of the Eastern Cape.Rural communities were chosen because they generally have little or no basic serv ices (w ater, sewerage, communications, electricity) compared to the large towns, even when they are located adjacent to the large towns (DWAF, 2002b: 1;Tladi et.al. 2002: 17 andDWAF, 1996: 8 ).It is hoped that the information derived from this study not only sheds some light on the health status of rural communities but also provide critical information upon which sanitation policy and programming efforts can be based.

Design and setting
A descriptive survey was conducted in the Eastern Cape Province which is situated along the southeast coast of South Africa and covers an area of 170 000 km2, representing about 14% of the country's landmass.

Sample and procedure
Approval for the research was requested from and granted by the Ngqushwa Municipality.A list of 112 villages spread across the 14 wards of the Ngqushwa local m u n icip ality w as provided.
Systematic random sampling was used to select 1 village from a list of the villages in each ward.The 14 villages identified for the study included: Bongweni, Dubu, Gcinisa North, Gcinisa South, Lower Qeto, Luxolweni, Machibi, Mpeko, Mtati, Nobum ba, Ntloko, Pedie extension, Q aw ukeni, and W oolridge.In each village, the researcher requested the local authorities to provide a list of 15 villagers who were knowledgeable about their com m unity san itatio n issues.Subsequently, the person chosen by the local authorities to assist the researcher with the research process in each village provided the researcher with a list of 15 villagers including grassroots women, nurses, teachers, the youth, village health w orkers, pastors, social w orkers, traditional leaders, traditional healers, representatives from various community structures, and pressure groups.The list contained the name of the participant, telephone number, fax number, office num ber and em ail address (w here applicable).The total number of villagers across the 14 villages amounted to 210 (15 villagers per village).These villagers were considered a purposive sample for the study.From a purposive sample of 210 villagers, 145 who constituted 69% o f the total sam ple consented to participate in the study after being advised o f their: a) th eir status as volunteers, (b) their right to refuse to answ er any question, (c) the legal liabilities of their participation, (d) confidentiality, and (e) the limitations of anonymity due to the nature of the study.The researcher ensured that: the group was sufficiently representative; there was an agreement on goals; and group members understood the constraints that applied.The distribution of villagers per village was as follows: 10 for Bongweni, Dubu, Gcinisa North, Gcinisa South, Lower Qeto, Luxolweni, Machibi, Mpeko and M tati resp ectiv ely and 11 for Nobumba, Ntloko, Peddie extension, Qawukeni, and Woolridge respectively.Only 31 % did not participate in the study, as they were not available at the time when the study was conducted.Of the 145 villagers, 49% (N=71) were males and 51% (N=74) were females.D unker's (2001: 1-11) KAP tool for hygiene in rural areas was adopted for the study.Prior to administering the tool, a pilot study with 1 0 villagers was undertaken in one of the non-sampled villages at Ngqushwa District.Thereafter, the wording of the original tool was review ed and m odified accordingly.Ambiguity of meaning was eliminated; clarity, comprehensibility and simplicity of items were ensured.The tool was adjusted in order to accommodate the cultural sensitivity of the participants.

Data collection method
Group interviews were used to collect data from the 14 random ly selected com m unity groups.Inform ation was collected from each small group in a single session.The group interviews involved an interactive procedure where the researcher collected the data in a dialogue with informants.This method of data collection was chosen because of its suitability to the type of data being collected and cost-effectiveness.

The process
Fourteen ( 14) trained community-based facilitators served as data collectors for the study.T heir m ain fu n ctio n as facilitato rs was to guide the group through the interviewing process.The purpose was to achieve an end result which is one that the group members have reached by themselves and which reflects their real views.For this to happen, each member of the group was made to feel able to contribute her/her views safely.Group members were also encouraged to listen to one another (or a genuine group consensus cannot em erge), and to communicate cooperatively rather than competitively.Facilitators helped each group to generate its own information while it takes responsibility for its own effectiveness in doing so.Each facilitator reminded group members that they were 42 Curationis May 2006 using a collaborative process.Their goal was to understand and communicate the view or views of the community as a whole.The facilitators then administered the questionnaire to the group members.Group m embers answered questions individually.Summaries of the responses to the questions were then written up and used as the basis for discussion.Group members used their individual responses as a means of knowing if there is close to a group consensus on some items.They decided on what should finally be written as a group response and they agreed on the wording with which the responses must be communicated.When the final wording was agreed on, it was then transferred to an appropriate space on the q u estio n n aire w ith o u t n either changing the words nor leaving out material.The group interviews were conducted in the indigenous language (Xhosa).The average number of members per group was 10.Each group interview lasted for about two hours.

Data Analysis
The 14 facilitators submitted completed group interview questionnaires for their respective groups to the researcher.Each group questionnaire was numbered to ensure that data capturers were able to go back to it should there be some queries.The researcher created the variables for quantitative data on SPSS version 11.0.R esponses were then entered on SPSS.The data was then cleaned and analysed as reflected in the results section.Qualitative responses to open ended questions were quantified using thematic content analysis.

Health
Communities' health was generally not considered good (78.6%) because of limited clean water, lack of money to treat water and unhealthy food.The majority of the communities (64.3%) did not have vegetable gardens and therefore did not eat vegetables daily (78.5%).Flies were p erceiv ed as a problem in the communities and participants indicated that they were attracted by dirty dishes, dirty w ater and dirty surroundings.Various methods were evenly used to prevent flies, namely disinfectants, fly ca tc h ers, m ain tain in g clean surroundings, dooming them and beating them with hands.All participants felt that hygiene education was necessary within their communities even if more than 60%

Diseases
The prevalence of diseases in the last 6 months in descending order, were: skin d isease s, w orm s, eye in fectio n s, d iarrh o ea, b ilh arzias and m alaria .However, the incidence rate was low across all diseases (<50%) except for skin diseases (92.8%), worms (64.3) and eye infections (50%), respectively.
The methods highlighted with regard to prevention of diseases, were all related to improving hygiene/sanitation.The suggested methods were evenly spread across the identified diseases.They ranged from using purified water, keeping environment clean, being hygienic to having a healthy diet and attending health consultation.

Community Institutional Capacity
Institutional capacity was generally lacking as m ore than 50% of the com m unities did not have sanitation committees and environmental health 44 Curationis May 2006

Health of communities
Communities' health was generally not considered good (78.6%) because of limited clean water, lack of money to treat water and unhealthy food.Flies were p erceiv ed as a problem in the co m m u n ities due to unhealthy surroundings (92.9%).It is assumed that the availability of flies in the communities contributed to diseases that led to poor health.The majority of the communities (64.3%) did not have vegetable gardens and therefore did not have vegetables daily (78.5%).It is assumed that the lack of vegetables in communities' daily diet c o n trib u ted to poor n u tritio n and consequently poor health.The poor health status in the communities is a course of concern because poor health keeps families in a cycle of poverty and lost income, which could otherwise be avoided.The national cost o f lost p ro d u c tiv ity , reduced educational potential and curative health care is substantial (DWAF, 1996: 9;DWAF, 2002b: 1).Investing in sanitation can lead to increased life expectancy and savings in health care costs (DWAF, 2001: 9).'It can contribute to enhancement of the quality of life through improved general health conditions and well being of the people.All participants were of the opin io n that hygiene education is necessary within their communities, even though more than 60% of the groups indicated that their communities were generally aware of re-hydration mixtures for diarrhoea, medicines and bandages for treating burns, antiseptics and bandages for treating cuts, bites, etc. and insect repellent for mosquitoes, flies, fleas, etc.This view is supported in literature as (DWAF, 1996:14) states that health and hygiene education should be provided to communities in order to: raise aw areness o f the diseases caused by unhealthy behavior and p ractices; enable communities to improve their health through correct hygiene practices and in crease the demand and willingness to pay for ap p ro p riate san itatio n facilities (DWAF, 1996: 14).DWAF (1996: 8 ) further states that often the san itatio n challenges in rural areas are associated among others with the lack o f access to health and hygiene education (DWAF, 1996: 8 ).Lack of hygiene education results in an ignorance of the consequences of personal and fam ily hygiene custom and practices (DWAF, 1996: 41).In this regard, DWAF (2002b: 9) has set as its target, the provision of hygiene education to 3 million ho u seh o ld s by 2010.The enormous backlog of basic water and sanitation services to local communities will not be reduced unless communities themselves are empowered to undertake their own development.This is not possible if they do not have the skills required which they can only acquire through hygiene education (DWAF, 1994: 20).Although education/training is not cheap, the costs of inadequate sanitation are greater.DWAF (2002a: 48) states that adequate education, among others, is a prerequisite to co st recovery and effectiv e management of service delivery.

Diseases
The prevalence of diseases in the last 6 months, in descending order, included: skin diseases, worms, eye infections, diarrhoea, bilharzias and malaria and their causes were m ainly related to poor sanitation.The results in this regard are in line with the literature that point out that health problems associated with in ad eq u ate san itatio n are typhoid, bilharzias, malaria, cholera, worms, eye infections, skin diseases and increased risk for bacteria, infections and disease for people with reduced immune systems 45 Curationis May 2006  , 1996:39;Tladi et. al. 2002: 17).All diseases suffered, were to a large extent, caused by poor hygiene/sanitation as follows: diarrhoea ( 1 0 0 %); malaria ( 1 0 0 %); skin diseases (92.9% ); worms (85.7% ); bilharzias (78.5%); and eye infections (64.3%).The prevalence of sanitation-related diseases in rural communities is not surprising in view of the fact sanitation conditions in rural areas are far from satisfactory (Alcock, 1999:27).
Like in literature, the methods cited by the participants in preventing the abovementioned diseases were related to the improvement of the sanitation conditions (ibid), i.e. they ranged from using purified water, keeping environment clean, being hygienic to having a healthy diet and attending health consultation.should be acknow ledged and used.Collaboration and cooperation of the various stakeholders within communities are critica l in addressing h y g ien e/ sanitation issues (DWAF, 1994: 11 & DWAF, 1996:4).UNICEF(1997:11) states that communities should use existing com m unity organisations rather than creating new ones and that education should be provided to improve both the organisational capacity of the community groups and their problem solving skills.Actions that encourage local leadership, governance and economic development can contribute to enhanced capability in a village to manage, operate and maintain sanitation facilities and other services.Actions that can promote village selfgovernance and leadership include: an acknowledgement that people know their needs and know where to start in meeting these needs; recognize that people can develop solutions to their needs; trust p eople w ith resources to d irectly implement solutions they have identified; and exercise flexibility in programme and project time lines (Alaska Native Health Board, 2002:4).

Conclusion
The results of the present study have im p licatio n s for po licy -m ak ers, program m e planners, academ ics and practitioners in the field of water and san itatio n in term s o f po licy and program m e form ulation, curriculum development, and service delivery.They serve as a knowledge base on which the national, provincial, local governments as well NGOs and the private sector can build strategies for prom oting good sanitation practices.

Table 1 : Health of Community Perception of health
When they are ready 1(7.1)During festive seasons 1(7.1) 43 Curationis May 2006