Prevalence, Reasons, Predictors, Perceived Effects, and Regulation of Alcohol Use among Children in Ghana.

Early initiation of alcohol consumption increases the risk of alcohol dependence and adverse health outcomes. Consequently, nations have enacted laws to make alcohol unlawful to be purchased by, sold to, or used in public by children. This study examined the lifetime prevalence of alcohol use among children and their reasons for consuming alcohol. In addition, the study investigated predictors of alcohol consumption and the effects of alcohol use on children. Finally, it examined the effectiveness of measures in place for regulating the sale and use of alcohol by children in the country. A total of 5024 children between the ages of 8 and 17 were sampled across the ten regions of Ghana using a cross-sectional convergent parallel mixed method. Children were interviewed with a semi-structured questionnaire, while focus group discussions were held with children, parents, and key informants. Lifetime prevalence of alcohol consumption was measured by "have you ever taken alcohol?". The study revealed that lifetime alcohol consumption was less prevalent (6.6%) among children. Sex, age, and region of residence were significant predictors of lifetime alcohol use among children. More than half of the children who reported ever taking alcohol were first introduced to drinking by friends, and more than six in ten children claimed having been intoxicated after drinking alcohol. The findings further revealed that efforts to control the sale and consumption of alcohol by children have proven difficult despite the existence of laws, policies, and national regulatory structures. While regulations on alcohol sales and consumption have been difficult to implement in rural areas, they have been successful in urban areas because institutions there ensure rigorous adherence to the regulations. The study encourages national organizations with responsibility for child protection and development to step up their regulation, investigation, and information-sharing efforts to discourage and limit children from purchasing and consuming alcohol.

Urban sanitation coverage and environmental fecal contamination: Links between the household and public environments of Accra, Ghana.

Exposure to fecal contamination in public areas, especially in dense, urban environments, may significantly contribute to enteric infection risk. This study examined associations between sanitation and fecal contamination in public environments in four low-income neighborhoods in Accra, Ghana. Soil (n = 72) and open drain (n = 90) samples were tested for E. coli, adenovirus, and norovirus. Sanitation facilities in surveyed households (n = 793) were categorized by onsite fecal sludge containment ("contained" vs. "uncontained") using previous Joint Monitoring Program infrastructure guidelines. Most sanitation facilities were shared by multiple households. Associations between spatial clustering of household sanitation coverage and fecal contamination were examined, controlling for neighborhood and population density (measured as enumeration areas in the 2010 census and spatially matched to sample locations). E. coli concentrations in drains within 50m of clusters of contained household sanitation were more than 3 log-units lower than those outside of clusters. Further, although results were not always statistically significant, E. coli concentrations in drains showed consistent trends with household sanitation coverage clusters: concentrations were lower in or near clusters of high coverage of household sanitation facilities-especially contained facilities-and vice versa. Virus detection in drains and E. coli concentrations in soil were not significantly associated with clustering of any type of household sanitation and did not exhibit consistent trends. Population density alone was not significantly associated with any of the fecal contamination outcomes by itself and was a significant, yet inconsistent, effect modifier of the association between sanitation clusters and E. coli concentrations. These findings suggest clustering of contained household sanitation, even when shared, may be associated with lower levels of fecal contamination within drains in the immediate public domain. Further research is needed to better quantify these relationships and examine impacts on health.

Within-Compound Versus Public Latrine Access and Child Feces Disposal Practices in Low-Income Neighborhoods of Accra, Ghana.

In crowded urban settlements in low-income countries, many households rely on shared sanitation facilities. Shared facilities are not currently considered "improved sanitation" because of concerns about whether hygiene conditions sufficiently protect users from the feces of others. Prevention of fecal exposure at a latrine is only one aspect of sanitary safety. Ensuring consistent use of latrines for feces disposal, especially child feces, is required to reduce fecal contamination in households and communities. Household crowding and shared latrine access are correlated in these settings, rendering latrine use by neighbors sharing communal living areas as critically important for protecting one's own household. This study in Accra, Ghana, found that household access to a within-compound basic latrine was associated with higher latrine use by children of ages 5-12 years and for disposal of feces of children < 5 years, compared with households using public latrines. However, within-compound access was not associated with improved child feces disposal by other caregivers in the compound. Feces was rarely observed in household compounds but was observed more often in compounds with latrines versus compounds relying on public latrines. Escherichia coli and human adenovirus were detected frequently on household surfaces, but concentrations did not differ when compared by latrine access or usage practices. The differences in latrine use for households sharing within-compound versus public latrines in Accra suggest that disaggregated shared sanitation categories may be useful in monitoring global progress in sanitation coverage. However, compound access did not completely ensure that households were protected from feces and microbial contamination.

Multipathway Quantitative Assessment of Exposure to Fecal Contamination for Young Children in Low-Income Urban Environments in Accra, Ghana: The SaniPath Analytical Approach.

Lack of adequate sanitation results in fecal contamination of the environment and poses a risk of disease transmission via multiple exposure pathways. To better understand how eight different sources contribute to overall exposure to fecal contamination, we quantified exposure through multiple pathways for children under 5 years old in four high-density, low-income, urban neighborhoods in Accra, Ghana. We collected more than 500 hours of structured observation of behaviors of 156 children, 800 household surveys, and 1,855 environmental samples. Data were analyzed using Bayesian models, estimating the environmental and behavioral factors associated with exposure to fecal contamination. These estimates were applied in exposure models simulating sequences of behaviors and transfers of fecal indicators. This approach allows us to identify the contribution of any sources of fecal contamination in the environment to child exposure and use dynamic fecal microbe transfer networks to track fecal indicators from the environment to oral ingestion. The contributions of different sources to exposure were categorized into four types (high/low by dose and frequency), as a basis for ranking pathways by the potential to reduce exposure. Although we observed variation in estimated exposure (108-1016 CFU/day for Escherichia coli) between different age groups and neighborhoods, the greatest contribution was consistently from food (contributing > 99.9% to total exposure). Hands played a pivotal role in fecal microbe transfer, linking environmental sources to oral ingestion. The fecal microbe transfer network constructed here provides a systematic approach to study the complex interaction between contaminated environment and human behavior on exposure to fecal contamination.

Quantification of exposure to fecal contamination in open drains in four neighborhoods in Accra, Ghana.

In low-income countries, rapid urbanization adds pressure to already stressed water and sanitation systems that are critical to the health of communities. Drainage networks, designed for stormwater but commonly used for disposing of waste, are rarely covered completely, allowing residents to easily come into contact with their contents. This study used spatial mapping, documentation of physical drain characteristics, microbiological analysis of drain samples, and behavioral observation to comprehensively examine drains as a route of exposure to fecal contamination in four low-income neighborhoods in Accra, Ghana. A stochastic model of six likely exposure scenarios was constructed to estimate children's exposure to drain water. Regardless of the age of the child, any exposure scenario considered resulted in exposure to a high level of fecal contamination. Fecal contamination levels in drains were high (Escherichia coli: geometric mean (GM), 8.60 cfu log(10)/100 mL; coliphage: GM, 5.56 pfu log(10)/100 mL), and did not differ by neighborhood or physical drain characteristics, indicating that frequency of contact with drains, and not drain type or location, drives exposure risk. To mitigate health risks associated with this exposure, drains should be covered, with priority given to large concrete and small to medium dirt-lined drains that children were most commonly observed entering.