Access to sanitation services is generally poor in developing countries including Ghana. Whereas works on the effect of sanitation on health have been interrogated, those on the relationship of socio-economic and demographic factors and access to sanitation services are limited. Besides, the issue of equity in access to sanitation services is least explored. The main objectives of this research were to explore the relationship between background characteristics of respondents and access to sanitation services and to examine whether there is equity in access to sanitation facilities in the Pru district of the Brong Ahafo region (Now Bono East Region) of Ghana. The integrated behavioural theory underpinned the study whilst the mixed methods approach was used as a research approach. A combination of simple random, systematic and accidental sample techniques was used to derive a sample of 380 based on the statistical table designed by Krejcie and Morgan (1970). Results show that, first and foremost, education and income levels had a positive effect on access to sanitation services. Secondly, women had better access to sanitation services than men largely due to the cultural factor of the recognition of the sacredness of the nude of women. Secondly, there is no equity in access to sanitation services since urban areas have better access than rural areas and the rich access safe sanitation services more. The propositions that there is inequity in access to sanitation services in the study area, and that the rich and affluent have better access to such services have been vindicated. Besides, the integrated behavioural theory has been justified.

1. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Access to Sanitation Facilities in a Predominantly Rural
District in Ghana: Socioeconomic and Cultural Determinants
and the Equity Syndrome
*1Buor, Daniel (PhD), 2Asuah Gyan, Mark, Tutor, MPhil.
1Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology (KNUST),
Kumasi, Ghana
2Berekum College of Education, Ghana
Access to sanitation services is generally poor in developing countries including Ghana. Whereas
works on the effect of sanitation on health have been interrogated, those on the relationship of
socio-economic and demographic factors and access to sanitation services are limited. Besides,
the issue of equity in access to sanitation services is least explored. The main objectives of this
research were to explore the relationship between background characteristics of respondents
and access to sanitation services and to examine whether there is equity in access to sanitation
facilities in the Pru district of the Brong Ahafo region (Now Bono East Region) of Ghana. The
integrated behavioural theory underpinned the study whilst the mixed methods approach was
used as a research approach. A combination of simple random, systematic and accidental sample
techniques was used to derive a sample of 380 based on the statistical table designed by Krejcie
and Morgan (1970). Results show that, first and foremost, education and income levels had a
positive effect on access to sanitation services. Secondly, women had better access to sanitation
services than men largely due to the cultural factor of the recognition of the sacredness of the
nude of women. Secondly, there is no equity in access to sanitation services since urban areas
have better access than rural areas and the rich access safe sanitation services more. The
propositions that there is inequity in access to sanitation services in the study area, and that the
rich and affluent have better access to such services have been vindicated. Besides, the
integrated behavioural theory has been justified.
Keywords: access, sanitation facilities, toilets, rural, urban, equity, socio-economic determinants.
INTRODUCTION
The world’s lack of progress in building toilets and ending
open defecation is having a staggering effect on the
health, safety, education, prosperity and dignity of 2.5
billion people (World Health Organisation (WHO), 2019).
About 1.1 billion people in 22 countries practise open
defecation in view of lack of adequate access to open
defecation (WHO 2015). So alarming is the problem that
the United Nations (UN) (2015) has captured the issue of
sanitation in its sustainable development goal 6 which is
on the theme “Clean Water and Sanitation” which is also
related to goal 3 on the theme “Good Health and Well-
Being”. In assessing access to sanitation facilities, not
much has been done on access in predominantly rural
communities in Ghana. Besides, works on access have
not concentrated on the socio-economic background of
people with or without adequate access. Moreover, studies
on access have not concentrated on the mixed methods
approach which gives a balanced view of the problem.
There was thus the need to explore the socio-economic
backgrounds of various levels of access of sanitation
facilities and how they relate to social equity.
United Nations Children’s Fund (UNICEF)’s (2013)
comprehensive monitoring report on water and sanitation
shows that access to improved toilet facilities in the
developed world is higher than developing countries, and
*Corresponding Author: Prof. Daniel Buor, Department
of Geography and Rural Development, Kwame Nkrumah
University of Science and Technology (KNUST), Kumasi,
Ghana. E-mail: drdrbuor@gmail.com
Co-Author Email: mark.gyan.mag@gmail.com
Research Article
Vol. 6(1), pp. 146-157, June, 2020. © www.premierpublishers.org. ISSN: 2021-6009
International Journal of Geography and Regional Planning

2. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Buor and Asuah Gyan 147
within the developing world, access is worst in Sub-
Saharan Africa. While the proportion of the world
population who had access to improved toilet facilities in
2010 was 63%, it was 95%, 56%, and 30% in the
developed world, developing world and Africa, South of the
Saharan (ASS), respectively (WHO/UNICEF, 2019). An
analysis of Afrobarometer Round 6 (2014/2015) data from
32 African countries shows that Ghana and Liberia have
the second highest proportion of the population, behind
Niger (65%), without access to toilets in their homes or
compounds. In Egypt, Mauritius, Algeria, and Tunisia, all
or almost all respondents say they have access to toilets
inside their homes or compounds (Armah, D.A. 2015).
Proper sanitation facilities (for example, toilets and
latrines) promote health because they allow people to
dispose of their waste appropriately. Throughout the
developing world, many people do not have access to
suitable sanitation facilities, resulting in improper waste
disposal. According to the latest estimates from the World
Health Organization (WHO)/United Nations Children’s
Fund (UNICEF) Joint Monitoring Programme for water and
sanitation (JMP), 2.5 billion people worldwide do not have
access to any type of improved sanitation. Thus, open
defecation is the practice of most people.
In 2015, Ghana recorded 694 cases of cholera with 11
deaths with case fatality rate (CFR) at 1.6 per cent,
stressing the risk factors as over-populated communities
(slums and refugee camps) characterized by poor
sanitation, unsafe drinking water, increased person to
person transmission, poor personal hygiene, poor food
hygiene and floods leading to contamination of domestic
water sources and broken-down water and waste disposal
systems (UNICEF, 2015).
According to UNICEF Ghana placed second in cholera
rankings in West Africa in 2015, with 28,944 cases and 247
deaths (UNICEF, 2015). This indicates that the disposal of
faecal matter through inappropriate ways leads to
incidences of sanitation-related risks, and this has socio-
economic consequences on every household that falls
prey to cholera and any of the other diseases. In addition,
unimproved sanitation services cause communicable and
diarrhoea diseases (cholera, typhoid and dysentery) which
are the second killer diseases, after pneumonia, of under-
5 children (Roma & Pugh 2012; WHO 2011). Lack of
sanitation leads to disease. The diseases associated with
poor sanitation are particularly correlated with poverty and
infancy and alone account for about 10% of the global
burden of disease (Prüss-Üstün et al. 2008). At any given
time, close to half of the urban populations of Africa, Asia,
and Latin America have a disease associated with poor
sanitation, hygiene, and water (WHO, 1999). Of human
excreta, faeces are the most dangerous to health.
Sixty-two per cent (62%) of Africans do not have access to
an improved sanitation facility - a proper toilet - which
separates human waste from human contact, according to
the WHO/UNICEF Joint Monitoring Programme for Water
Supply and Sanitation (WHO/UNICEF, 2008). The
absence of adequate sanitation has a serious impact on
health and social development, especially for children.
Diarrhoeal diseases are the most important of the faecal-
oral diseases globally, causing around 1.6–2.5 million
deaths annually, many of them among children under 5
years old living in developing countries (Mathers et al.
2006). In 2008, for example, diarrhoea was the leading
cause of death among children under 5 years in sub-
Saharan Africa, resulting in 19% of all deaths in this age
group (Black et al. 2010).
The theory that has been used variously in the study of
access to sanitation and sanitation behaviour has been the
integrated behavioural theory for water and sanitation and
hygiene. Promotion and provision of low-cost technologies
that enable improved water, sanitation and hygiene
(WASH) practices are seen as viable solutions for
reducing high rates of morbidity and mortality due to
enteric illnesses in low-income countries. According to the
authors of this model (Dreibelbis et al. 2013), existing
health promotion models under-represented the potential
role of technology in influencing behavioural outcomes,
focused on individual-level behavioural determinants, and
had largely ignored the role of the physical and natural
environment. IBM-WASH attempts to correct this by
acknowledging three dimensions (conceptual factors,
psychosocial factors, and technology factors) that operate
on five-level (structural, community, household, individual,
and habitual). Technology is the focus of this model. If
modern technology is incorporated in the way we manage
our sanitation, most diseases related to sanitation would
not occur.
Whereas works on the effects of sanitation on health are
easy to lay hands on, there is a dearth of works on
characteristics of people with various levels of access to
the facilities and how they relate to equity especially rural
communities in Ghana. Appiah-Effah, et al. (2019)
examined Ghana’s post MDGs sanitation situation: an
overview specifically examined why the MDGs target on
sanitation was missed. There was no discussion on
access by socio-economic characteristics. In Ampadu-
Boakye et al. (2011) work on improving access to basic
sanitation in Ghana: lessons from water and sanitation
project in Ghana, the sanitation component of the project
was discussed without relating access to sanitation
facilities by socio-economic background of the people.
There was no discussion on access by socio-economic
characterises and an expropriation on social equity. Kosoe
and Issaka (2013) wrote a paper titled “Where do I answer
nature’s call? An assessment of accessibility and
utilization of toilet facilities in Wa, Ghana.” Although their
work was on the adequacy of toilet facilities, their focus
was on mainly public toilets. Besides, the study did not
explore the socio-economic backgrounds of levels of
access to sanitation facilities.

3. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Int. J. Geogr. Reg. Plan. 148
Sanitation and its effects on health is such that there must
be equity in access to them. This research work is very
important because it assessed how equitable access to
sanitation facilities in the Pru district of the Brong Ahafo
region (Currently Bono East Region) of Ghana is and its
potential to affect health conditions of those with poor
access to them drawing a sample from the communities
and using a mixed methods research design to explore
assess of the communities to sanitation facilities. Besides,
studies on access to sanitation facilities in a typical rural
district with a few urban centres by demographic and
socio-economic characteristics are limited. The research
questions addressed are as follows:
1. How adequate are toilet facilities in the Pru District?
2. How accessible are the facilities to the population by
socio-economic and demographic backgrounds?
3. Is equity addressed in access to sanitation facilities in
the district?
The propositions underlying the study are twofold: that
there is no equity in access to sanitation facilities in the Pru
District; and that income and education have a strong
influence on access to sanitation facilities.
Access to Sanitation Facilities in Ghana and the Pru
District
The statistics on sanitation in Ghana are alarming— five
million people do not have access to any toilet facilities,
and 20 million do not have access to basic improved
sanitation. Poor sanitation is costing the country over
US$290million yearly, while open defecation is costing a
whopping US$79million (UNICEF, 2014). Almost two-
thirds of Ghanaians (64%) are at risk of engaging in open
defecation because they do not have toilets in their homes
or in their compounds. The 2010 Population and Housing
Census (Ghana Statistical Service (GSS), 2012) and
2012/2013 Ghana Living Standards Survey (GLSS 6)
(GSS, 2015) showed even higher proportions (73% in the
PHC 2010, 74% in the GLSS 6) at risk of engaging in open
defecation.
Lack of toilet facilities in many homes in the country is
something that cannot be ignored, and as a result, people
form long queues early in the mornings to have access to
the few existing public toilets, whereby putting extreme
pressure on these facilities. In most parts of Ghana, it is
common practice for people to answer the call of nature in
the open field as a result of the lack of household and
public toilet facilities, which results in a poor sanitary,
health and environmental situation (Kosoe and Osumanu,
2018). Several studies, including Benneh et al. (1993),
Songsore and McGranahan (1998) and Osumanu (2007a;
2007b), have shown that it is poor households who are
often unable to afford a toilet facility at home. This then
puts pressure on public toilets which could have served
visitors, shoppers, and pedestrians etc., who would find
themselves in places other than their homes and need to
use such facilities.
According to the Ghana-UNICEF inequality briefing paper,
sanitation coverage is a major national problem in the
country (UNICEF, 2014). The proportion of the population
using improved and unshared sanitation facilities barely
changed between 2006 and 2011 rising to just 15% in
2011. Inequalities, especially between rural and urban
dwellers, persist and regional inequalities are the most
pronounced with well over 70% of households in the 3
northern regions having no toilet facility whatsoever.
The most common toilet facility used in the Pru district
(Figure 1) is the bush, beach or field representing 52.1 per
cent followed by public toilet, water closet (WC), ventilated
improved pit (VIP), pit, pan etc. constituting 33.5 per cent
(GSS, 2012).
Figure1: Pru District in National Context
Source: GIS Consult and I.T. Revolution, 2017
This implies that more than half of the households in the
Pru District have no toilet facilities. The facility which is a
bit close to the WC (with septic tank facility) is the pour
flush, a facility that requires that the excreta is disposed of
by pouring water into the toilet hole but it costs not less
than Two Thousand Five Hundred Ghana Cedis
(GhC2,500.00)[$500.00] to construct; a cost which cannot
be borne by over 90% of the population especially in the
rural communities. The use of public toilet facility is twenty
pesewas (GhC0.20/$.04) per one use. In some
communities, more than 150 people use one public toilet
hole which implies about 7 people per hole per hour.
Equity in Government Policy on Access to Sanitation
The term equity is a normative concept which is concerned
with equality, fairness and social justice (World Bank,
2005). It is based on the idea of moral equality, justice and
fairness of social policy. Equity is buttressed on three
principles but the one which is compatible with this study
is ‘equal concern for people’s needs’ (Harry, 2009). In
2009 the Government of Ghana revised its Environmental
Sanitation Policy. In the new policy the District Assemblies

4. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Buor and Asuah Gyan 149
“shall regulate technologies for domestic toilets by
legislation and application of the building code”. They were
further to “arrange for the provision of public facilities
(toilets) in the central business districts, major commercial
and light industrial areas, local markets and public
transport terminals (lorry/bus stations)”. They were further
to “promote the construction and use of household toilets,
including the conversion of pan latrines to approved types”
(Government of Ghana, 2010). The policy to promote the
construction and use of household toilets, including
conversion of pan latrines to approved types, however,
gives an indication of government’s desire to ensure
access to decent sanitation facilities.
METHODOLOGY
Design and Units of Analysis
The researchers made use of both qualitative and
quantitative methods (mixed methods) of to satisfy the
pragmatic research philosophy. The cross-sectional
design was also used to collect data from respondents
from selected communities in the Pru district. Data were
collected from respondents from households.
Data and Variables
Primary and Secondary data were used. Primary data was
collected from the people in the Pru district and secondary
data from the Ghana Health Service, the District Assembly
as well as books, internet, articles and journals. The
independent variables used included age, sex, level of
education, place of residence, income, employment
status, marital status, family size, and toilet facility at
home. Sex and age of the respondents ensured a
balanced response from the respondents. Level of
education of respondents was to help identify whether
people’s educational background influences the decision
to provide toilets in the home or not. The place of
residence, employment status, the income of respondents,
all in one way or the other, affect the provision of toilets in
the home. The dependent variable was access to toilet
facilities.
Sampling
The population of Pru District, according to the 2010
Population and Housing Census, is 129,248. The six
communities the researcher used for this study namely
Yeji, Prang, Daman Nkwanta, Komfourkrom, Abease and
Parambo have a combined population of 40,981. The
sample size for the study was derived using the table by
Krejcie and Morgan (1970) (Appendix 1). By the table, a
population size of 40,000 gives a sample size of 380,
hence the sample used for the selected 6 communities
was 380. Simple random sampling technique was used to
select the six communities namely, Daman Nkwanta,
Komfourkrom, Abease, Parambo, Prang and Yeji (Table
1). There was the need to select a combination of rural and
rural communities, hence, Yejj and Prang, the only urban
communities, were selected. The other communities were
listed on pieces of paper which were folded and placed in
a bowl, shifted and a research assistant asked to pick four
pieces with eyes closed. The proportionate sampling
fraction method was used to allocate samples to the
communities as indicated in Table 1.
Table 1: Sample Distribution by Residence
Community Population Sub-Sample
Daman Nkwanta 4,018 37
Komfourkrom 2,897 27
Abease 3,499 32
Parambo 4,828 45
Prang 7,146 67
Yeji 18,593 172
Total 40,981 380
Source: Field Survey, 2017
NB: The total population of the communities was
divided by the population of each community and
multiplied by 380 to derive the sub-samples.
The simple random technique was again used to select
respondents from the six communities. In each
community, the houses were listed and a systematic
(probability) random technique used to select the houses
using a sampling interval of three for the rural communities
and five for the urban communities where there were more
houses. In each house, a head of household who was at
home during the visit by the research assistants were
selected for interview. Where there was more than one
head of household at the time of visit, the same sampling
process for selecting the communities was used to select
the heads of household. Five respondents were selected
from each community for the interviews through the
accidental method. The probability (simple random)
techniques was used specifically to select respondents for
the questionnaire survey whilst the non-probability
(accidental) technique was used to select respondents for
collecting the qualitative data.
Methods of Data Collection
Questionnaires and interviews were the instruments used
in collecting data for the research. With the primary data,
a questionnaire, both closed-ended and open-ended, was
designed to solicit information regarding the respondents’
gender, age, highest educational level attained,
employment status, income level, place of residence and
availability of toilet facilities in their homes or
neighbourhoods and other related variables. An interview
guide was applied on the respondents selected through
snowballing, a non-probability technique, because it was
necessary to get specific persons suffering from
sanitation-related infections to facilitate a linkage between
infections and environmental conditions.

5. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Int. J. Geogr. Reg. Plan. 150
The literate completed their questionnaire in English whilst
the illiterate who could not complete the questionnaire
communicated in the local language, Twi, and translated
into English by the research assistants.
The secondary data collection involved the collection of
official statistics from both the District Assembly and the
District Health Directorate Services, as well as from books,
journals and the internet. The questionnaire instrument
was validated by pre-testing on selected respondents in a
community outside the study communities. The pre-testing
revealed a few flaws that were addressed. It was found
that a few of the questions were similar. The few having
such similarities were amended. Data collection was done
in eight weeks in May and June 2017 by two university
graduates who were trained in the exercise.
Data Analysis
Both qualitative (descriptive) and quantitative techniques
were used for the analysis. Quantitatively, results from the
structured questionnaire were analysed using the
Statistical Package for the Social Sciences (SPSS Version
20). All primary data sets were subjected to tabular and
statistical analysis involving simple and statistical
measures like frequencies and percentages, as per the
objectives of the study. In the qualitative analysis,
discussions and observations that were made during the
study period were used to support results that were
obtained quantitatively. Qualitative data were analysed
thematically and manually. The interviews were tape-
recorded and transcribed for detailed copying for analysis.
The codes derived were level of education, income,
residential status, age, marital status, employment status,
culture, open defecation, etc. For the themes, the codes
were combined with access to specific toilet facilities, open
defecation, cultural traits, etc. There were a few outliers
which were not factored in the analysis.
RESULTS
Adequacy of toilet facilities in the District
The toilet facilities in the community are water closet, pour
flush toilet, VIP latrine, latrine with a slab and others. The
facilities regularly used by the respondents are indicated
in Table 2.
Table 2: Sanitation (Toilet) facilities regularly used by
respondents
Type of Facility No. %
Water Closet 49 20.9
Pour Flush 3 1.7
VIP* Latrine 95 56.2
Latrine with a Slab 22 13.0
Total 169 100.0
Source: Public Health Office, Yeji, 2017
NB: The rest, 211, used unconventional means such
as open defecation.
*Ventilated Improved Pit Latrine
The water closet facility, 49 in number, and pour-flush
facilities were from individual homes whilst the VIP latrines
and latrines with slabs were public facilities. Water closet
toilet facility which is the most ideal toilet facility is
concentrated in the two semi-urban communities of Yeji
and Prang. Even for the VIPs which are many, the
concentration is in the semi-urban centres. This
undermines equity. In the urban centres dwell the district
administrative and political authorities who decide on the
siting of facilities. They serve a population of over 40,000
implying a facility serves over 800 persons which is
woefully inadequate. With 169 facilities in all, a facility
serves a population of 242 persons which are inadequate.
The World Bank observes that a maximum of 15 persons
legally require one toilet per each gender-designated
restroom (World Bank, 2018).
A respondent from Daman Nkwanta in the interview on the
adequacy of toilet facilities said:
The facilities are very few. The government must
provide more toilet facilities. In the absence of
that, the fields are there for me to ease myself (In-
depth Interview (II), Uneducated Male
Respondent, Daman Nkwanta).
A female respondent expressed her view on the
inadequately of toilet facilities as follows:
As for the toilet facilities, the least said about
them the better. They are woefully inadequate.
Sometimes you have to queue to attend a public
toilet for more than an hour, especially in the early
morning when people want to prepare to go to
work. It is too bad. The government must do
something about it (II, Male Respondent, 37
Years, Senior High School Education).
Access to Toilet Facilities by Background
Characteristics: Residence and Sex
Respondents were asked to indicate their level of access
to toilet facilities by place of residence and sex. Access
was categorized into three (3) as follows:
Easy Access (E): Having toilets in the home;
Average Access (A): Paying to use public toilet facility;
Poor Access (P): Using open defecation and other non-
conventional means.
The background characteristics used to relate to access to
toilet facilities are place of residence, sex, age, marital
status, income, occupation, education and family size.
From Table 3, not many people in the study communities
had easy access to toilet facilities.

6. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Buor and Asuah Gyan 151
Table 3: Access to toilet facilities by Place of Residence and Sex
Community
Male Female
TotalEasy access Average
access
Poor access Easy access Average
access
Poor access
Daman Nkwanta 0 0 17 1 1 18 37
Komfuorkrom 0 1 8 1 0 17 27
Abease 0 5 9 1 12 5 32
Parambo 5 8 5 8 12 7 45
Prang 7 8 22 10 14 6 67
Yeji 19 15 81 21 20 16 172
Total 31 37 142 42 59 69 380
Source: Field Data, 2017
A total of 73, representing 19.2% had easy access to
sanitation (toilet) facilities of all types and 44.5% had easy
and average access to toilet facilities. Over 55% resorted
to open defecation and non-conventional practices. A
greater proportion of the respondents in the urban
communities (49.3%) had easy and average access to
toilet facilities whilst 36.9% of the rural had. Females
(59.4%) had better access to toilet facilities than males
(32.3%). This supports the cultural notion that
communities expect females to have better access than to
resort to open defecation which exposes their nude held
sacred by society.
A male respondent in an interview stated:
I heard the water splashes on your buttocks when
you sit on it (water closet) to ease yourself. I
would rather do it in the bush than for toilet water
to touch my body. As for my wife, I do not want
anybody to see her nakedness so I would pay for
her to use the public toilet (32-year old Male
Respondent, Primary School Dropout, Abease).
A female respondent with Senior High School Education
also said:
It is not safe for a woman, given our biological
conditions to do this thing (defecate) in the bush.
You could get an infection so I do the best I could
to go to the public toilet to pay to ease myself. It
is not uncommon for a snake to bite you when
you do open defecation (28-year-old Female
Respondent).
This may explain why females have better and easy
access to toilet facilities than males. If more women do not
have access to toilet facilities, it poses danger to their
health and security as supported by Amnesty International.
Lack of access to sanitation facilities also has significant
non-health consequences, particularly for women and
girls, including lack of security and privacy, decreased
school attendance and basic human dignity (Amnesty
International, 2010).
Interviews with residents in urban and rural communities
showed that those in the urban communities who did not
have the facilities in their homes did not have much
difficulty paying to access the facilities. Respondents in the
rural and urban communities respectively made the
following remarks when interviewed on their ability to
access the facilities:
I do not have a toilet in my home and it’s not easy
for me to pay to use the public toilet even though
it is not expensive. Sometimes when I must
attend the toilet more than once, I am compelled
to go to the bush to do it because I cannot afford
(Male Respondent, 42 years, Primary Education;
Komfourkrom).
I have to pay for using the public toilet because I
do not have the facility at home. Indeed, if I have
to use it about three times a day or when I get
diarrhoea in which I use it a lot of times the money
needed is much but I try to use it. I prefer using it
rather than going to the bush which is risky and
indecent (Female Respondent, 39 Years,
Secondary Education, Prang).
Above statements are an indication that the level of
education plays a role in access to sanitation services and
open defecation. The educated would give accessing
sanitation services a priority than to indulge in open
defecation.
Access to Toilet Facilities by Age
There were disparities by access to toilet facilities by
demographic and socio-economic characteristics of
respondents. The researchers assessed access to toilet
facilities by age (Table 4).
It was proven that the old-age group (65+) had access to
a greater proportion of toilet facilities than the rest of the
age groups. They however had the least access to water
closet which is safer. It was expected that, given their
vulnerability, they should have access to safer sanitation
services than the other age groups. Again, it is evident that
respondents within the working class had greater access
to safer toilet facilities (water closet) than those
respondents below the working class. This also raises the
issue of equity. There must be a policy for the vulnerable
in society to have greater access to safe sanitation
facilities.

7. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Int. J. Geogr. Reg. Plan. 152
Table 4: Access to Toilet Facilities by Age
Age
Type of facility by age of respondents
Total
No.
Total
%
Water
Closet %
Pour Flush
Toilet %
Latrine
with a Slab %
VIP
latrine %
18-44 16 19.0 2 2.4 14 16.7 52 61.9 84 100
45-64 31 43.1 1 1.4 7 9.7 33 45.8 72 100
65+ 2 15.4 0 0 1 7.7 10 76.9 13 100
Total 49 28.9 3 1.8 22 13 95 56.2 169 100
Source: Field Data, 2017
NB: The others, 211, use either open defecation or unconventional methods.
Fieldwork by interview established that the community is
particular about the sanitation situation of the aged and the
need to let them have access to toilet facilities at home to
save them from the risks of accidents whilst commuting to
places of convenience. It has been established that,
because of the vulnerability of the aged, they are more
likely to have toilet facilities at home (WHO/UNICEF,
2013).
An old woman in the interview said:
I cannot walk for long distance to go and defecate
that is why my children constructed this toilet
facility for me (71Years, No-Formal Schooling,
Prang).
The aged are not affected by sanitation-related diseases
since their sensitivity to sanitation issues would urge them
to clean their toilets and also abstain from open defecation.
There is a cultural issue in the access of sanitation facilities
by the aged. Children of the aged are obliged to provide
sanitation services for the parents. Besides, adults, and
especially the elderly, maintain some special ethics such
as not exposing their nude in public (WHO/UNICEF,
2013).
Access to Toilet Facilities by Marital Status
Married couples have greater access to improved toilet
facilities as compared to the unmarried. Apart from the
married, others may not see the reason why they should
have toilet facilities in their homes. Routray et al. (2015)
have proven this in their study on “Socio-cultural and
behavioural factors constraining latrine adoption in rural
coastal Odisha: an exploratory qualitative study”. From
Table 5, the married have more of water closet toilets than
any other group.
Table 5: Access to Toilet Facilities by Marital Status
Marital Status Access to toilet facility by marital status Total
Water
Closet %
Pour Flush
Toilet %
VIP
Latrine %
Latrine with
a Slab %
No. %
Married 30 37.9 2 2.5 40 50.6 7 8.8 79 100
Single 14 21.5 1 1.5 39 60 10 17 64 100
Divorced 3 33 0 0 6 67 0 0 9 100
Separated 1 14 0 0 4 57 2 29 7 100
Widowed 0 0 0 0 1 33 2 67 3 100
Cohabitating 1 14 0 0 5 72 1 14 7 100
Total 49 100 3 100 95 100 22 169
Source: Field Data, 2017
NB: 211 respondents resort to either open defecation or unorthodox methods.
Out of the 49 water closet toilets, the married had access
to 30 (61%). On the whole, the married had access to
better toilet facilities than the single, divorced, separated,
widowed and cohabitating. According to a married woman
in Prang, the toilet was provided her by her husband when
they got married. She narrated:
My husband said he doesn’t want other people to
see my nakedness so he constructed a toilet
facility for me (43-Year Old Married Woman,
Prang, Senior High School Education).
There is also a cultural implication in access by married
women, and, indeed the female due to their biological
condition. The nakedness of women is held sacred so
society expects it to be upheld as such. Husbands feel
obliged to provide for their wives to access public toilets
and not to go openly defecating.
Access to Toilet Facilities by Income
Results show that income exhibits a positive association
with access to sanitation facilities, with respondents with
higher income having easy access to safe sanitation
facilities (Table 6).
The minimum wage according to the 2016 Ghana Living
Standards Survey round 6 was GHC 8.80p per day (GLSS
2016). For this research, low-income earners were those
who earned below GHC264 (i.e. GHC 8.80*30 days).
Average income earners were those who earned between
GHC264 to GHC528 and high income were those who
earned above GHC528. Low-income earners did not have
adequate toilets at home so faced sanitation problems.

8. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Buor and Asuah Gyan 153
Table 6: Access to toilet facility by income
Income
Access to toilet facility by income
Total Total
%
Water
closet %
Pour
flush %
VIP
latrine %
Latrine
with slab %
Low Income 15 14.4 1 1.0 68 65.4 20 19.2 104 100
Average Income 4 13.8 1 3.4 22 75.9 2 6.9 29 100
High Income 30 83.0 1 3.0 5 14.0 0 0.0 36 100
Total 49 30.4 3 1.8 95 54 22 13.6 169 100
Source: Field Data, 2017
NB: Other respondents, 211, use open defecation and other unauthorized devices.
High-income earners had access to better toilet facilities
than low- and average-income earners; the reason being
that, high-income earners could provide toilet facilities due
to their economic standing. A low-income earner in
Abease commented on accessing toilet facilities as
follows:
Money to cater for our basic needs is a problem,
not to talk of having a toilet at home. If we want to
defecate we will do it in the bushes close to our
house. (Female, 38 years, Low-Income, Never-
Been-to-School, Abease).
A male high-income earner also had this to say:
Toilet facility has something to do with health. It
affects health in diverse ways. A water-closet
toilet should be a basic need the government
must provide. Most health problems in developing
countries could be addressed with decent toilet
facilities (Male, 41 years, University Graduate,
Yeji).
From Table 6, low-income earners had the least access to
toilet facilities in the study area. They only had 15 (14.4%)
of their toilets being water closets. High-income earners,
on the other hand, had better access to toilet facilities.
They had 30 (83%) of their toilet facilities being water
closets. Songsore and McGranahan (1998) support this
view in their work on “Proxy Indicators for Rapid
Assessment of Environmental Health Status of Residential
Areas: The Case of the Greater Accra Metropolitan Area
(GAMA), Ghana.” Several other studies, including Benneh
et al. (1993) and Osumanu (2007a; 2007b), support the
findings.
Access to Toilet Facility by Occupation
Results showed that the unemployed had no water closet
toilets (Table 7).
Table 7: Access to toilet facility by Occupation
Occupational
Status
Access to toilet facility by occupation
Total
No.
Total
%
Water
closet %
Pour
Flush %
VIP
latrine %
Latrine
with slab %
Student 5 16.66 1 1.33 15 50.00 9 30.00 30 100
Trader 4 13.79 1 3.44 22 72 2 8 29 100
Farmer 9 23 0 0 20 51 10 26 39 100
Civil Servant 30 83 1 3 5 14 0 0 36 100
Unemployed 0 0 0 0 16 100 0 0 16 100
Fishing 1 5 0 0 17 89 1 5 19 100
Total 49 30.4 3 1.8 95 54 22 13.6 169 100
Source: Field Data, 2017
NB: 211 respondents resort to open defecation and other unorthodox methods.
Civil servants had 30 (83%) of their toilets facilities being
water closet whilst fishermen had only 1 (5%) water closet
toilets of their total toilet facilities. This means that those
who are gainfully employed had access to better toilet
facilities. A civil servant responded to a question on
possessing a toilet facility in the home thus:
People will laugh at me if I don’t have a toilet
facility in my house because of the work I do. In
this community, everyone thinks I’m rich, so
imagine if I join them to defecate openly, it will be
a shame. Besides, I have adequate income to
provide a water closet for my family (Male Civil
Servant, 44 Years, University Graduate, Yeji).
On the other hand, a male peasant farmer when
interrogated about the need to have easy access
to decent toilet facility remarked:
I wish I could afford a simple toilet, not even,
water closet in my home but I cannot. Sometimes

9. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Int. J. Geogr. Reg. Plan. 154
I find it difficult to pay to use the public toilet. They
say poverty is a disease. As a peasant farmer, I
learn very little. The work is seasonal so that it is
not every month that I work (49-Year-Old Male
Farmer, Primary Education, Parambo).
Those who were gainfully employed and in sophisticated
employments such as the civil servants had access to
better sanitation facilities. This also has negative
implications for equity. Safe sanitation facilities should be
a basic requirement of all, given the health implications
involved in accessing unsafe sanitation facilities.
Access to Toilet Facilities by Education
Level of education has a strong association with access to
sanitation facilities (Table 8).
Table 8: Access to toilet facilities by education
Educational level Access to toilet facility by level of education
Total Total
%Water
closet %
Pour
flush
toilet
%
VIP
latrine %
Latrine
with slab %
None 3 15 0 0 16 80 1 5 20 100
Primary School1 6 19 1 3 18 56 7 22 32 100
JHS/Middle School2 6 11 1 2 41 75 7 12 55 100
SHS/SSS/O'Level3 3 10 0 0 20 69 6 21 29 100
Tertiary 31 94 1 3 0 0 1 3 33 100
Total 49 28.9 3 1.7 95 56.2 22 13 169 100
Source: Field Data, 2017
NB: 211 respondents have poor access to sanitation facilities so either openly defecate or resort to unorthodox
means.
Those respondents who had acquired education to the
tertiary level had access to better toilet facilities than the
rest. From the total number of toilets that those who have
had education to the tertiary level had access to, water
closet toilets formed 31(94%). There is a significant
relationship between the educational level of respondents
and access to toilet facility by type of toilet. There appears
to be some deviations between the never-been-to-school
and primary education and those with JHS/Middle School
education due to the small numbers. Those with tertiary
education emerged significantly as having an adequate
number of safe toilet facilities. This also draws in the equity
issue. The elite in the community who had attained a good
level of education and had higher incomes had access to
better sanitation facilities (Refer to the male university
graduate at Yeji and male peasant farmer at Parambo).
Access to Toilet Facilities by Family Size
Respondents with small family sizes had access to better
toilet facilities than those with large family sizes (Table 9).
Table 9: Access to Toilet Facility by Family Size
Family size Access to toilet facility by family size Total Total
%Water closet % Pour flush toilet % VIP latrine % Latrine with slab %
Two 8 67 1 8 3 25 0 0 12 100
Three 7 31 1 4 14 61 1 4 23 100
Four 8 67 0 0 3 25 1 8 12 100
Five 6 32 0 0 13 68 0 0 19 100
Six 3 30 0 0 7 70 0 0 10 100
Seven 2 8 0 0 19 76 4 16 25 100
Eight 2 14 0 0 7 50 5 36 14 100
Nine 5 17 1 3 18 60 6 20 30 100
Ten 5 38 0 0 5 38 3 24 13 100
Above ten 3 27 0 0 6 54 2 19 11 100
Total 49 28.9 3 1.8 95 56.2 22 13 169 100
Source: Field Data, 2017
NB: 211 respondents resort to open defecation and non-conventional methods.
1
The Primary level of education is the first six years after the child attains year six.
2
The Junior High School (JHS) is a three-year post-primary school education whilst the middle school, a four-year course pursued after the primary
school, is replaced by JHS.
3
The Ordinary Level certificate was awarded after passing the traditional 5-year secondary education which has been replaced by the Senior High
School (SHS). The Senior Secondary School (SSS) has been replaced with the SHS.

10. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Buor and Asuah Gyan 155
With large family sizes, access is very poor because of the
number of people in the household. Accessibility becomes
a problem because the facility may not be readily available
at night or during periods of high demand as supported by
WHO/UNICEF (2013) in their report on Shared Sanitation
versus Individual Household Latrines: A Systematic
Review of Health Outcomes.
DISCUSSION AND CONCLUSION
The study examined access of a predominantly rural
district to sanitation (toilet) facilities by demographic and
socio-economic characteristics and how access relates to
equity. Whereas there are works on general inadequacy of
sanitation facilities in Tropical Africa, not much has been
done on access by background characteristics. Besides,
the issue of equity has not been generally explored. The
mixed-methods approach was used to interrogate the
problem and to find answers to the research questions.
Despite the important role good sanitation plays, most of
the respondents do not have access to proper and safe
sanitation facilities. The study has revealed that more than
60% of the respondents do not have access to toilet
facilities. Most of them, therefore, resort to open defecation
as a substitute for toilet facilities. There are 49 water closet
toilets in the district to serve a population of over 40,000,
implying a population of over 800 being served by a water
closet toilet. In the study area, there are 169 of all types of
toilet serving a community of over 40,000. From the study,
people in rural areas are those who face more challenges
when it comes to access to sanitation facilities. Most of the
residents thus resorte to open defecation. This is not to say
that the problem of inadequate toilet facilities does not
exist in urban areas. They do but the problem is more
prevalent in the rural areas. This creates an equity
problem. The government of Ghana has the policy to
provide decent sanitation facilities for the communities
(Government of Ghana, 2010) and this policy must be
followed through. The policy fulfils the principle of equality,
fairness and social justice epitomized in the principle of the
World Bank (World Bank, 2005). Access to sanitation
facilities and the equity problem is reflected in income
disparities, with the low-income segment of the community
having weak access. It is also reflected in the level of
education and occupational status. The well-educated
have access to better sanitation facilities. They can
provide decent toilets for their homes. The same applies to
the upper rung of the working class. Civil servants who
also have higher levels of education have access to better
sanitation facilities. This problem of inequality must be
addressed if the Sustainable Development Goal 6 which
relates to clean water and sanitation shall be attained. The
attainment of this goal shall have implications for
development. The attainment of the goal will ultimately
result in health which has a symbiotic relationship with
development.
The demographic factors that relate to access to sanitation
services that emerged in the study are age, sex and marital
status. These have cultural implications. Although the
aged generally have better access to all types of sanitation
services, access to safe sanitation services such as water
closet toilet, is relatively low. Given their vulnerability,
access to safe sanitation services must be a basic
provision. Children are supposed to provide for their
ageing fathers in old age; and a child who fails to do this
loses societal respect. It thus becomes a cultural
obligation. Females have adequate and better access to
sanitation facilities. This has a cultural underpinning as
revealed in the interviews. The nude of a woman is held
sacred and a man will be prepared to pay for the wife to
pay for sanitation services whilst he openly defecates to
safe the dignity of the woman and the man’s reputation.
The same goes for a married woman. Besides, a married
man will like to hold a modicum of dignity than the
unmarried as made evident in the interviews.
The adapted form of the integrated behavioural theory
(Dreibelbis et al., 2013) has been justified. There is also
the behaviour aspect in which the attitudes of the
community contribute to their non-use of the facilities.
Some community members do not see the use of paid
toilet facility as a priority.
Sanitation facilities are basic to health, welfare and human
dignity. To ensure the satisfaction of these needs, and to
ensure equity in society, it is recommended that the
government give their provision a priority. There must also
be education by health educators to the community to
recognize the effect of safe sanitation on human welfare.
Finally, the issue of open defecation is an area to explore
in such a predominantly rural community. There must be
pragmatic policies to provide adequate sanitation facilities
to reduce the frequency of this practice.
ACKNOWLEDGEMENTS
We express our gratitude to the research assistants who
assisted in data collection, all the participants in the
research and the Public Health officer at the Pru District for
the information given.
CONFLICT OF INTEREST
There was no conflict of interest in the execution of the
project.
ETHICAL ISSUES
Consent of respondents was sought before the research
commenced. No personal interest was injured in the
process. Accordingly, ethical approval from an institution
was not required.

11. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Int. J. Geogr. Reg. Plan. 156
FUNDING
The research did not receive financial support
from any organization.
DATA AVAILABILITY
Data used were those generated from the field and self-
analysed. Primary data used were those collected and
processed by the researchers. Data from secondary
sources were acknowledged through citation and
referencing.
REFERENCES
Amnesty International, 2010 Kenya: Insecurity and
indignity: Women's experience in the slums of Nairobi,
Kenya.
Ampadu-Boakye, J., Mawuena Dotse, F., Nii Odai Anidaso
Laryea, etc. (2011). Improving access to basic
sanitation in Ghana: Lessons from a water and
sanitation project in Ghana. Ghana Water Forum
Journal, 1(23-30).
Armah A.D. 2015. World Toilet day: Eradicating open
defecation still a challenge in Ghana. Afrobarometer
West Africa, Dispatch No. 60: Centre for Democratic
Development. Accra Ghana.
Appiah-Effah, E., Duku, A.G., Naziru, Y.A., Kojo Aduako
Aggrey, R., etc. 2019. Ghana’s post-MDGs sanitation
situation: an overview. Journal of Water, Sanitation and
Hygiene for Development, 9(3):397-415.
Benneh, G., Songsore, J., Nabila S.J. Amuzu A.T., Tutu
K.A, Yaugyuorn 1993 Environmental problem and
urban household In Greater Accra Metropolitan Area
(GAMA). M.A.C. Stockholm, Ghana.
Black, R., Cousens, S., Johnson H., Lawn J., Rudan, I., et
al. 2010. Global, regional, and national causes of child
mortality in 2008: a systematic analysis. Lancet. 375:
1969-1987.
Dreibelbis R., Winch P. J., Elli L., et al (2013). The
integrated behavioural model for water sanitation and
hygiene: A systematic review of behavioural models
and a framework for designing and evaluating change
interventions in infrastructure-restricted stings. Bio Med
Central.
Ferriman A., 2007. Readers choose the ‘sanitary
revolution’ as greatest medical advance since 1840.
British Medical Journal; 334:111.
Ghana Statistical Service, 2011. Ghana Multiple Indicator
Cluster Survey, Final Report. Accra: Ghana Statistical
Service.
Ghana Statistical Service, 2012. Population and Housing
Census. Accra: Ghana Statistical Service.
GSS, 2015. Ghana Living Standards Survey, Sixth Round
Report (GLSS 6). Accra: Ghana Statistical Service.
Government of Ghana, 2010. Ministry of Local
Government and Rural Development. Environmental
and Sanitation Policy, Accra.
Harry Jones, 2009. Equity in development: why it is
important and how to achieve it. Overseas
Development Institute, Working Paper 311, London.
Kosoe, E. A., Issaka, K.O. 2015. Water is Lifer: Situation
analysis of access to household water supply in the Wa
Municipality, Ghana. International Journal of
Environmental Protection and Policy. 39(1):1-13.
Kosoe, E.A., Osumanu, I.K., 2018. Ghana Journal of
Development Studies, Vol 15 (1): 151-172.
Krejcie R. V., Morgan D. W., (1970). Determining sample
size for research activities. Educational and
Psychological Measurement, 30:607-610.
Mathers C. D., Lopez A. D., Murray C. J. L., (2006). The
burden of disease and mortality by condition: data,
methods, and results for 2001. In: Lopez A. D., Mathers
C. D., Ezzati M., Jamison D. T., Murray C. J. L.,
(editors). Global burden of disease and risk factors.
New York: Oxford University Press.
Osumanu, I. K., 2007a. “Household environmental and
behavioural determinants of childhood diarrhoea
morbidity in the Tamale Metropolitan Area (TMA),
Ghana”, Danish Journal of Geography Vol. 107(1): 59-
68.
Osumanu, I. K., 2007b. “Environmental concerns of poor
households in low-income cities: the case of the
Tamale Metropolis, Ghana”, GeoJournal 68: 343–355.
Prüss-Üstün A., Bos R., Gore F., Bartram J., 2008. Safer
water, better health: costs, benefits and sustainability of
interventions to protect and promote health. Geneva:
World Health Organization.
Roma, E., Pugh, I. 2012. Toilets for health. London School
of Hygiene and Tropical Medicine. London.
Routray P., 2015. A socio cultural and behavioural factors
constraining latrine adoption in rural coastal Odisha: An
exploratory qualitative study. Bio Med central.
Songsore J., and McGranahan G., 1998. “The Political
economy of household environmental management:
gender, environment and epidemiology in the Greater
Accra Metropolitan Area,” World Development 26
(3):395-412.
UN, 2015. Sustainable Development Goals, UN
Resolution 70/1. New York.
UNICEF, 2013. Progress on Sanitation and Drinking
Water-2013 Update. UNICEF, New York, United
States.
UNICEF, 2014. Lack of Toilets Dangerous for Everyone.
UNICEF. New York, United States.
UNICEF, 2015. UNICEF Annual Report, Ghana. UNICEF,
New York, United States.
World Bank, 2005. World Development Report 2006.
Equity in Development. Washington DC. World Ban.
World Bank, 2018. World Bank Blogs. How many people
can share a toilet? WHO, Geneva, Switzerland.
WHO, 1999. Creating healthy cities in the 21st century. In:
Satterthwaite D., editor. The Earthscan reader on
sustainable cities. London: Earthscan Publications;
1999. pp. 137–172.

12. Access to Sanitation Facilities in a Predominantly Rural District in Ghana: Socioeconomic and Cultural Determinants and the Equity Syndrome
Buor and Asuah Gyan 157
WHO/UNICEF, 2008. Essential environmental health
standards in health care. Geneva: World Health
Organization.
WHO/UNICEF, 2013. Progress on sanitation and drinking
water: 2013 Update. Geneva, Switzerland.
WHO/UNICEF, 2013. Joint Monitoring Programme for
Water Supply and Sanitation, 2013. Geneva,
Switzerland.
WHO/UNICEF, 2019. Progress on household drinking
water, sanitation and hygiene, 2000-2017. Geneva,
Switzerland.
WHO, 2011.Water safety in buildings. WHO. Geneva,
Switzerland.
WHO, 2019. Sanitation: Key Facts. WHO. Geneva,
Switzerland.
Accepted 23 June 2020
Citation: Buor D, Asuah Gyan M (2020). Access to
Sanitation Facilities in a Predominantly Rural District in
Ghana: Socioeconomic and Cultural Determinants and the
Equity Syndrome. International Journal of Geography and
Regional Planning 6(1): 146-157.
Copyright: © 2020: Buor and Asuah Gyan. This is an
open-access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are cited.
Appendix 1: Table for Determining Sample Size from a given Population
N S N S N S N S N S
10 10 100 80 280 162 800 260 2800 338
15 14 110 86 290 165 850 265 3000 341
20 19 120 92 300 169 900 269 3500 246
25 24 130 97 320 175 950 274 4000 351
30 28 140 103 340 181 1000 278 4500 351
35 32 150 108 360 186 1100 285 5000 357
40 36 160 113 380 181 1200 291 6000 361
45 40 180 118 400 196 1300 297 7000 364
50 44 190 123 420 201 1400 302 8000 367
55 48 200 127 440 205 1500 306 9000 368
60 52 210 132 460 210 1600 310 10000 373
65 56 220 136 480 214 1700 313 15000 375
70 59 230 140 500 217 1800 317 20000 377
75 63 240 144 550 225 1900 320 30000 379
80 66 250 148 600 234 2000 322 40000 380
85 70 260 152 650 242 2200 327 50000 381
90 73 270 155 700 248 2400 331 75000 382
95 76 270 159 750 256 2800 335 100000 384
Source: Krejcie, R.V., 1970
NB: “N” is Population Size
“S” is Sample Size