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Household survey data from 27 sites in 22 countries were collected in 2017–2018 in order to construct and validate a cross-cultural household-level water insecurity scale. The resultant Household Water Insecurity Experiences (HWISE) scale presents a useful tool for monitoring and evaluating water interventions as a complement to traditional metrics used by the development community. It can also help track progress toward achievement of Sustainable Development Goal 6 ‘clean water and sanitation for all’. We present HWISE scale scores from 27 sites as comparative data for future studies using the HWISE scale in low- and middle-income contexts. Site-level mean scores for HWISE-12 (scored 0–36) ranged from 1.64 (SD 4.22) in Pune, India, to 20.90 (7.50) in Cartagena, Colombia, while site-level mean scores for HWISE-4 (scored 0–12) ranged from 0.51 (1.50) in Pune, India, to 8.21 (2.55) in Punjab, Pakistan. Scores tended to be higher in the dry season as expected. Data from this first implementation of the HWISE scale demonstrate the diversity of water insecurity within and across communities and can help to situate findings from future applications of this tool. HIGHLIGHTS We present comparison scores of the Household Water Insecurity Experiences (HWISE) scale, a novel household water insecurity index validated for use in low- and middle-income countries.; These scores can aid interpretation of future implementation of the HWISE scale.; The HWISE scale should still be evaluated in new contexts, such as high-income settings.

COVID-19 has brought global attention to the critical role of water in managing infectious outbreaks. Although Sub-Saharan Africa could become a COVID-19 hotspot, some are optimistic that given the...

Background The periodic and seasonal outbreaks of cholera in Ghana make the disease a vital health concern. The country is cholera endemic with several communities within cholera hotspots. This study, therefore, assesses health literacy on cholera and the association between health literacy competency and health outcome. Methods The study adopted a health literacy framework that theorized the pathways between health literacy and health outcomes controlling for confounding factors. A survey questionnaire was administered to a representative sample of 401 individual household heads in James Town, Accra, Ghana. Reliability analysis was undertaken to ascertain the internal consistency of the instrument. Bivariate methods of analyses used were chi-square tests, ANOVA, Mann–Whitney U test, and Kruskal–Wallis test. Binary logistic regression models were run to examine the relative effects of health literacy competency on health outcome (having not had cholera). Results There are substantial knowledge gaps about environmental risk factors for cholera like the presence of the cholera germ in coastal water, as well as the likelihood of contracting cholera due to overcrowded spaces. However, better knowledge on cholera risk factors was found to be associated with better health literacy competency (food safety and personal hygiene practices). An increase in health literacy competency score was associated with lower likelihood of having had cholera, after controlling for intermediate factors. Conclusion Furthering health literacy on cholera environmental risk factors as well as a deliberate and targeted effort in encouraging consistency in the translation of disease knowledge into healthier practices may improve the well-being of the people.

Water sharing between households could crucially mitigate short‐term household water shortages, yet it is a vastly understudied phenomenon. Here we use comparative survey data from eight sites in seven sub‐Saharan African countries (Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Malawi, Nigeria, and Uganda) to answer three questions: With whom do households share water? What is expected in return? And what roles do need and affordability play in shaping those transfers? We find that water is shared predominantly between neighbors, that transfers are more frequent when water is less available and less affordable, and that most sharing occurs with no expectation of direct payback. These findings identify water sharing, as a form of generalized reciprocity, to be a basic and consistent household coping strategy against shortages and unaffordability of water in sub‐Saharan Africa.

Background: Foodborne diseases are significant reasons for in-patient and out-patient morbidity in Ghana. Of the foodborne illnesses reported in the country, cholera incidence and outbreaks have resulted in food-related mortality since the disease was first reported in the 1970s. Cholera is now endemic in the country. This study attempts to develop and pilot a tool to measure household health literacy among the urban poor in James Town, a cholera endemic neighborhood. Methods: A survey questionnaire was developed based on four of the World Health Organization’s (WHO) recommendations on issues for measurement of health literacy in low- and middle-income countries. The instrument was administered to 401 households in the community. We undertook reliability and validity analyses. T-test, Kruskal Wallis test, and Mann–Whitney test were used to examine the association between the health literacy scores of the scale and subscales and the demographic characteristics of households. Results: The reliability analyses showed that the instrument was internally consistent (Cronbach alpha = 0.762). All the subscales were reliable except the beliefs about health and healthcare subscale. Based on content and construct validity analyses, 13 items were used for further examination of health literacy. We found that majority of households know about the information, education, and communication materials and 52% of households indicated that these materials remind them about the dangers of cholera. About 39% of the households decide together as a unit on steps to avoid getting cholera during an outbreak. Overall health literacy scores and the subscales were significantly associated with sex, age, marital status, and educational level of household head. Specifically, females, being married, increasing age and higher household income had a significant association with higher health literacy scores. Conclusion: Household units in James Town impacts individual health literacy through: family discussions; access to information, education, and communication materials on cholera; and intentional efforts made to get information on cholera risk factors. Keywords: Cholera, Health literacy, Household health, Foodborne diseases, Infections, Ghana

Billions of people globally, living with various degrees of water insecurity, obtain their household and drinking water from diverse sources that can absorb a disproportionate amount of a household's income. In theory, there are income and expenditure thresholds associated with effective mitigation of household water insecurity, but there is little empirical research about these mechanisms and thresholds in low- and middle-income settings. This study used data from 3655 households from 23 water-insecure sites in 20 countries to explore the relationship between cash water expenditures (measured as a Z-score, percent of income, and Z-score of percent of income) and a household water insecurity score, and whether income moderated that relationship. We also assessed whether water expenditures moderated the relationships between water insecurity and both food insecurity and perceived stress. Using tobit mixed effects regression models, we observed a positive association between multiple measures of water expenditures and a household water insecurity score, controlling for demographic characteristics and accounting for clustering within neighborhoods and study sites. The positive relationships between water expenditures and water insecurity persisted even when adjusted for income, while income was independently negatively associated with water insecurity. Water expenditures were also positively associated with food insecurity and perceived stress. These results underscore the complex relationships between water insecurity, food insecurity, and perceived stress and suggest that water infrastructure interventions that increase water costs to households without anti-poverty and income generation interventions will likely exacerbate experiences of household water insecurity, especially for the lowest-income households.

The impact of acculturation on health status has been a subject of debate for over three decades. In this exploratory study, we use cross-sectional data to examine the relative effects of acculturation inclinations on self-rated health statuses among migrants in a poor, urban neighborhood in Accra. Much emphasis is placed on the role of the urban environment in disease outbreaks within the city, the patterns of communicable and non-communicable diseases, spatial health inequalities, and the distribution of sexual and reproductive illness risks in Accra. However, the ways by which acculturation inclinations and dimensions may exert positive or negative influence on health outcomes in such contexts have not been examined. We developed proxies for four main acculturation elements: assimilation, separation, integration, and marginalization. We used results from a semi-structured survey questionnaire with 296 migrants. After controlling for socio-demographic characteristics and social capital, findings from Ordinal Logistic Regression models indicate that the acculturation predictors of subjective health status are assimilation and marginalization. This study is the first step in understanding the possible trajectories by which acculturation affects health in the internal migration context in Ghana.

The patterns of infectious and chronic diseases are discussed in this chapter. Drawing on the concept of the double burden of disease, a deliberation on the trends of communicable and noncommunicable diseases in the developing world is undertaken. A detailed portrait of the prevalence of these diseases in Ghana and Uganda is presented using secondary data sources. To ascertain whether the patterns observed at the national level is synonymous with the patterns in the slums, data are collected from the immediate clinics in the study communities. The data from the health facilities in all the four informal settlements illustrate the double burden of disease and echo the predominant diseases plaguing the two countries. The top ranked diseases responsible for years of life lost and living with disability in these countries including malaria, respiratory infections, diarrheal diseases, sexually transmitted diseases and other urinary tract infections, as well as hypertension. And these are experienced by residents in the poor communities. Body health mapping activity revealed that in addition to the disease mentioned, occupation-related illnesses contribute heavily to morbidity among the urban poor.

This chapter examines migrant’s health literacy on communicable and noncommunicable diseases. Based on the most reported infectious disease, apart from malaria, and noncommunicable disease from the immediate clinics in Old Fadama and James Town, a survey questionnaire was developed to measure migrant’s functional, communicative/interactive, and critical health literacy based on Nutbeam’s health literacy typologies. The questionnaire was administered to a random sample of 150 individuals per site. The data were analyzed using descriptive statistics, reliability analyses, validity analyses, independent samples t-test, Pearson correlation, and analysis of variance (ANOVA). The instruments were reliable and achieved very good Cronbach Alpha values. The results indicate that, in James Town, there is a low level of functional, communicative, and critical health literacy among the study respondents regarding infectious disease. Similar trend is found in Old Fadama although migrants in Old Fadama scored better on communicative health literacy regarding upper respiratory disease. Hypertension was the noncommunicable disease mostly reported in both slums. Health literacy was found to be demographically differentiated. Generally, the higher one’s general literacy, the better their scores on health literacy.

In this chapter, we discuss the interrelationship between social capital, acculturation, lifestyle, and health. First, we explore the forms of social capital acquired at the destination and the constituents of social capital formation. Secondly, an assessment of the impact of social relations in the acculturation process is undertaken. Further, we show how social relations influence lifestyles that border on diverse forms of acculturation inclinations including assimilation, integration, separation, and marginalization. Thirdly, an examination of the perceptions of the impact of lifestyles on health outcomes is undertaken. Conceptual mapping was used to elicit information from migrants. Acculturation elements enabled by social relations include language acquisitions and comprehension, food, customs and values, as well as clothing styles. Forms of social capital such as bonding, bridging, and linking social capital were present in the social capital formation of migrants and each construct contributed uniquely and jointly to acculturation preferences and inclinations. For example, the place (community) and the ability to function effectively as a member of the community influenced one’s acculturation inclination regarding language. Migrants indicated that while some lifestyles learned from social relations, as adaptive strategies, may have positive effects on health outcomes, other lifestyles were mentioned as having detrimental health effects.

This chapter focuses on environmental risk to health in the study sites. Environmental exposures and contaminants are assessed through testing of chemical and biological contaminants using test strips, undertaking participatory hazard mapping activities on perceived dangerous and safe places for migrants’ health, and survey on the perception of the effects of the environment on food safety and its correlation with receipt of foodborne diseases information. Results from the chemical and biological contaminant tests show that many households sampled in the slums in both countries have high levels of heavy metals and bacteria pollutants in their nondrinking water that may be dangerous for health. The participatory hazard mapping activities showed migrants’ perceptions of their places of residence and environmental risks to health. Place characteristics and its relationship with perceptions of environmental risk to health were apparent. For instance, the presence of the unkept surroundings of the abattoir in James Town determined the kinds of risks and associated diseases, whereas the soap factory in Kinawataka influenced perception of risks in that place of residence for migrants. However, we observe that migrants demonstrated limited knowledge of diseases that may be associated with the environmental hazards in their neighborhoods.

This chapter focuses on the health literacy of migrants regarding environmental risks to health. Health literacy as a concept is first interrogated and conceptualized, positioning it as both a conceptual framework and measuring tool. Assessing health literacy was achieved by using survey questionnaires and conceptual mapping to demonstrate people’s perceptions of environmental pollution and how information was accessed about environmental contamination. Basing on the WHO recommendation of measuring health literacy in developing countries, the same parameters were used to measure health literacy in the participating communities. Results from the survey revealed that the migrants were aware of environmental pollution and they had access to information about it. Findings further revealed poor intentionality in seeking health information although general literacy impacted health literacy positively. The conceptual maps revealed that fecal contamination in the communities was perceived to be directly because of inadequate toilet facilities as well as unhygienic practices, which results in the spread of diseases. Most importantly, we notice big gaps in disease knowledge. Although mention is made of diseases such as cholera, dysentery, and typhoid, other predominant diseases associated with fecal contamination such as hepatitis, ascariasis, and gastroenteritis are not stated.

In this chapter, the interconnections between migration, social capital, and health is reviewed. The purpose is to show the inextricable link between these concepts through the lenses of theoretical and empirical literature on the subject. The chapter presents a short description on drivers of migration trends and the “globalization of migration” phenomenon. Through the prism of migration systems theory, we discuss the macrostructural and microstructural factors that shape migration. We zoom in on microstructural factors such as social networks and their contribution to both facilitating population movement and aiding in adaptation at the destination. Furthermore, the role of social networks in enhancing social capital notwithstanding, arrival of migrants at the destinations predisposes them to varying stressors. The stressors are more pronounced in the urban periphery, which host most poor migrants. Irrespective of the poor conditions in the urban periphery, the literature shows that migrants’ health statuses upon arrival are usually better than their hosts, especially with respect to chronic diseases; a situation referred to as the “epidemiological paradox.” The chapter concludes with a discussion on how social capital mediates migration and health outcomes.

This paper assesses the relative effects of acculturation preferences (assimilation, separation, integration, and marginalization) on migrants’ perception of acceptability in James Town, a traditional urban neighborhood in Accra, Ghana. There is a paucity of academic work on the relationship between migrants’ acculturation inclinations and their assessment of the hosts’ attitude towards them in Ghana. Cognizant of the fluidity of acculturation strategies, the study focuses on individual inclinations towards acculturation. To examine migrants’ perception of acceptability by the host, we use perceived personal discrimination. We utilize results from a semi-structured questionnaire administered to 301 migrant individuals from different migrant households in James Town. Our findings suggest that migrants with assimilation preferences are less likely to have a higher rating on the extent to which they are discriminated against by the host population. Such an exploratory study is pertinent to understanding relationships (conflicts or “togetherness in difference”) in poor multi-ethnic settings.

This exploratory study examines how migrants’ lifestyles are associated with subjective assessment of their health status in a relatively poor urban neighborhood in Accra. For more than half a century, urban centers have been on the receiving end of internal migrants in Ghana with Accra, Kumasi, and Sekondi-Takoradi receiving the lion’s share. However, a lot of migrants end up in poor neighborhoods due to inability to afford relatively costly rents in the better residential areas in the cities. Migrants who live on the margins of society are adversely impacted by poor environmental conditions that make them susceptible to environmentally-induced diseases such as malaria, cholera, and typhoid. While the poverty, health, and place research in Accra, Ghana, have focused on spatial distribution of inequalities in health, burden of sexual ill health, double burden of diseases, environment, wealth and health relationship, as well as income and health connections, there is paucity of research on association between the daily lifestyles of migrants in poor urban neighborhoods and their health status. Specifically on lifestyle and contextual factors, we examine (1) eating and drinking behavior, (2) perception of environmental factors, (3) attitudes and practices during illnesses, and (4) physical activities. Results from Ordinal Logit Regression models suggest that the key predictors of self-rated health status are: (1) socio-demographic elements like length of stay, job type, and religiosity; and (2) eating and drinking behavior—frequency of buying food from food vendors, and (3) social capital.

This paper seeks to understand the daily lived struggles for water in two slum settlements in Greater Accra, Ghana. Poor infrastructure and governance leave the Ghana Water Company Limited (GWCL) unable to fulfill the demand for water production in the capital city Accra, thus resulting in chronic intermittency of the urban water supply, and a high percentage of households purchasing water from neighbors and alternative sources such as sachet water, water kiosks, and water tankers. Utilizing theoretical insights from informality discourse, we examine household-level water access and the impacts of water supply disruption on daily lives by analyzing the emergent themes of eight focus group discussions (FGDs) about water access that were conducted in two slum settlements in Greater Accra. We observed intricate effects of water interference on daily lives, including negative perceptions about the government’s role in improving water access. The emergent themes from the FGDs included: (1) disruptions of indiv...

Background Although substantial progress has been made in reducing total mortality resulting from foodborne diseases, diarrheal illness are still the second most common illnesses among children. In Ghana, foodborne diseases have consistently been among the top 20 causes of outpatient illness over the last couple of decades. This study, therefore, examines health literacy on foodborne diseases and the relative effects of health literacy on self-rated health. Methods Foodborne diseases are major causes of morbidity and mortality globally. A mixed-method approach was used for this study. A survey questionnaire and an in-depth interview guideline were administered to samples of 401 and 30 individuals, respectively. We undertook reliability and validity analyses. ANOVA and chi-square tests were undertaken to assess bivariate association between health literacy and demographic variables as well as health status. Ordinal logistic regression models were used to examine the relative effects of health literacy on self-rated health status controlling for individual characteristics. Results The instrument was internally consistent (Cronbach alpha = 0.744) and valid. On health literacy, 40% of the respondents reported not to require help when they are given information on foodborne diseases to read by a doctor, nurse, or pharmacist. Approximately 60% of respondents need help with completing or filling out hospital documents. Educational level was found to be positively related to functional health literacy. Ordinal logit regression models showed that health literacy is a predictor of self-rated health after controlling for demographic variables. Conclusion Functional literacy is relatively low in the community. There is a positive association between educational level and functional health literacy. The study has also demonstrated the direct positive relationship between health literacy and health status controlling for covariates. Subsequent studies will need to examine multiple level dimensions of health literacy with direct link between specific foodborne diseases and health literacy. Electronic supplementary material The online version of this article (10.1186/s41182-018-0097-6) contains supplementary material, which is available to authorized users.

Packaged “sachet” water has become the primary drinking water source for millions of West Africans despite ongoing controversy over inadequate management of the new waste streams created by all the plastic wrappers. While recent literature from Ghana has shown that municipal water rationing and lower socioeconomic status tend to drive sachet consumption at the metropolitan scale, some low-income communities with a reliable piped water supply still exhibit diverse drinking water-seeking behaviours. This paper explores the drinking water landscape of one poor, informal community in Ashaiman, Ghana, as a case study of the individual- and community-level factors that shape household drinking water decisions. Using the results of a water questionnaire completed by 95 households and the transcripts of four focus groups, our findings suggest that, after controlling for demographics, sachet water consumption is associated with proxies for higher disposable income and lack of knowledge about household water treatment methods, while social processes and attitudes toward water quality do not seem to drive drinking water decisions. This community presents a paradoxical drinking water landscape, as poverty abounds despite excellent piped water access, and low-income households with slightly greater means tend to opt for packaged water as opposed to being driven to it by piped water shortages. These nuances in drinking water purchasing behaviour can inform policy and planning for drinking water provision in urban slums across the region.

The general pattern of internal migration in Ghana has been north to south. While a number of studies have focused on the vulnerabilities and urban problems associated with this pattern, the dynamics of internal migration with emphasis on young people in a slum setting have not been explored. To accomplish the goal of understanding the dynamics of internal migration among young people from the north of Ghana to Old Fadama, an Accra slum in the south, two specific objectives have been pursued. First, I explore the housing and environmental stressors encountered by young migrants at the destination and their proposed strategies to deal with these stressors and second, I explain how government policies are lagging behind to deal with these stressors. I use insights from the concepts of pirate urbanization and landlordism to show that substandard structures and the monetization of equity (property) among the relatively more privileged in the slum exacerbate the predicaments of these migrants. Drawing on the concepts of sovereign power and non-sovereign power, I suggest that lessons from the elements of these concepts (such as ethnic net-like organizations and governmental agencies) provide entry points for programmatic and policy directions aimed toward these young migrants in a high-risk environment. I use a mixed-methods approach to examine the objectives of this work. Semi-structured interviews and focus group discussions were conducted with young migrants (aged 10–29) in Old Fadama. I find that the major stressors faced by these young people include poor shelter, lack of sanitation, poor health outcomes, and human right violations, and these are exacerbated by the privatization of squatting.

Science and policy attention to global environmental and climatic change has been growing substantially. Yet, the psychological and emotional distress and pain triggered by these transformations have been largely ignored, particularly among poor and marginalized populations whose livelihoods depend on the living land. Building upon key geographical concepts of landscapes and place and embodied engagements within, we focus on environmentally-induced distress and loss of belonging (‘solastalgia’) in the coupled context of environmental and climatic changes and internal migration in Ghana. We assess the differential emotional experiences and memory among those who migrate from deteriorating environments in the North to urban slums in the capital Accra and those who stay behind in these altered homes. We use participatory mapping and 'walking journeys' in northern regions to examine understandings of landscapes of everyday life and identify places that induce solastalgia. Results illustrate that the combination of withered crops, drying up of wells, loss of beauty, and deteriorating social networks trigger strong emotional responses, in particular feelings of sadness. We conclude that these emotional responses are expressions of solastalgia in what we call “hollow homes” where place and self of agrarian livelihoods undergo both figurative and literal desiccation.

A number of young people from the north of Ghana migrate to live in the slums of the city of Accra, the administrative capital. These slums, characterized by poor quality housing, and inadequate sanitary facilities, make the young migrants vulnerable to the effects of economic, social, political and environmental insecurities and stressors. One of such slums is Old Fadama, which is located in the heart of the city. The main objective of this paper is to explain how resilient a sample of young migrants are to the stressors encountered at the slum through a self-rated level of resilience. Drawing on resilience thinking, the Youth Resilience Framework and Social Resilience perspectives are discussed and variables for analysis are considered from their synthesis. A survey questionnaire instrument is used to collect data from 104 young migrant residents in the slum. The methods of analysis include: analyses of variance, Chi-square test, and ordinal regression. From the multivariate analyses (that is, the ordinal regression analyses), it is suggested that significant predictors of resilience among the sampled young migrants in Old Fadama include type of employment, social capital, number of stressors experienced, and ability to afford medicine. Specific social capital constructs such as having a boy or girlfriend and strong leadership are predictors of resilience among these young migrants in the slum.

Sachet water has become an important primary source of drinking water in western Africa, but little is known about bacteriologic quality and improvements to quality control given the recent, rapid evolution of this industry. This report examines basic bacteriologic indicators for 60 sachet water samples from two very low-income communities in Accra, Ghana, and explores the relationship between local perceptions of brand quality and bacteriologic quality after controlling for characteristics of the vending environment. No fecal contamination was detected in any sample, and 82% of total heterotrophic bacteria counts were below the recommended limit for packaged water. Sachets from brands with a positive reputation for quality were 90% less likely to present any level of total heterotrophic bacteria after controlling for confounding factors. These results contrast with much of the recent sachet water quality literature and may indicate substantial progress in sachet water regulation and quality control.

Multi-faceted and complex factors resulting from the continual changes in our societies are, arguably, negatively impacting the people of the Global South, especially the young ones. These changes, which are characteristically multi-scalar, include ethnic conflicts, decentralization of government structures, poor agricultural yields and food insecurities, and unfavorable environmental issues (Blum 2007). Although these factors, which are felt both on the global and local scales, may lead to genius novelty, they usually bring about social disruption typified by population displacements, refugee situation, urbanization, and general population movements.

Primarily due to a high dependence on agro-ecosystems and their vulnerability to environmental changes, Africa is one of the most vulnerable continents to climate change and variability (IPCC, 2007). Poor rural societies that are dependent on climate-sensitive resources will be the most affected, with potential negative impacts including loss of income, displacement, and internal migration.