Knowledge and Perception of Pupils on Health and Environmental Risk of Open Defecation: A Ghanaian case Study


By Dzidzo Yirenya-Tawiah,
Institute for Environment and Sanitation Studies (IESS), University of Ghana, Legon,




Adjibolosoo Savoiur .V.K,
Presbyterian Women’s College of Education (PWCE) Aburi, Ghana,


For Citation: SITE4 Society Brief No 20 2019                                         
Related to Sustainable Development Goals (SDGs): #SDG 6 (Clean Water and Sanitation) #SDG 3 (Good Health)
SITE focus: Science and Engagement (Needs for eradicating open Defaecation)
National Programs: Media Coalition against Open Defecation (M-CODE)
Country Focus: Ghana —Emerging Countries
Sub-Disciplines:  Science of Environment and Public Health.
Based on: Adjibolosoo, S.V.K., Adongo, P.B., Yirenya-Tawiah, D., Ofori, B.D and Afranie, S (2018). Knowledge and Perception of Pupils on Health and Environmental Risk of Open Defaecation: A case Study in the First Cycle Schools in Eastern and Volta Regions of Ghana. Journal of Environment and Earth Science, 8(11), 129-142.


Open defecation (OD) is a serious public and environmental health problem in Ghana. Its prevalence has increased from 19% in 1990 to 23% in 2010 indicating that the number of Ghanaians engaged in OD daily increased from 4.8 million to over 5.7 million over the same period, ranking Ghana second in OD in Africa after Sudan.

OD leads to contaminated water sources, soil and land, which in turn causes excreta related diseases like cholera and diarrhoea. Every year there are about 1,800 cases of cholera affecting children aged 0-5 years in Ghana. Once blighted by disease, children are unable to complete their formal education, and are later hindered in their capacities to work, provide for themselves and educate their children later in life. Likewise, illness within the community’s senior population represents a significant drain on family budgets and healthcare resources. These factors only perpetuate the poverty cycle. 

Extensive education has gone to highlight the negative consequences of OD behaviour on public health and environmental quality.   Nevertheless, OD remains pervasive in many schools, especially public ones where children spend greater part of their time learning. Why? To contribute to giving elements for the answer, we undertook a study to assess the knowledge and perception level of pupils on the risks of OD on health and the environment. Understanding student perceptions on utility or disutility of toilet use is essential to convince them to use toilets.

Ghana like many other countries does not have reliable data on WASH in schools, a situation that is worrisome for evidence-based decision making. This study therefore aimed to understand the knowledge and perception of first cycle school pupils—aged between 9 and 18 years—on health and environmental risks of OD basically to generate data to inform policies and decision making.

Research Questions: Considering the adverse effects of OD on health and the environment:

  1. What knowledge and perceptions do school pupils have on health and environmental risks of OD?
  2. What insights can this give to sanitation stakeholders and policy makers in decision making to improve sanitation in the first cycle schools?


Motivation for Research Question: Children are the future of society and the practice of OD practice is also very pervasive in many schools, especially public ones. Understanding the knowledge and perception levels of pupils will not only help appreciate the importance of toilet use, but it will also provide the needed information on sanitation behaviours that will help policy-makers make informed decisions on efficient and sustainable excreta management in basic schools towards ending OD in Ghana.

Eight public first cycle schools from eight communities were studied. The main sanitation facilities used in communities of these schools are the shared Kumasi Ventilated Improved Pit (KVIP) latrine. A few of the households, however, used the pit latrine, and water closets. Water sources used in these schools and communities included streams, bore holes, and wells. Data was collected using questionnaires, focus group discussions and interview.

 The variables used to measure pupils’ knowledge and perceptions on health and environmental risks of OD included: views on OD as a behaviour; how OD impacted the environment and human health, and advantages of OD over toilet usage. 

The measure of knowledge was based on the dichotomous response, either yes or no, while perception was measured on a five scale likert -(i) (1 = Very unlikely; 2 = unlikely; 3 = don’t know; 4 = likely; and 5 = very likely. (ii) (1= Very bad practice; 2= bad practice; 3=don’t know; 4 =good practice;5= very good practice), and (iii) (1 = Very undesirable; 2 = Undesirable; 3 = don’t know; 4 = desirable; 5 = very desirable).

The reliability and validity of the instruments were first piloted on 20 pupils in non-selected basic schools after obtaining the ethical clearance certificate from the University of Ghana. A verbal assent was obtained from parents and appropriate guardians of participants before they were used in the study. Verbal informed consent was also provided by all study participants to participate in the study.

Data Collection: The questionnaire was administered to 400 randomly selected respondents by the researcher supported by two trained research assistants to gather self-reported data from respondents on knowledge and perception of health and environmental risks of open defecation. This was followed by the administration of the focus group discussion to 192 respondents randomly selected from pupils who reported practicing OD to gather data on knowledge and perception of health and environmental risks associated with OD practices. The in-depth interview was also conducted (with 24 pupils) to solicit their views and opinions on health and environmental risks of OD practice. English language was used. The interview section was conducted on one-on-one basis and in the convenient locations decided on by each interviewee. The duration for the interview was between 20-30 minutes for each interviewee and English language was used. Quality control measures such as the need for independent completion of the questionnaires and freedom of participation or withdrawal from the study were followed. Special efforts were also made to minimize methodological, personal and social desirability biases.

Data Analysis: Statistical package for social sciences (SPSS) version 20 (IBM) software was used to analyse the data. Descriptive statistics was used to estimate the percentage distribution of pupils’ level of knowledge and perception of health and environmental risk of OD practice. Chi-square test was used to assess possible association between OD and knowledge of health and environmental risks. The focus group discussions (FGDs) and the in-depth interview data were analysed using thematic content analytical procedures. Relevant illustrative quotes that reflected group opinions were identified and used to support the detailed descriptive analyses of the final themes.

Main Findings:

Knowledge and Perceptions (Table below): While 89.8% of students viewed OD as a bad practice and 52% of the students knew that the OD has a negative effect on the environment, nearly 53% of the students thought that OD is unlikely to have a negative effect on health. Surprisingly, younger children were more aware than the older ones. About 57.2% in age groups 9-14 years viewed OD to be undesirable, while the corresponding ratio among 14-18 year olds was 42.8%.

Intention-behaviour gap: In our study, all the schools had one KVIP toilet facility on its compound. Regardless of a majority of pupils perceiving OD to be bad behaviour, many admitted engaging in it. Why?  Three factors were revealed by the FGDs and in-depth interview results, as illustrated by the following quotes:

i) State of cleanliness of school toilets:
Female pupil: “There is no scent in the bush so I go there; I get some neatness in the bush”.
Male pupil: “You feel very comfortable to defecate in the bush.”

ii) Smell in school toilets that prevents both use and maintenance:
Male pupil: “…The toilet smells and you have to remove your uniforms before defaecating in the toilets”
Male pupil: “…When we are asked to go and clean the toilets, we can’t go there because the toilet smells”

iii) Comfort offered by open spaces:
Male pupil: “Even though I have a toilet in the house, I feel more comfortable defaecating in the bush than in the toilet”.

Policy Recommendations: Open defecation practice is being nurtured in schools because of the poor state of school shared toilets and the lack of adequate knowledge on the health and environmental implications of the practice. Thus, we have the following recommendations.

   Improvement in sanitation infrastructure:

  1. The Ghana Education Service must set standards for the state of school toilets and School Heads who do not comply must be sanctioned.
  2. Sanitation stakeholders must also ensure that toilet provided for the school children are appropriate to their age, and meet their defecation preferences.


  1.  The School Health Education Program must expose school pupils to the need for having good sanitation by show casing good sanitation systems through
  2. The Ministry of Education must introduce courses into the school curriculum to help pupils acquire adequate knowledge on health and environmental consequences of open defecation.
  3. The Ghana Health Service must extend their health education on faeco-oral diseases to cover the basic schools, the Christian Churches and the Muslim Mosques motivating them to integrate best practices on sanitation behaviours into their discourses.



Photo Credits: Chester Holme,