Urban and peri-urban EcoHealth markers and health promotion intervention in Addis Ababa Ethiopia by TARIKU BERHANU DESALEGN submitted in accordance with the requirements for the degree of DOCTOR OF LITERATURE AND PHILOSOPHY in the subject HEALTH STUDIES at the UNIVERSITY OF SOUTH AFRICA SUPERVISOR: PROF B L DOLAMO OCTOBER 2013 Student number: 4717-841-8 D E C L A R A T I O N I declare that Urban and peri-urban EcoHealth markers and health promotion interventions in Addis Ababa, Ethiopia is my own work, that all the sources that I have used or quoted have been indicated and acknowledged by means of complete references, and that this work has not been previously submitted for any other degree at any other institution. Full name: Tariku Berhanu Desalegn Date: OCTOBER 2013 ii ACKNOWLEDGMENTS First and foremost, my sincere gratitude goes to my mother, Ms Etalemahu Minda, for her unconditional love, care and support. Furthermore, my special thanks to my promoter, Professor BL Dolamo, for her guidance, patience, support and encouragement and to the Unisa bursary programme coordinators and the University for Financial Assistance. In addition, my sincere appreciation and thanks go to: • For unreserved support of Unisa Akaki learning centre staffs. • The Addis Ababa City Administration Health Bureau, sector offices of subcities and woredas, factories and establishments’ management and staff members for their valuable time and participation. • The Addis Ababa City Administration Water and Sewerage Authority and the Addis Ababa City Administration Environmental Protection Offices for the laboratory services. • The study participants in the qualitative and quantitative methods and the vegetable growers and their association management for their time and participation. • Data collectors and field supervisors who assisted me in the collection of the data. • Gemechu Kebed, Semuniguse Mehrete, Aragaw Haile, Zelalem Tadesse, Waltaji Terfsas, Dr Micheal Dejene, Dr Asaheber Gaym, Dr Mitike Mola, Dr. Habtamu Belete, Dr Yodits S/Maraiam, and Dr Tirsit Aseffa for their valuable comments and encouragement. • Last, but not least, my heartfelt thanks go to my wife, Hiowt Mulugeta, and my children’s Christian and Kidus for their love and emotional support. iii Urban and peri-urban EcoHealth markers and health promotion interventions in Addis Ababa, Ethiopia STUDENT NUMBER: 47178418 STUDENT: TARIKU BERHANU DESALEGN DEGREE: DOCTOR OF LITERATURE AND PHILOSOPHY DEPARTMENT: HEALTH STUDIES, UNIVERSITY OF SOUTH AFRICA SUPERVISOR: PROFESSOR BL DOLAMO Abstract The purpose of this study was to explore and describe the EcoHealth markers and health promotion interventions in the behaviour and practices of vegetables growers in Addis Ababa. The objectives were to assess the urban and peri-urban community members’ knowledge and practices on the existing environmental health policies/regulations/guidelines, assess the perspectives of women and youth on urban and peri-urban EcoHealth promotions and protections and evaluate the development and implementation of the health promotion activities on waste water use by applying an ecological model aimed at changing behaviour and by providing Bio-sand filter to promote hand wash practice which helps to reduce potential health risks among urban vegetable growers. Both quantitative and qualitative descriptive researches were conducted to identify the urban and peri urban community members’ knowledge and practices of the existing environmental health regulators and the perspectives of women and the youth on EcoHealth. Additional quasi experimental method; multiple baseline survey along with the EcoHealth Stress Process promotion method was employed to identify stressors, measure changes in environmental health promotion intervention and use of hand wash (biosand filter for hand wash). Six woredas from two subcities of the Addis Ababa City Administration were purposely selected, and a total of 845 (98.9% response rate) households participated in the quantitative study, while 142 community members (public sector offices, factories and iv establishments’ management and employee), participated in the qualitative survey. For quasi experimental method, six settings/blocks (of which 3 sites were provided with a bio-sand filter for hand washing) cultivated by 6 to 8 vegetable growers and their family members, were included in the intervention (multiple baseline survey). The findings revealed that about 77 percent of participants reported, knowledge of one or more of the selected environmental health and EcoHealth regulations. Ownership of assets and education tend to influence the public awareness of selected EcoHealth and environmental health regulations. Women and youth found to be significant contributors to better urban and peri-urban EcoHealth conditions and were the ones primarily affected by environmental hazards. The intervention study results also indicated evidence-based IEC interventions and ecological health promotion methods proved useful in promoting EcoHealth in an urban environment. Moreover, the bio- sand filter used to provide evidence of health promotion was found to be valuable for wastewater treatment and significantly reduced chemical, physical and biological contaminates from the wastewater. Key Concepts EcoHealth; ecoHealth intervention; ecological systems/ecosystems; environment; ecohealth markers; per-urban areas, urban, urban health; youth v Table of Contents Page Abstract ............................................................................................................................................. iii LIST OF BOXS .............................................................................................................................. xiii ACRONYMS ...................................................................................................................................xiv CHAPTER 1 ...................................................................................................................................... 1 ORIENTATION OF THE STUDY ................................................................................................... 1 1.1 INTRODUCTION ....................................................................................................................... 1 1.2. PROBLEM STATEMENT ........................................................................................................ 3 1.3 Research Purpose ..................................................................................................................... 5 1.4 Research Objectives ................................................................................................................. 5 1.5. SIGNIFICANCE OF THE STUDY .......................................................................................... 6 1.6 DEFINITION OF KEY CONCEPTS ........................................................................................ 6 1.7 FOUNDATION OF THE STUDY ............................................................................................. 7 1.8 RESEARCH DESIGN AND METHOD ................................................................................... 8 1.9 THE SCOPE OF THE STUDY ................................................................................................ 8 1.10 CONCLUSION ......................................................................................................................... 8 CHAPTER 2 .................................................................................................................................... 10 THE LITERATURE REVIEW ........................................................................................................ 10 2.1. INTRODUCTION .................................................................................................................... 10 2.2 ENVIRONMENT ...................................................................................................................... 10 2.2.1 Physical environment ........................................................................................................... 11 2.2.2 Climate changes ................................................................................................................... 12 2.2.3 Social environment ............................................................................................................... 13 2.2.4 Urban environment ............................................................................................................... 15 2.2.4.1 Health risks in the urban environment ........................................................................... 17 2.3 ECOHEALTH ........................................................................................................................... 18 2.3.1 Conserving and revitalising the urban ecosystem........................................................... 19 2.3.2 Wastewater recycling and reuse for urban agriculture ................................................... 19 2.3.3 Environmental health regulations and their applications ................................................ 20 2.4 HEALTH PROMOTION AND ECOHEALTH APPROACH ................................................ 22 2.4.1 Health promotion .................................................................................................................. 22 2.4.1.1 Health promotion theories ............................................................................................... 23 vi 2.4.1.1.1 Behavioural changes models which focus on individual and interpersonal behavioural changes ...................................................................................................................... 24 Pre-contemplation Contemplation Decision/ Determination Action Maintenance ................ 28 2.4.1.2 EcoHealth Approach ......................................................................................................... 31 2.4.2 Ecological stress process model........................................................................................ 32 2.4.3 Advantages and limitations of using an EcoHhealth promotion methods ................... 36 2.5 THE CONTEXT OF THE STUDY AREA ............................................................................. 37 2.5.1 Local level action .................................................................................................................. 37 2.5.1 The environmental health conditions and challenges in the urban centre of Ethiopia .......................................................................................................................................................... 39 2.5.2 The modern health services and environmental health activities development and challenges in Ethiopia .................................................................................................................... 43 2.6 CONCLUSION ......................................................................................................................... 47 CHAPTER 3 .................................................................................................................................... 48 RESEARCH DESIGN AND METHODOLOGY .......................................................................... 48 3.1 INTRODUCTION ..................................................................................................................... 48 3.2 RESEARCH DESIGN ............................................................................................................. 48 3.2.1 Descriptive study design ..................................................................................................... 50 3.2.2 Experimental study design .................................................................................................. 51 3.2.3 Multiple baseline design ...................................................................................................... 53 3.3 RESEARCH METHOD ........................................................................................................... 56 3.3.1 Triangulation ........................................................................................................................ 57 3.3.1.1 Qualitative method ............................................................................................................ 58 3.3.1.2 Quantitative research method ......................................................................................... 60 3.4 QUANTITATIVE METHOD .................................................................................................... 61 3.4.1 Study areas ........................................................................................................................... 62 3.4.2 Study population and sampling .......................................................................................... 63 3.4.3 The study population ........................................................................................................... 63 3.4.4 Sampling and sample size determination ......................................................................... 64 3.4.4.1 Sample size determination .............................................................................................. 66 3.4.5 Data collection ...................................................................................................................... 69 3.4.5.1 Data collection approach and method .......................................................................... 70 3.4.5.2 Development and testing of data collection instrument .............................................. 70 3.4.5.3 Pre-testing of the questionnaire ...................................................................................... 73 3.4.5.4 Data collection process .................................................................................................... 73 vii 3.4.6 Data analysis......................................................................................................................... 74 3.5 INTERNAL AND EXTERNAL VALIDITY OF THE STUDY ............................................... 75 3.5.1 Validity and reliability ........................................................................................................... 75 3.5.2 Selection bias ........................................................................................................................ 75 3.5.2.1 Information bias (observation bias) ................................................................................ 75 3.5.2.2 Confounding variables ..................................................................................................... 76 3.5.2.3 Generalizability of the study ............................................................................................ 76 3.6 QUALITATIVE REASERCH DESIGN .................................................................................. 77 3.6.1 Inclusion criteria .................................................................................................................... 78 3.6.2 Data collection ...................................................................................................................... 78 3.6.3 Data analysis......................................................................................................................... 79 3.6.4 Trustworthiness .................................................................................................................... 79 3.7 ETHICAL CONSIDERATIONS .............................................................................................. 80 3.7.1 Protecting the participants .................................................................................................. 81 3.7.2 Protecting the right of the Institution .................................................................................. 82 3.7.3 Scientific integrity of the research ...................................................................................... 82 3.8 CHAPTER SUMMARY ........................................................................................................... 83 3.9 CONCLUSION ......................................................................................................................... 83 CHAPTER 4 .................................................................................................................................... 84 ANALYSIS PRESENTATION AND DESCRIPTION OF RESEARCH FINDNGS ................ 84 4.1 INTRODUCTION ..................................................................................................................... 84 Table 4.1 4.1.1 Purpose of the study .......................................................................................... 84 4.2 RESULTS PRESENTATION ANALYSIS AND DESCRIPTION: QUANTITATIVE DATA SET ................................................................................................................................................... 85 4.2.1 Selected demographic and socioeconomic characteristics of the respondents ......... 86 4.2.2 Respondents’ housing conditions and household environment .................................... 89 4.2.2.1 Households’ source of energy and awareness of air pollution .................................. 90 4.2.2.2 Status of sanitation facilities ............................................................................................ 92 4.2.2.3 Water sources ................................................................................................................... 94 4.2.2.3 Solid and liquid waste management .............................................................................. 96 4.2.2.4 Awareness of noise pollution and protection methods ................................................ 98 4.2.2.4 Built-up environment and EcoHealth regulations ......................................................... 99 4.2.2.5 Standards and regulations on water, hygiene and sanitation .................................. 101 4.2.3 Health education and EcoHealth promotion .................................................................. 104 viii 4.2.3.1 Participants’ perceptions of health risks due to poor environmental conditions.... 105 4.2.4 Policy issues ....................................................................................................................... 105 4.3 RESULTS PRESENTATION ANALYSIS AND DESCRIPTION: QUALITATIVE METHOD ....................................................................................................................................... 106 4.3.1 Methods and materials ...................................................................................................... 106 4.3.2 Overview of data collection, and analysis ...................................................................... 107 4.3.2.1 Organisation of data ....................................................................................................... 107 4.3.2.2 Reporting on techniques used for analysing the data ............................................... 108 4.3.2.3 Data analysis ................................................................................................................... 109 4.3.3 Demographic data of participants .................................................................................... 109 4.4 RESULTS PRESENTATION, ANALYSIS AND DESCRIPTION: THE INTERVENTION STUDY METHOD. ........................................................................................................................ 121 4.4.1 Methods and materials ...................................................................................................... 122 4.4.2 Selected socio-demographic characteristics of participants in the baseline and follow-up studies ........................................................................................................................... 124 4.4.3 Urban agriculture as a benefit for green cover and employment opportunities ........ 126 4.4.4 Practitioners’ views on risks related to use of wastewater for farming (growing vegetables) .................................................................................................................................... 127 4.4.4 Administration and policy support for the practices ...................................................... 131 4.4.5 Implementation progress and observed changes in knowledge of possible hazards and practices resulting from selected precautionary methods .............................................. 132 4.5 METHODS IDENTIFIED FOR FARM TOOLS, HARVEST AND HAND WASHES IMPLEMNTION PROGRESS ..................................................................................................... 135 4.5.2 Evidence of diffusion: awareness change and observed behavioural changes markers .......................................................................................................................................... 141 DISCUSSION AND INTERPRETATION OF RESULTS ........................................................ 143 5.1 INTRODUCTION ................................................................................................................... 143 5.2 ENVIRONMENTAL HEALTH SITUATION OF THE STUDY AREA .............................. 143 5.2.1 Solid and liquid wastes ...................................................................................................... 144 5.2.2 Air and noise pollution ....................................................................................................... 145 5.2.3 Sociocultural and economic impacts ............................................................................... 146 5.3 STAKEHOLDERS’ CONTRIBUTIONS TO THE ENVIRONMENTAL HEALTH OF THE STUDY AREA ............................................................................................................................... 146 5.3.1 Perspectives of women and youth ................................................................................... 147 5.3.2 The private sector ............................................................................................................... 148 5.3.3 The public sector ................................................................................................................ 149 ix 5.4 KNOWLEDGE OF EXISTING ENVIRONMENTAL HEALTH REGULATIONS AND THEIR APPLICATIONS .............................................................................................................. 150 5.5 INTERVENTION METHOD: BIO-SAND FILTER FOR ESTABLISHING EVIDENCE AND FOR WASHING HANDS AND HARVESTS ................................................................... 150 5.6 CONCLUSION ....................................................................................................................... 152 CHAPTER 6 .................................................................................................................................. 154 CONCLUSIONS AND RECOMMENDATIONS ....................................................................... 154 6.1 INTRODUCTION ................................................................................................................... 154 6.2 CONCLUSIONS ..................................................................................................................... 154 6.2.1 Individual and community level ........................................................................................ 154 6.2.3 The private sector ............................................................................................................... 155 6.2.4 The public sector ................................................................................................................ 156 6.2.5 Media .................................................................................................................................... 156 6.2.6 The intervention method, wastewater use and bio-sand filter for hand washing promotion ....................................................................................................................................... 156 6.3 Recommendations ................................................................................................................. 157 6.3.1 Recommendations to households and community members ..................................... 157 6.3.2 Recommendations to the Ministry of Health .................................................................. 157 6.3.3 Policy recommendations ................................................................................................... 159 6.4 CONTRIBUTION OF THE STUDY ..................................................................................... 160 6.5 STRENGTHNING AND LIMITATION OF THE STUDY ................................................... 160 6.6 CONCLUDING REMARKS .................................................................................................. 160 REFERENCES ............................................................................................................................. 162 Annexure 1: The study tools (Quantitative Method) ............................................................... 194 Annexure 2: The study tools (Qualitative Method) .................................................................. 218 Annexure 3: The study tools (Intervention Method) ................................................................ 223 Annexure 4: Examples of the transcribed/translated Focus Group Discussion (full text) . 224 Annexure 5: Health Promotion Material .................................................................................... 233 Annexure 6: Ethical clearance copy – From UNISA ............................................................... 235 Annexure 7 : Copy of the ethical clearance from Addis Ababa Health Bureau .................. 236