Urban and peri-urban EcoHealth markers and health promotion intervention in Addis Ababa Ethiopia

251 Pages·2014·4.68 MB·English

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