Introduction

Access to safe drinking water and improved sanitation and hygiene are key to human and environmental health. They are also vehicles for promoting social equity and development globally [1]. Sustainable development goal 6 (SDG6) targets universal and equitable access to safe and affordable drinking water, adequate sanitation and hygiene for all and ending open defecation by 2030 [2]. Currently, the world is far from achieving these ideal situations and it does not augur well for good health especially in developing countries [1]. Poor sanitation, hygiene and water quality increase the risk of diarrhoeal and respiratory illnesses, especially in children less than five years old [3, 4]. Diarrhoea accounted for about 8% of global under-five deaths while lower respiratory tract infections were responsible for nearly 700, 000 deaths in the same population in 2016 [3, 5]. An estimated 16% of the burden of protein-energy malnutrition, 43% of schistosomiasis, 80% of malaria and 100% of soil-transmitted helminth infections/trachoma, and were attributable to inadequate water, sanitation and hygiene in 2016 [6]. These have implications for anaemia in vulnerable populations like pregnant women and children less than five years old.

In spite of their health importance, access to safe water and sanitation is not universal as 2 billion people lacked safely managed drinking water while 3.6 billion lacked safely managed sanitation globally in 2021 [7]. Improved water sources include protected wells, boreholes, piped water, packaged or rainwater while unimproved water sources include unprotected wells or springs, dug-outs and surface water [8]. Packaged water refers to bottled and sachet/bagged water. In settings where it is used, sachet water is usually sourced from underground, filtered using mechanical devices and sealed in 500 millilitre plastic bags for sale. Improved sanitation/toilet describes toilet facilities that hygienically separate excreta from human contact and these include flush/pour-flush toilet with sewer systems to septic tanks, ventilated improved pit latrines, pit latrines with slabs and composting toilets [9]. Unimproved sanitation/toilet facilities do not safely and hygienically separate excreta from human contact and include pit latrines without slabs, bucket latrines and open defecation [9]. Between 2017 and 2020, the population in sub-Saharan Africa with access to basic drinking water increased minimally from 34% to 34.6% while access to basic sanitation was stagnant at 12% with notable urban-rural disparities [8, 10]. In 2020, 54% of the urban sub-Saharan African population had access to safely managed drinking water compared to only 13% for the rural population [10]. Basic water access is improved water source that is accessible in a 30 minute round trip while basic sanitation is use of improved toilet facilities that are not shared with other households [8, 9]. Safely managed drinking water is an improved water source that is accessible on one’s premises, available when needed and free from faecal and priority chemical contamination [8, 9].

While about 8% of diarrhoea-related deaths in sub-Saharan Africa have been attributed to unsafe WASH based on recent data [8], it is estimated that there were ˃41 million episodes of diarrhoea and 7000 diarrhoea-related deaths in Ghana in 2017 [5]. The World Health Organization / United Nations Children Fund Joint Monitoring Programme Report (WHO/UNICEF JMP) reported that 86% of Ghana’s population had basic water access in 2020 compared to 89% indicated in 2015 [11, 12]. This may suggest an increasing population with basic water access that is not commensurate with the rate of population increase. In 2021, basic water access in the country was about 87.7% with urban-rural differences while basic sanitation access was 25.3% [13]. Access to basic sanitation in Ghana previously stood at 24% in 2020 [12] and 21% in 2017/2018 [14]. Access to improved sanitation for rural and urban areas were 17% and 25% respectively in 2018 while only 48% of the population had access to basic hygiene services (availability of handwashing facility on premises with soap and water) [14].

The prevalence of open defecation in the country currently stands at 17.7% from the recent 2021 population and housing census compared to the 22% reported in a multiple indicator cluster survey in 2017/2018 [14, 15]. Only about 24% of the Ghanaian population had access to improved toilet facilities in 2017/2018 compared to the 15%-21% reported over 2014–2018 [14–16]. Previously, an analysis of national demographic and health survey data showed 51% of Ghanaians used communal toilet facilities over 2008–2014 [17]. Despite an apparent improvement in access to improved toilet facilities in the country, this remains a far cry from the 2015 54% target under the millennium development goals [13] and the envisioned 100% access to basic sanitation services and elimination of open defecation by 2025 under the sustainable development goals [18]. Open defecation remains significantly high in Ghana and is driven by aesthetic, economic and sociocultural factors among others [19–21]. Sociocultural norms underpinning the practice of open defecation include frowning upon having any contact in any form with human feaces in homes, females being barred from using the toilet in the house during their menstrual periods and perceptions of a lowered social status with use of public toilets [20].

Some regions and districts in the country with hitherto poor WASH-related services have benefitted in recent times from non-governmental organizations-supported interventions such as Community-Led Total Sanitation (CLTS) and support for one household-one toilet initiatives [22, 23]. However, little is known about the WASH situations in other regions including the Volta Region. The present study was conducted to assess the WASH situation in the Volta region to help address existing knowledge gaps and also as proxy measures of progress towards achievement of WASH-related SDG targets. In addition, the study was a platform to help build data collection and basic statistical analysis capacity in medical students of the University of Health and Allied Sciences in the Volta Region. In this context, the students were expected to get experiential learning of challenges in the WASH situation and learn to better appreciate the socioeconomic background of their clients/patients as they are trained to become health experts who can take up advocacy to improve WASH issues in the country.

Materials and methods

Results

Respondents’ socio-demographic characteristics

Table 1 shows the socio-demographic characteristics of the respondents. More than half of the households surveyed, 393 (54.3%), were in the Ho West district. Four hundred and fifty-seven (63.6%) of the respondents were females. The respondents’ age ranged from 14–98 years and the mean (SD) was 48.3 (17.3) with majority of them, 549 (76.4%), educated up to either the basic or senior high school/vocational level. More than half, 413 (57.4%), were married. Farming was the most common occupation and was practiced by 265 (36.9%) of the study participants. Nearly all the respondents, 702 (97.6%), were Christians.

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Table 1. Respondents’ socio-demographic characteristics.

https://doi.org/10.1371/journal.pwat.0000134.t001

Household characteristics and access to water and toilet facilities

Table 2 shows house/household characteristics regarding the main type of material used to construct the house, household socioeconomic status, main source of water for drinking and other uses and type of toilet facility in the house among others. Five hundred and six (70%) of the houses/premises in the survey had only one household and the majority, 512 (71%), were cement houses. About 4 out of 5 households were categorized as being of low socioeconomic status while 27 (5%) were of high socioeconomic status.

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Table 2. Characteristics of houses/households surveyed in the study.

https://doi.org/10.1371/journal.pwat.0000134.t002

Public taps and piped water to the house were the commonest sources of drinking water and were used in 356 (49.4%) households. Bagged or sachet water (locally called “pure” water) was the next most common source of drinking water and it was patronized in 144 (20%) of households. Public taps were the most common source of water for domestic uses in 227 (31.5%) of the households. Though surface water was used, it was employed more for other domestic purposes and less for drinking. One hundred and seventy-two households (23.8%) had their water source within their residence. Four hundred and eighty-four (90.0%) out of the 548 respondents who sourced water from outside their residence reported they were able to do so in a less-than-30 minutes round trip by foot.

The data did not indicate whether the hand-dug wells were covered /protected or not. There were thus uncertainties as to whether they were to be categorized as improved or unimproved water sources and we chose to classify them as the latter. Analysis of improved water sources was thus restricted to boreholes/ piped water/rainwater/ sachet water alone and 706 (97.9%) of all households surveyed had access to improved water sources for drinking. Of these, 356 (50.0%) had access to piped water either through public taps or by direct access on the household premises. Only 144 (20.0%) of all respondents indicated their drinking water is subjected to any form of treatment.

About three-quarters, 526 (73.3%), of households had access to improved toilet facilities that they mainly used while 69 (9.6%) did not indicate any toilet facility and most likely mainly defecated in the bush or in communal toilets (see Table 2). Of the 526 households with improved toilet facilities, 158 (30.0%) had pit latrines with slabs and 198 (37.7%) used ventilated improved pit latrines. All the unimproved facilities were open pits without slabs. Majority of toilet facilities, 381 (53.1%), mainly used by households were located outside their residence. There were 40 cases where ≥5 households shared the toilet facility in a house. Asked about other places for defecation aside the mainly used ones, 243 of the 718 respondents who answered the question indicated they sometimes engaged in open defecation in the bush mainly, on the farm and at the refuse dump. The study did not inquire the reasons for the practice of open defecation.

Comparison of the distribution of respondents in various categories of selected variables

Among respondents with no formal education, there was a higher proportion of households that used unimproved toilet facilities (54.2% vs 45.8%; p<0.001) while the reverse was true across the basic, SHS/Vocational and tertiary levels of education (see Table 3). Regarding the location of toilet facilities mainly used, it was observed that higher proportions of households used toilets outside their residence across all categories of the variable ‘level of education’ except in the tertiary level where more households mainly used toilet facilities on their premises (65.3% vs 34.7%; p = 0.001) (see Table 3).

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Table 3. Distribution of educational level and socioeconomic status categories across the type and location of toilet mainly used.

https://doi.org/10.1371/journal.pwat.0000134.t003

Household socioeconomic status was independent of whether the toilet facility mainly used was improved or unimproved (see Table 3). A statistically significant higher proportion of households of low socioeconomic status had their mainly-used toilet facilities located outside their premises (55.5% vs 44.5%; p = 0.039). More households in the middle socioeconomic category had significantly higher proportions of their mainly-used toilets within their premises.

There was no statistically significant difference in household socioeconomic status across both study districts (see Table 4). Ho West district had lower proportions of respondents with no formal education (5.1% vs 16.0%; p < 0.001) and basic education (49.9% vs 53.4%; p < 0.001) but higher proportions of those with SHS/Vocational (29.0% vs 20.0%; p < 0.001) and tertiary (16.0% vs 10.7%; p < 0.001) education level compared to Adaklu district. A higher proportion of participants had their mainly-used toilets located in their residences in the Ho West district than in Adaklu (51.2% vs 41.9%; p = 0.013). Adding up the categories ‘none’ and ‘unimproved facility’ for the variable “type of toilet facility mainly used” (see Table 2), the proportion of participants using unimproved toilet facilities was higher in Adaklu than in Ho West (49.5% vs 7.9%; p<0.001). Conversely, the use of improved toilet facilities was more common in Ho West district (92.1% vs 50.5%; p<0.001) (see Table 4).

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Table 4. Comparison of selected household and participant characteristics between districts.

https://doi.org/10.1371/journal.pwat.0000134.t004

Boreholes (30.0% vs 7.8%) and rain water (15.8% vs 9.1%) were significantly more used as the major source of drinking water in Adaklu compared to Ho West (p < 0.001). On the other hand, household pipe-borne water/public tap (59.4% vs 39.8%) and sachet water (23.7% vs 16.5%) were the major sources of water for drinking in Ho West district (p<0.001).

The major sources of water for domestic use followed a pattern similar to that observed with water for drinking. Borehole (25.2% vs 9.9%), surface water (12.0% vs 4.0%) and rain water (19.9% vs 15.5%) were the major sources of water for domestic use in Adaklu district (p<0.001). Conversely, household pipe-borne water/public tap (68.5% vs 41.4%; p<0.001) were the major source of water for domestic use in Ho West.

More participants had their water sources in-house in Ho West than in Adaklu (32.4% vs 13.5%; p<0.001). A significantly greater proportion of participants in Adaklu compared to Ho West spent less than 30 minutes to get to their water source, fetch water and return home (72.7% vs 62.8%; p<0.001). Similarly, more people in Adaklu spent more than 30 minutes accessing water compared to Ho West (13.8% vs 4.8%; p<0.001).

Discussion

This study presents findings from a large cross-sectional assessment of the WASH situation in Ho West and Adaklu; two rural districts of the Volta Region in Ghana. Access to improved water sources was very high (97.9%). Overall, 95.2% of households either sourced water in-house (32.4%) or from outside but within a 30-minute round trip (62.8%). Access to improved sanitation was 73.3% but sharing of improved toilet facilities was rife in both districts. There were differences in some variables between districts including level of education, type of toilet mainly used and major source of drinking water even though both districts are described as rural.

Close to 80% of households sourced their water from outside their residence in the present study and 90% of these indicated they were able to do this in less than 30 minutes. The distance to these water sources was not estimated in the study but the time used suggests a relatively short distance to reach a water source which fits into standard recommendations [29]. This observation is also comparable to a finding where 93% of participants depended on outside sources of water within a mean of 1km round trip by foot in the Offinso-North district in the Ashanti Region of Ghana [30]. The present study did not investigate who actually goes to fetch water for the household but in most African settings, this is typically done by women and children.

The rather high access to improved water sources observed in the current study (97.9%) is reflective of the relatively high 83% improved water source access reported for the rural population in Ghana [14]. Currently, access to improved water sources in rural Volta Region stands at 77% [15]. After piped water from public taps, sachet water and piped water to the house were comparable as the most common sources of water for drinking. Sachet water enjoys a lot of patronage in Ghana (and in other West African countries) and is reported to be used more in the urban areas in the 2021 population and housing census report [15]. The present study findings mirror the 2021 census report as Ho West district, which the said report describes as being less rural, recorded greater use of sachet water than the more rural Adaklu district. The apparent ‘less rural- more rural’ disparity with respect to sachet water use noted in the study is similar to the findings of an urban study in Ghana where sachet water was the main source of drinking water for many households [31]. Sachet water use may be driven by a lack of access to public water supply systems, unreliability of the public supply system even where one has access and perceived better quality and taste of the sachet water [32–34].

Water provision in Ghana is largely implemented by government through the Ghana Water Company (GWC), the Community Water and Sanitation Agency (CWSA) and the Metropolitan/Municipal/District Assemblies (MMDAs) which are decentralized units of government in the various districts. There is also support from non-governmental organizations (NGOs), corporate and religious institutions and individual philanthropists who construct community boreholes as well. The GWC is responsible for urban/city/large town water supply and oversees about 90 water treatment stations across the country for distribution. The GWC does not manage boreholes.

The CWSA primarily and the MMDAs secondarily are responsible for rural water provision. They build boreholes and these can be mechanized for distribution to a number of communities with about 1800 inhabitants through pipelines [35]. The CWSA also builds more elaborate small town water supply systems that serve bigger areas of 20,000 or more inhabitants [35]. Some NGOs like World Vision also support government to develop policies regarding WASH.

A community ownership and management approach has been employed in managing the water supply facilities. Upon construction, the facility is handed over to the community and MMDA holds it in trust for the community [35]. A 7–9 member water and sanitation management team (WSMT) comprising representatives from the assemblies, traditional authorities and community membership oversee the day-to-day operations of the borehole and implements a tariff regime (pay-as-you-fetch) initially agreed on by the community for maintenance purposes [35]. There are trained artisans all over the country who carry out major repairs on these boreholes while minor faults are handled by two designated members of the WSMT who have been trained [35]. The community ownership approach has gaps and one is the rampant failure of the WSMT to maintain these boreholes. The CWSA is now taking over and managing a number of these water facilities on behalf of the communities.

The overall access to improved toilet facilities was 73.3% and was much higher than the 15%-24% reported nationally over 2014–2020 [12, 14, 16] and the 17% reported for rural Ghana in 2018 [14]. The observed household access to improved toilet facilities of 73.3% needs cautious interpretation though as it may reduce when one considers that even those with toilets in their residence may actually be sharing them with other households in that house. In the 2021 national population and housing census in Ghana [15], 55% of households with improved toilet facilities shared with other households. Improved toilet facilities that are shared tend to be regarded as losing their ‘improved’ status [36] and have been reported to be generally associated with increased risks of moderate-to-severe diarrhoea in children in some settings but protective in others [37].

Though shared toilet facilities may not be the global standard, they remain useful for bridging the equity gap; more or less, in achieving better access to improved sanitation [36] and likely contribute to reducing open defecation. While this may be the case in resource-poor settings such as the study sites, it is necessary to put in some interventions to limit sharing of improved household toilet facilities to no more than two or three households. Presumably, this would help to maintain better hygienic conditions for the facilities. Given the traditional communal and “sharing” nature here in Ghana and in many sub-Saharan African countries, reclassification of shared toilets as improved facilities (provided some minimum standards are met) should be argued for at the international front. Government and non-governmental agencies are urged to extend support for household toilet construction in low-income communities such as the study districts to help reduce the burden of sharing and ultimately increase true access to improved toilet facilities. The availability of land/space in and around the house for construction and attendant costs may be formidable challenges in this regard. Environmental health units at local government agencies must engage community members to help them understand the health benefits of limiting sharing of household toilet facilities to only a few households.

In the context of household toilet construction, it would have been useful to know how long pit latrines in the community last averagely, how often new ones are constructed as well as cost estimates but these assessments were outside the scope of the study. Though it can last 1–10 years, pit latrines may fill up after 2 years where the water table is high and with many users [38, 39]. This will necessitate more frequent emptying or construction of new ones. No published data was found on the life expectancy of pit latrines in Ghana. There is currently a World Bank project [40] that funds 70% of the cost of household toilet construction within the Greater Accra and Kumasi areas (the two largest cities). Households wishing to benefit from this project are required to pay the remaining 30% which translates to about GHS 1200 (US$ 100).

The present study found that about a third of improved toilet facilities were water closets but did not differentiate between flush-to-septic tank and flush-to-pit latrine systems. Either way, the study did not enquire about how frequently these are emptied and where they are disposed of. Piped sewage networks that conduct sewage to central treatment plants are not the norm in Ghana although such systems are known to exist in some military barracks in the country. Septic tanks are typically emptied using mobile vacuum tanks and disposed of at points designated by local government authorities. Currently, sewage treatment plants exist only in Accra and Kumasi; the two largest cities. In other parts of Ghana, sewage is disposed of unsafely into water bodies, dug pits and other isolated areas.

Public/communal toilets are built by the MMDAs mainly, communities themselves, philanthropists and NGOs especially in rural areas and are managed in similar fashion as the water facilities by the WSMT. Some individuals build and operate public toilets for profit at lorry stations, markets and in some urban poor communities.

The current study also showed an open defecation prevalence of about 33% across the two study districts, either as a matter of routine or occasional practice. This compares favourably with an earlier WHO sanitation progress report, over 2000–2017, that about 30% of the rural population in Ghana practice open defecation and another report of 38% specifically in the Volta Region [8, 15]. An enquiry of the reasons underpinning open defecation was not included in the current study but other studies have reported various reasons such as poorly-constructed communal toilets, perceived high costs of constructing household toilets, unpleasant smell and traditional norms and values such as beliefs that restrict menstruating women from using household toilets or people of high status in the community from using communal latrines [19–21, 41]. In about half of the households surveyed, the toilet facility mainly used was located outside the premises and in such situations, it may be safely presumed that child fecal disposal practices would likely be sub-optimal. Faeces of children are likely to be thrown into surrounding bushes and this has been linked to increased reports of diarrhoeal diseases [42]. In such areas, sanitation plans appear to be developed with only adults in mind and rarely are the needs children considered [42].

A greater proportion of respondents in Ho West had relatively higher levels of education and this seemed to reflect in a greater proportion of households with in-house improved toilets and pipe-borne water. Also, while household socioeconomic status did not appear to influence the type of toilet facility mainly used, households of middle and upper socioeconomic status were more inclined to having their mainly-used toilet facilities within their houses compared to those of low status. The present study was mainly descriptive and did not quantify associations (in terms of odds ratios) between variables such as demographic characteristics and access to improved water sources or sanitation. However, it still compared well with other studies that have reported that sex, age, level of education and wealth/socioeconomic index of household heads are associated with access to improved water sources and type/location of toilet facility [17, 41, 42].

Handwashing with soap and water was commonly practiced in the study area with about 95% of respondents self-reporting it. This is much higher than the 48% and 37% reported for the entire country and Volta Region respectively in 2017/2018 [14]. The high prevalence of handwashing observed was presumably influenced by prevailing COVID-19 risk perception and adoption of relevant preventive measures including handwashing with soap under running water at the time of the study. A similar high prevalence of handwashing, in relation to the COVID-19 pandemic, was observed in online surveys across 10 sub-Saharan African countries [43] conducted roughly within the same period as the present study. It must be noted that the students adhered to all COVID-19 preventive protocols. They were provided with nose masks, 70% alcohol hand sanitizers and trained on safe distancing before going to the communities.

The observation of a few reports of diarrhoea in the two weeks preceding the survey is remarkable, especially when only a fifth of respondents indicated treating their drinking water. A number of factors may account for this observation. Though the study districts largely have water supply through CWSA, some public taps and household pipe-borne water supply come from the GWC. This water is treated and safe for drinking. Some households and communities tap their supply from large GWC pipelines passing through or near their areas. Underground sources of water are also relatively safe as contamination from sewage and industrial waste does not occur as frequently as surface water contamination [44]. Surface water accounted for less than 2% of the sources of drinking water in the present study. Sachet water was the third leading source of drinking water. It is underground water that has been further treated and is thus considered safe. Nevertheless, both physico-chemical and bacterial contamination in sachet water have been reported in Ghana [45, 46]. The present study did not assess physico-chemical and bacterial contamination of drinking water either from the source or from storage containers. It is possible challenges with recall on the part of respondents may have led to an underestimation of diarrhoeal episodes over the defined period but this is not likely to be the case as 2 weeks is not a very long period to suffer a significant effect from recall bias. Lastly, the almost universal practice of handwashing with soap and water reported in the study (95%) could be protective against diarrhoeal episodes similar to findings reported from Nigeria [47].

Adaklu district had a significantly higher proportion of people with skin rashes (7.3% vs 3.3%) among the other household members aside the respondents themselves compared to the Ho West district. This may be linked to the observation that Adaklu also had higher proportions of households sourcing water for domestic use from boreholes and surface water. A study in northern Ghana showed that respondents who sourced water from wells, rivers, streams and dams had more skin diseases than those who used pipe or borehole [48]. Surface water is more prone to contamination [49] and water contaminants such as solid waste, pesticides and heavy metals beyond recommended levels have been linked with skin rashes in Ghana [49, 50]. It is also possible that the higher prevalence of skin rashes in Adaklu district does not emanate from the water sources used and study designs such as a case-control approach, on account of the relatively few cases, may be needed to investigate it further.

The purposive selection of the study districts limits the generalizability of study findings. A formal sample size calculation was not done for the survey but it would have been useful to take clustering into account and survey a larger ‘sample’ of the population in the two districts. This gap can reduce study precision and is acknowledged as a study limitation. Furthermore, even though household socioeconomic status was not comprehensively evaluated using principal component analysis methods, the proxy approach used is useful since the study was mainly descriptive and did not seek to identify possible factors influencing the WASH situation. Nevertheless, the study findings mirror some national population survey results and are useful as a needs and progress assessment endeavour that also identifies areas for immediate support. The household level fine scale data provided by the study are informative and important despite the limitations of the study. These data are needed for planning at the local and national levels.

Conclusion

The study findings contribute knowledge to a WASH-related needs assessment in rural Ghana and helps to identify areas for social intervention. While access to improved water sources does not appear to be a problem in the study area, a lot more can be done to improve on sanitation. Pragmatic steps including supporting poor households to have their own improved toilet facilities or to increase the number if they already exist are needed. Existing policies and frameworks guiding sanitation provision can be revised to formally adopt a ‘one household-one toilet facility’ policy by the government, where appropriate, and implementation scaled up across the country. In this regard, increased resourcing of government units/agencies responsible for WASH services such as the metropolitan/municipal/district assemblies, district health administrations and the community water and sanitation agency is needed while non-governmental organizations and development partners like Plan Ghana, United States Agency for International Development (USAID), Japanese International Cooperation Agency (JICA) and Korea International Cooperation Agency (KOICA), can also provide support modelled along partial funding from households. Local government and traditional authorities can work jointly to fend off open defecation by instituting fines, for instance, and ensuring adherence to building codes / by-laws.

Furthermore, qualitative studies are required to explore perceptions and experiences of sharing household toilet facilities and open defecation in the study area. This will improve understanding of the phenomena and help to shape WASH-related health promotion and social support interventions. Future studies must also seek to address the question of lifespan of toilets, how often new ones are constructed, attendant cost implications and how they impact sanitation to help give a more comprehensive overview of the WASH situation.

Supporting information

Acknowledgments

We thank all the respondents who welcomed us into their homes and participated in the survey. We are grateful to the leadership of the study communities and the preceptors who helped to make the students’ stay in the communities a success.