International Journal of Environmental Health Research
ISSN: 0960-3123 (Print) 1369-1619 (Online) Journal homepage: https://www.tandfonline.com/loi/cije20
Population awareness and attitudes toward waste-
related health risks in Accra, Ghana
Gina Kanhai, Samuel Agyei-Mensah & Pierpaolo Mudu
To cite this article: Gina Kanhai, Samuel Agyei-Mensah & Pierpaolo Mudu (2019): Population
awareness and attitudes toward waste-related health risks in Accra, Ghana, International Journal of
Environmental Health Research, DOI: 10.1080/09603123.2019.1680818
To link to this article:  https://doi.org/10.1080/09603123.2019.1680818
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INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH
https://doi.org/10.1080/09603123.2019.1680818
ARTICLE
Population awareness and attitudes toward waste-related health
risks in Accra, Ghana
Gina Kanhaia, Samuel Agyei-Mensahb and Pierpaolo Muduc
aInstitute for systems science, innovation and sustainability science, Karl-Franzens University of Graz, Graz, Austria;
bDepartment of Geography and Resource Development, University of Ghana, Legon, Ghana; cWorld Health
Organization (WHO), Public Health, Environmental and Social Determinants of Health (PHE), Geneva, Switzerland
ABSTRACT ARTICLE HISTORY
Despite significant knowledge about the potential health hazards of Received 29 March 2019
waste, there are few studies in African cities that investigate awareness Accepted 11 October 2019
of health issues related to waste management, although such research is KEYWORDS
needed to lower population exposure. This paper examines the case study Household attitude; health;
of Accra in Ghana, a city dealing with serious health and pollution pro- waste collection; waste
blems. Three focus groups and 157 households in Accra were surveyed on burning; waste dumping
household waste disposal and awareness of waste-related health hazards.
Surveyed households had limited knowledge of waste-related health
hazards in their neighbourhoods. Although the households reported dis-
eases that could be associated with environmental factors linked to waste
management, 87% of all surveyed households did not think that someone
in their household could have fallen ill of a disease that can be related to
waste. In middle- and high-income neighbourhoods, waste burning
increases substantially when waste is not collected.
Introduction
For most of the global population, cities provide the chance of a life of employment, far from war or
other miserable living conditions (Satterhwaite 2005). However, the speed and scale of urban
growth increases the challenges for city planning and management. In particular, the rapid
urbanization of the developing world has exceeded the capability of most cities to provide
a sufficient level of services to their citizens, leading to daunting sustainability challenges (Cohen
2006; Fobil et al. 2008; Ezeah and Roberts 2012; Almazán-Casali et al. 2019). The main aim of many
developing countries is the basic provision of food, shelter, security and livelihoods (Konteh 2009).
Therefore, in most cities of the developing world, municipal solid waste management is a neglected
area, with no formally organised waste collection and/or insufficient waste management and
recycling policies and practices (Seo et al. 2004; Al-Khatib et al. 2010; Hoornweg and Bhada-Tata
2012; Marshall and Farahbakhsh 2013). When solid waste management is given importance in
developing countries, it is often driven by the issue of public health (Wilson 2007; Coffey and Coad
2010). The everyday nature of household waste generation and waste collection leads to an under-
estimation with regard to the adoption of long-term and sustainable waste management strategies
(Petts 2000). Africa is a continent where the challenges associated with waste management are
CONTACT Gina Kanhai gina.kanhai@gmail.com Institute for systems science, innovation and sustainability science, Karl-
Franzens University of Graz,, Graz, Austria
The data that support the findings of this study are available from the corresponding author, GK, upon request.
This article has been republished with minor changes. These changes do not impact the academic content of the article.
© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://
creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the
original work is properly cited, and is not altered, transformed, or built upon in any way.
2 G. KANHAI ET AL.
already high and expected to worsen significantly, due to its large population growth and the health
hazards associated with inadequate waste collection and treatment (Guerrero et al. 2013).
Studies on the connection between inadequate waste management and health have found that
contamination due to improper waste collection can affect soil and water, exacerbating the
diffusion of microbial agents, cholera and malaria (Abul 2010; Dzotsi et al. 2016; Songsore
2017) and other vector transmitted diseases (Fobil et al. 2010; Dhar-Chowdhury et al. 2015).
Additionally, it is associated with limited evidence of congenital anomalies, low birth weight,
respiratory diseases and increased risk of cancer (Porta et al. 2009; Amegah et al. 2012; Mattiello
et al. 2013). The practice of burning domestic waste is associated with pollution by particulate
matter (Dionisio et al. 2010; Arku et al. 2011), acidic gases and aerosols, as well as metals and
organic compounds (Rushton 2003).
To help counteract the expected negative trend, this paper presents a case study of Accra in
Ghana, a city dealing with serious health challenges, the most notable being two recent cholera
epidemics (Dzotsi et al. 2016), and pollution problems also related to the ineffective management of
the large amounts of solid waste and e-waste generated (Oteng-Ababio 2010, 2011; Agyei-Mensah
and Oteng-Ababio 2012; Oteng-Ababio et al. 2013; Anaman and Nyadzi 2014; Wittsiepe et al. 2015;
Oteng-Ababio and Grant 2019). Data from the Ghana Health Service 2010 states that 60% of the
most frequent diseases in the country were related to insufficient environmental sanitation. Several
studies demonstrate waste collection services to be a limiting factor of population health in Ghana
(Boadi and Kuitunen 2005; Oteng-Ababio 2011; Owusu-Sekyere 2014; Miezah et al. 2015; Oteng-
Ababio et al. 2017). Depending on the source of literature, it is estimated that only 33% to 55% of
the waste produced in Accra is collected (National Climate Change Committee (NCCC) of Ghana
2015; Miezah et al. 2015). Low-income settlements are usually the last to be sufficiently serviced or
are neglected altogether (Coffey and Coad 2010). While this paper focuses on impacts to human
health, the potential medical expenses and loss of income due to ill health often lead to economic
impact on households (McIntyre et al. 2006). In a country such as Ghana, where about 50% of the
urban population is estimated to live below the poverty line of one US dollar a day (UN-Habitat.
2015. UN-Habitat Global Activities Report 2015), the loss of income is especially debilitating.
Unlike other studies done in Accra, the aim of this study is to provide insights into possibilities to
protect human health by analysing how citizens in Accra deal with their household waste and by
connecting this with the theoretical background of environmental health literacy. Environmental
health literacy is a protective factor against environmental hazards as it helps households address
exposure (Finn and O’Fallon 2015). Studies have examined health literacy for medical waste in
Ghana (Sasu et al. 2011). Nevertheless, studies on household health literacy and household waste
management are scarce, and this research, therefore, aims to provide an original contribution to the
understanding of waste management perception; a detailed analysis of areas covered by previous
studies; and insights into health literacy and household waste, as understanding household aware-
ness forms the basis for developing measures to reduce household exposure, thereby addressing
several Sustainable Development Goals (SDGs), namely 1 (no poverty), 3 (good health and well-
being), 6 (clean water and sanitation) and 11 (sustainable cities and communities).
Marshall and Farahbakhsh (2013) developed a systems model for waste management in devel-
oping countries with four main drivers: rapid urbanization, the cultural and socio-economic context,
the political context and international influences. We took this model into account during data
collection and also when discussing suggestions on how to reduce the health hazards posed by
improper waste collection and management.
We made two hypotheses: 1. that formal collection capacity in high-density low-income neigh-
bourhoods is lowest, leading to indiscriminate dumping and waste burning at the household level,
while the reverse holds true in low-density high-income areas; 2. that awareness of health hazards
related to waste management is highest in high-income low-density settlements.
Indiscriminate dumping of waste and waste burning have been associated with significant health
hazards (Rushton 2003; Dionisio et al. 2010; Fobil et al. 2010; Modak 2011); therefore, we use these
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 3
two variables, income and density, as proxies for related health hazards. In conclusion, we expect
health hazards to be highest in high-density low-income neighbourhoods, while awareness of health
risks is lowest.
There are several definitions and conceptualizations of waste management, emphasizing eco-
nomic, hygienic, anthropological, and environmental aspects, or framing waste from hazard or
resource perspectives (Basel Convention 1989; Moore 2012). Due to the focus on health hazards, for
this paper, we have adopted the following waste management definition ‘the control of waste related
activities, with the ultimate aim of resource conservation and protection of human health and the
environment.’ (Pongrácz et al. 2004).
Methods
Study design
The general methodological approach was a case study of Accra, Ghana, which employed both
qualitative and quantitative methods of data collection. Quantitative data were obtained with
a survey of 157 households, while qualitative data were collected through three focus group
discussions. All participants gave informed consent.
Case study area description
Ghana is a country in West Africa with a population of 24,658,823 and an annual growth rate of
2.5% (Ghana Statistical Service 2012). Accra, the country’s capital city, has more than 2 million
inhabitants. According to the latest estimates published by the Ghana Statistical Service for 2018,
there are almost 5 million inhabitants in the greater Accra region. Various major ethnic groups have
settled in Accra. The population consists of 47.5% Akan, 16.6% Mole-Dagbani, 13.9% Ewe, 7.4%
Ga-Dangme, 5.7% Gurma, 3.7% Guan, 2.5% Grusi, 1.1% Mande and 1.4% others (Ghana Statistical
Service 2012).
The current state of Accra’s waste management system was greatly affected by the political
turmoil and coups in the 1980s, amongst other things, leading to increased deficiencies in waste
management. In 1985 the waste management department of the Accra Metropolitan Area (AMA)
was established to ensure the collection and treatment of waste in Accra (Oteng-Ababio 2010). The
Canadian company ‘City and Country Waste’ was given a monopoly on the waste sector in 1999
after the decision was taken to privatize the sector. When the company failed to deliver the expected
results, the contract was cancelled. In its wake, private waste service providers emerged which
currently provide 80% of waste-related services in Accra. Informally organized waste collection, e.g.
through tricycles, is a response to the perceived inefficiencies in privatized waste management
(Oteng-Ababio 2011; Asibey et al. 2019), which cannot provide collection services for all parts of the
city (Anaman and Nyadzi 2014).
Within the city, four neighbourhoods were identified for the survey. These represent three
relevant socioeconomic levels (high-income low-density, middle- and low-income high-density
areas), which is particularly relevant as it was hypothesized that both the ability to pay for waste
collection services and environmental health literacy regarding waste, differ by socioeconomic level.
The neighbourhoods of James Town (JT) and Nima (NM) represent low-income high-density
settlements; Asylum Down (AD) middle-income and East Legon (EL) high-income, low-density
settlements. These four neighbourhoods lie in a line from the coast to Accra’s northern boundaries.
The neighbourhoods have also been selected in other studies related to either waste or air pollution,
which provided additional information (Rooney et al. 2012; Zhou et al. 2013; Arku et al. 2014).
Furthermore, the neighbourhoods consist of various ethnic groups, which can be an influential
factor in the municipality’s capacity to successfully implement solid waste management strategies,
as public awareness and attitude lead to differences in household waste storage and separation,
4 G. KANHAI ET AL.
interest in waste reduction, recycling, demand for collection services and willingness to pay for
services, waste disposal through indiscriminate dumping or opposition to proposed locations of
waste facilities (Marshall and Farahbakhsh 2013).
Focus groups
The purpose of conducting the focus groups in Accra was 1. to provide insights on relevant waste-
related topics and 2. to clarify the use of terms for the household survey.
Three different target groups were defined: (a) students, and middle-aged mothers from (b) low-
and (c) middle-income areas. The first target group included university students from different
parts of the AMA. This target group was selected in order to gain an overview of waste management
practices in different neighbourhoods and to observe potential differences in health awareness
between participants with advanced education levels and the participants of other focus groups with
on average lower education levels. Middle-aged mothers were selected for two focus groups as it was
hypothesized that older female household members coordinate household waste management. For
these two focus groups, the differentiation between middle and low-income was made, because it
was hypothesized that waste management and health knowledge could differ based on income and
education level. Additionally, differences in vocabulary used by members of different income
groups were of interest.
The participants were selected to be homogenous (Krueger 1988). In the student focus group,
homogeneity was based on occupation, educational level and age. In the other two focus groups, the
criteria for selection were social group, age, residential area and family characteristics. The parti-
cipants in the student focus group were selected from students living in one dormitory of the
University of Ghana campus with a focus placed on each student growing up in a different area of
Accra. The low-income focus group was organized via the headmaster of a school located in the
same district. The middle-income focus group was organized via a large Presbyterian church. In all
focus groups, the value was placed on ensuring that the participants were not familiar with one
another, in order to reduce bias in answers. Participants in the focus groups numbered 8, 9 and 11.
Each focus group was interviewed in the language of preference of the participants; English, Ga or
Twi, by schooled interviewers. Each interview was recorded and then transcribed for analysis.
A pragmatical content analysis was done to draw conclusions.
Household survey
The sample size, of 162 households, was calculated based on the United Nations guideline for household
surveys, which provides concepts and procedures for designing samples for household surveys (UN,
Department of Economic and Social Affairs 2005). The total number of households in the four
neighbourhoods from the last census was considered as the population to be surveyed. Epi_Info 7 was
used to calculate a random sampling size with four clusters and 5% error. Forty surveys were to be
completed in each of the four neighbourhoods. The data collection was distributed throughout each
neighbourhood. The results of five interviews were unfortunately lost and it was not possible to repeat
them, and eventually, 157 household surveys were collected over a period of 4 weeks in April 2017. The
number of non-respondents was extremely low and equal to 7 cases. The survey target population were
adult mothers living in Accra in 2017, due to the focus group results indicating that middle-aged female
members of households are responsible for household waste management. Additionally, various studies
of risk perceptions have demonstrated that in general women are more concerned about environmental
hazards than men (Flynn et al. 1994; Greenberg and Schneider 1995).
The survey consisted of 35 questions and was designed to take a maximum of 20 min to
complete. The mode of data collection of the cross-sectional survey was a face-to-face interview
in which the survey participant was asked the questions by the interviewer. This mode was selected
because 26% of the Ghanaian population over the age of 11 are illiterate (Ghana Statistical Service
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 5
2012). Additionally, as within a single neighbourhood various languages are spoken by the
inhabitants, interviewers were able to translate questions into the respondent’s preferred language.
Due to the different linguistic, ethnic and religious backgrounds in each neighbourhood, 13
interviewers were schooled on survey data collection. The interviewer selection was aimed to
decrease the household non-response rate. Survey participants were recruited in randomly selected
areas of each neighbourhood. As the residents’ GPS locations were collected in the survey, it was
mandatory that participants live at the location of survey participation.
The data from the household survey were analysed with Epi_Info 7 and SPSS, with the analysis
based on descriptive statistics. Statistical association’s measures were analysed with chi-square tests.
It is supposed that the results obtained in this research are relevant for the whole city of Accra, as the
neighbourhoods are representative of different social conditions in Accra with sufficiently defined
boundaries to create identifiable areas for urban health research (Engstrom et al. 2013).
Results
Focus groups results
The focus group results are depicted in the following order: students, low-income high-density
mothers and thereafter the middle-incomemothers. All nine participants of the student focus group
were from different areas of Accra and were aged 20–23. Regarding waste collection, five of the nine
participants had a door-to-door collection, while two had a roadside collection, one had communal
collection facilities, and the final participant stated that they disposed of the household waste
themselves. All participants declared that there was no separate collection of waste by type in
their neighbourhood.
Some participants detailed that their waste was collected by a formal provider, e.g. Zoomlion,
while others explained that informal collectors, e.g. tricycles, came to pick up the waste. When waste
was not collected it was disposed of through waste burning, indiscriminate dumping, e.g. in gutters
during the rainy season or on open plots of land during the dry season, or through the collection by
the informal sector. When asked about possible health effects of waste management in their
neighbourhood, participant responses included respiratory disorders, eye and throat irritations
due to waste burning at refuse dumps, malaria through mosquito breeding, cholera and diarrhea
transmission due to flies.
The high-density low-income focus group was conducted in La Abormli and consisted of
eight participants, all mothers and the wives of household heads. In all households, adults
were responsible for waste disposal. In this neighbourhood, waste was disposed of at
a communal collection site or was picked up by informal waste collectors. One participant
stated that when waste was not collected, paper and plastic are separated and burned with
kerosene, while the rest of the waste was taken to a nearby collection site. Another participant
detailed that the household waited for the waste collectors to come or that they took their
waste to the collection site. Additionally, a participant complained about waste and faeces
being dumped in the gutter behind her house. When asked about possible health effects
related to waste management, the following were mentioned: respiratory problems, transmis-
sion of airborne diseases from incorrectly dumped waste, and cholera. Additionally, malaria,
diarrhea, dracunculiasis, and tuberculosis were named. Waste burning was a topic that the
focus group strongly identified with: three participants stated that they would either put out
a neighbours’ fire or tell a neighbour to stop burning waste. Waste management, and not
water, air dust, or other environmental or social topics, was identified by the participants as
a priority for the improvement of the neighbourhood.
The middle-income focus group in Haatso consisted of 11 participants, all mothers and the wives
of household heads. The participants of this focus group prioritized improving both water and
waste management for their neighbourhood. Waste collection was mainly formal in this
6 G. KANHAI ET AL.
neighbourhood. Under normal circumstances, the trucks came to pick up the waste twice a week.
Participants mentioned that household waste management, when the service provider fails to pick
up the waste, is by burning parts of their waste, letting waste accumulate as it will be picked up
eventually or taking the waste to a collection site. This focus group again reinforced the fact that
while any member of a household could dispose of the household waste, it is commonly seen as the
responsibility of the women in the house. Diseases mentioned in association with poor waste
management were cholera, diarrhea and malaria. One participant said that as almost all households
burned waste when the formal collection was not done on time, neighbours do not tell each other to
stop burning waste. When asked how and whether the participants prevent exposure to smoke, one
participant stated that smoke enters the house even through closed windows. Differing from the
other two focus groups, the middle-income focus group placed the responsibility for improving
waste management with the government, while the other two focus groups saw it as a shared
responsibility.
Household survey results
The average survey respondent throughout all neighbourhoods was 46 years of age. The average time the
survey respondent had been living at the same address was 32 years in JT, 25 in NM, 26 in AD and 12 in
EL. The average income and income distribution of the target group were difficult to determine as most
of the households in all neighbourhoods do not keep a budget. The survey respondents were mainly
retired or working in sales and service jobs, with the majority being self-employed selling food. The
respondents were representative of the target population of mothers and household head wives in the
neighbourhoods.
Regarding respondent ethnicity, it is important to note that the number of Akans rose with
income level. Ga-Dangme was the predominant ethnic group in JT and contributed to 50% of the
survey respondents in AD (compare Figure 1).
Waste is collected differently in each of the four neighbourhoods. In the high-income, low-density
parts of the neighbourhood EL, waste collection was provided almost exclusively by the formal sector
via door-to-door collection. Waste collection in JT and AD, a low-income, high-density neighbour-
hood and the middle-income neighbourhood, respectively, was also mainly through door-to-door
collection, but by both the formal and informal sector. In NM, a low-income, high-density neighbour-
hood, waste was mainly collected formally through communal collection. The frequency of door-to-
door waste collection was mainly once a week in AD and EL while it was twice a week in JT. In NM,
the households which had door-to-door collection had waste collected mainly once a week. Waste
containers overflowed regularly in NM and the least in JT (compare Figure 2).
Of the 69 households that stated that their waste containers overflow, 44.9% exclusively waited for the
collection service, while 24.6% of households directly called the informal collectors, 4.3% of households
burned their waste, 4.3% of households brought it to a waste collection site, one household buried their
waste and 2.9% dumped it indiscriminately while 8.7% households stated combinations of waste
disposal, e.g. both burning waste and waiting for formal collection services (compare Figure 3 for
information by neighborhood). Therefore, 75% of the households with overflowing waste containers
either waited for waste collection, thereby providing a breeding space for vectors and rodents, or
organized informal collection. Nevertheless, households in which waste containers do not overflow
also reported burning waste, in total 18.73% of the surveyed households burned waste.
Of the 28 households which burned waste, 90% were from either the middle-income
neighbourhood AD or the high-income neighbourhood EL, where, respectively, 27% and 34% of
the surveyed households burned some or all their waste (see Figure 4). In comparison, only one
household (2.5%) in NM answered that they burn their waste. The main rational stated for burning
waste was to ‘get rid of waste’ (89% of respondents) or ‘other’ reasons (11%) such as costs or
hygiene, e.g. the burning of toilet paper. When looking at the motives of households to burn waste,
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 7
50 Foreign
40
Mole Dagbani
30
Ga
20
Mande
10
Ewe
0
JT NM AD EL Akans
Figure 1. Survey respondent’s ethnicity by neighbourhood.
100.0
90.0
80.0
70.0
60.0
50.0
Regular overflow
40.0 of waste
30.0
20.0
10.0
0.0
AD EL JT NM
Figure 2. Percentage of household waste containers overflowing by neighbourhood.
X2(3) = 10.7*, p < 0.01
100.0
90.0
80.0
70.0
60.0
50.0 Wait/Alternative collection
Burn/dump
40.0
30.0
20.0
10.0
0.0
AD EL JT NM
Figure 3. Household action when waste overflows.
X2(3) = 4.05, p < 0.26
75% of the households who burned waste wanted to get rid of their waste while 25% stated that they
only burned waste when it was not collected.
% %
8 G. KANHAI ET AL.
100.0
80.0
60.0
Burn_Yes
40.0
Burn_No
20.0
0.0
AD EL JT NM
Figure 4. Households burning waste by neighbourhood.
X2(3) = 19.56**, p < 0.001
The majority of the waste burned by the surveyed households in EL was garden waste with
a small quantity of plastic and paper. In AD, burned waste was mainly paper and some plastic and
food waste. The 7% of households which burned waste when it was not collected were mainly from
the high-income settlement EL and primarily burned garden waste. Participant responses to the
question of whether waste was burned in the neighbourhood (JT 18%, NM 9%, AD 33%, EL 61%)
suggest that the belief that neighbours burn waste is more prevalent in the high-income low-density
neighbourhood and middle-income neighbourhoods than in the low-density low-income
neighbourhoods.
Turning to household health awareness in relation to waste, households throughout all neigh-
bourhoods stated that waste disposal is important due to a fear of illness, associated flies and the
need for cleanliness.
In each neighbourhood, 90–98% of the surveyed households stated that no person within their
household had suffered, during the past 12months, from a disease or condition that could be linked to
waste. The responses showed that individuals within 77% of the households suffered from malaria,
29% from stomach discomfort, 24% from skin infection, 20% from respiratory infections, 13% from
diarrhea, 10% from typhoid fever and 8% from cholera (compare Figure 5), all of which can be linked
to various environmental and hygiene factors including poor sanitation. Only 6% of the households
surveyed stated that they had not had any of the above-mentioned diseases or conditions during the
past 12 months. The number of different types of diseases per household during the past year was
higher in the low-income high-density neighbourhoods. No statement can bemade about the number
of people affected per household or the severity of the health issue.
Respondents were asked to gauge the likelihood of falling ill with a specific disease due to the
proximity to waste. Answers differed based on the household’s perception of the likelihood of falling ill
90
80
Other
70
Diarrhea
60
Skin infection
50
Typhoid
40
Cholera
30
Stomach Discomfort
20
Resp Infection
10
Malaria
0
JT NM AD EL
Figure 5. Household disease burden declared by respondents by neighbourhood.
%
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 9
by disease and neighbourhood (see Figure 6). Awareness of the interrelation of cholera and waste was
high in all neighbourhoods. This is probably due to large-scale education measures after the recent
cholera epidemics in Accra. In all neighbourhoods except for JT, residents had a high awareness that
improper waste management can increase the risk of falling ill with malaria and diarrhea.
100.00
90.00
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
0.00
Malaria Diarrhea Allergies TRTD PRTD Cancer Cholera
AD EL JT NM
Figure 6. Household perception regarding the potential of becoming ill due to waste, by neighbourhood.
The highest level of awareness of health hazards was among the Mole Dagbani and the lowest
among the Ga-Dangme (compare Figure 7).
80%
60%
40%
20%
0%
Malaria Diarrhea Allergies TRTD PRTD cancer cholera
Akans Ewe Ga-Dangme Mole Dagbani
Figure 7. Ethnicity and health awareness.
Discussion
Focus group discussions
In each of the focus groups, the question order differed slightly. The order of questions could account for
some differences in the answers provided by the participants. For example, in the second focus group the
question ‘What would you prioritize when improving the environment in your neighbourhood (e.g. waste,
water, air pollution, dust, lack of green spaces, etc)?’ was asked towards the end. In this group, all
participants prioritized waste, whichmight be an influence of the focus group topic revolving around the
%
10 G. KANHAI ET AL.
waste. In the third focus group, this question was asked before the topic of waste formally came up. In
this group, both water and waste were strongly prioritized. Nevertheless, it can be assumed that waste is
a topic of interest for the participants of all the focus groups.
Throughout all three focus groups, it emerged that formal waste collection service providers in
Accra are not collecting waste in a reliable manner. This implies that the utilization of informal
collection or household indiscriminate dumping and burning is common practice, which was also
found by other studies in Accra (Fobil et al. 2008; Oteng-Ababio et al. 2013). Boadi and Kuitunen
(2003) found that 14.3% of surveyed households in Accra burn a part of their waste. The 2010
census in Ghana states that in the Greater Accra Region about 11.2% of households burn their waste
(Ghana Statistical Service. 2014). Results obtained from fieldwork in a low-income settlement
published by Anaman and Nyadzi (2014) gave an approximate figure of 11% of respondents who
burned all of their waste, with an additional 50% burning a part. Our study does not support this
negative figure for the low-income areas, but does show a similar picture for the middle- and high-
income areas. In all three focus groups, at least some of the participants in each group mentioned as
waste-related health hazards; malaria, cholera and diarrhea. Due to the cholera epidemic in 2014
and 2015 in Accra, which was linked in the media to the inadequate provision of liquid waste
management, it was expected that participants of all focus groups would be aware of the connection
between cholera, diarrhea and waste management. Participant knowledge about the connection
between improper waste collection and malaria was an unexpected finding. This connection was
most clearly drawn in the first focus group with students, which might be ascribed to their higher
educational level, age or on average higher-income families. The middle-income focus group
named the least number of illnesses in relation to waste and was also the only group that did not
mention respiratory disease. This is relevant as this is also the group where the largest percentage of
participants stated that they burned waste. While the awareness of potential health-related effects
due to poor waste management was comparatively low, the middle-income group strongly
expressed dissatisfaction, ill-feeling and claimed a poor quality of life which aligns to the concept
of well-being (Diener and Seligman 2004). Despite the large public awareness campaign after the
cholera epidemic on the relevance of sanitation, it seems that faeces were indiscriminately dumped
in some areas in Accra, suggesting the need for further education and an academic review of the
challenges of the sanitation system. This is important, because where sanitation infrastructure is
limited excreta is sometimes mixed with municipal solid waste, thereby increasing the potential
hazardousness of the waste (UN-Habitat 2010). The provision of public toilets in low-income
neighbourhoods could also lead to a decrease in open defecation and the indiscriminate dumping of
faeces (Chalfin 2014), which reduces risk of exposure to waterborne diseases (Morua et al. 2011).
Elements of good governance, such as public participation, are needed to successfully implement
changes in waste management. Various members of the middle-income focus group stated that the
responsibility for the environment and waste management lies with the government. The participants
showed a willingness to support initiatives such as the greening of former landfills and dumps if the
government was seen to invest in the area, e.g. through the passing of regulations and lowering levels of
corruption. Participants in all three focus groups showed a strong interest in environmental protection.
In the student and middle-income focus groups, participants suggested decreasing their personal use of
plastic bags and the wish formore formal recycling in Accra.Miezah et al. (2015) conducted a large-scale
study on household waste, in which household willingness to participate in recycling activities was
measured. The willingness shown in the earlier study aligns with the interest and suggestions received
during this study. The willingness to actively participate could be used for innovation, as was done in
Liberia with the bottle-house, which was a transdisciplinary project with a focus on the sustainability
challenge of waste (Oyinlola et al. 2018).
The results from the focus groups provided insights on how to modify the instrument for the
household survey. All questions aligned to recycling and current separate collection of waste were
removed from the survey, while options for household waste disposal in the case of delays in the
formal collection were added.
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 11
Household survey
The difference in the frequency of waste collection between JT (2/week) and the other neighbourhoods
(1/week) could be explained by the processing offish in JT. It is expected thatwaste collection frequency is
higher due to the smell and diseases associated with fish remains. Waste containers overflow more in
neighbourhoods in which formal service providers are responsible for collection. Twenty percent of the
households with overflowingwaste containers then dispose of it in amanner that resulted in either health
or environmental hazards, such as by dumping or burning it. About 90% of the households, which
burned their waste, burned it for a different reason than out of necessity when their waste was not
collected. Potential reasons for household-level waste burning could be financial or related to the effort
connected with organizing collection or missing collection service provision for certain wastes, such as
garden waste. This is aligned to the results of Anaman and Nyadzi (2014), who found a relationship
between waste burning/indiscriminate dumping, and the distance to, and charges associated with, waste
disposal sites. We found the number of households burning waste to be lower in low-income high-
density neighbourhoods thanmiddle- and high-income low-density neighbourhoods. In Nima, the only
respondent whose household burned waste also said this was always done at night in secrecy. This
suggests that social pressure to not burn waste was high in low-income high-density settlements. In
Jamestown, two respondents stated that if one of their neighbours burntwaste, theywould go and put out
the fire, as there was a high risk of their house catching fire. This leads to the assumption that waste
burning inneighbourhoods could be related to population density andproximity of neighbouring houses
instead of education or income level.
Regarding health awareness, over 90% of respondents stated that no person in their household
had suffered from a disease that could be linked to waste during the past year. Further in the survey,
the respondents provided details of diseases that members of their household had had during the
past year. The misalignment between these answers suggests that population health awareness was
low throughout all neighbourhoods, even though household disease-burden potentially related to
waste was highly affected, and that household health hazard was underestimated. These results align
with other results from Ghana on the health awareness of informal sector workers in waste
management (Asibey et al. 2019). Additionally, Grasmück and Scholz (2005) show that inhabitants
with high exposure often underestimate their risk of falling ill through the exposed risk. As
households throughout all neighbourhoods, besides Jamestown, stated that they are very likely to
fall ill with malaria due to poor waste management, and individuals in 77% of households had
malaria within the 12 months leading up to the survey, Fischhoff et al. (1997), explained that ‘asking
people about risks to other people like themselves is not the same as asking them about their
personal risk’ (p. 994). Therefore, household hazard perception appears to be distorted. The few
respondents who recognized potential waste-related diseases in their household disease burden are
mainly health professionals or employees of ministries connected to health; therefore, their health
awareness is not deemed as representative of the average population in Accra. Neither the education
level of the household head, nor the ethnicity, nor the assumed income due to residency in
a neighbourhood, appeared to have an effect on the respondent’s hazard perception of household
waste.
Household risk perception needs to be addressed, as Vandermoere (2008) suggests that the
awareness of a health hazard leads to a household’s willingness to cleanse exposure-relevant
contaminated sites, thereby leading to a reduction of health hazards.
Suggested measures for urban solid waste management in Accra
In order to increase the population’s awareness of waste-related health hazards, measures to
increase environmental health literacy regarding the connection of diseases and waste are needed,
for example, on the link between waste dumping and malaria, as well as the diffusion of other
vector-borne disease and the risks of exposure to mold (Abul 2010; Kretchy et al. 2015).
12 G. KANHAI ET AL.
Additionally, measures to increase household participation in the waste collection are needed.
Community-based waste management has shown the potential to increase household participation
and environmental health literacy (Sekito et al. 2013; Sinthumule and Mkumbuzi 2019).
Recommendations on how to increase the capacity of waste collection differ by income area and
are provided in the following order: first low-income areas, followed by middle and then high-
income areas.
Low-income areas
In Accra, collection capacity is currently being increased through the privatization policies initiated
in the 1990s (World Bank 1996), but which have not lead to an efficient waste collection system in
Accra (Fobil et al. 2008). While privatization can theoretically improve efficiency and lower
operating costs, to date there is no evidence on differences in costs in public or private delivery
of solid waste management. Privatization can lead to a displacement of the poor and thereby to
significant social costs of greater inequality and more poverty in cities (Bel et al. 2010; Medina
2010). Hence, when increasing the collection capacity in Accra, it is important to consider informal
sector integration into the waste collection system. Alfaro d’Alençon et al. (2018) provide
a discourse on recognizing the informal sector. In some low-income areas of Accra, such as
Nima, where waste is collected door-to-door, it is mainly collected on foot due to the narrow and
uneven roads in the area. Thus, it is unlikely that formal sector collection can provide an adequate
service in these areas. Additionally, results from the survey suggest that informal waste collection is
more reliable and that payment schemes between informal workers and households appear to be
functioning well, as households rarely stated that their waste containers overflowed in low-income
high-density areas. Integrating the informal sector into collection services could be an option for
increasing the reliability of waste collection and reducing environmental hazards related to informal
collection. Modak (2011) suggests a process for informal sector integration, which could be applied
to Accra in order to reduce the risk of indiscriminate dumping and burning of collected waste by
the informal sector (Nyametso 2010). There are also some good case practices of scavengers
organizing themselves into successful micro-enterprises, scavenger cooperatives or public–private
partnerships in Africa (Rockson et al. 2013). More innovative approaches should integrate the
informal sector and support recycling and re-use. All of these options require the public policy
support that leads to sustainable grassroot development (Medina 2010) and consequently, should be
supported when implementing Agenda 2030.
Middle-income areas
In middle-income areas of Accra, one of the challenges for formal waste collection is the mainly
unpaved roads in these areas. Especially in the rainy season, road quality can decline dramatically,
leading to irregular waste collection. In order to increase collection capacity in this area, it is vital
that the road network is improved.
High-income areas
In high-income areas, the majority of waste burned by households is garden waste. One survey
respondent stated that if he placed his garden waste in the rubbish bin for formal collection, there
would be no room for other waste. Therefore, he and other neighbours choose to burn their garden
waste. Decentralized composting could be an option to lower black carbon and CO2 emissions in
high-income areas. As many residents have household staff, which could either transport the waste
or organize its collection, and sufficient financial means to pay for the additional service of
decentralized composting, this option could be viable if residents are made aware of the health
hazards of biomass burning.
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 13
Summary of suggested measures
The following table provides a summary of the identified challenges in the waste management
sector, including suggestions for addressing them (see Table 1).
Table 1. Suggested measures for tackling problems in the waste sector in Accra.
Challenges identified Suggested measures
Waste burning & indiscriminate dumping by ● Health education measures on health hazards of burning and
households dumping
● Better governance, including public participation – to understand
the motivation or problem
● Decentralized organic waste treatment facilities, e.g. composting
(high-income areas)
● Community-based waste management
Lack of public knowledge on health hazards from ● Health awareness information campaign
waste
Population lacks feeling of accountability, waste ● Address governance issues, including public participation:
responsibility is solely attributed to the government ○ define the role and involvement of citizens in waste
management
○ promote waste separation measures for households
● Educational promotion for households on recycling/waste
separation
● Publicize infrastructure investments made by the government.
Public dissatisfaction with the government’s approach ● Address governance issues, including public participation, to
to waste management support:
○ transparency (financials, aims, priorities, challenges of solid
waste management)
○ public education measures on health hazards of insufficient
waste collection, to explain the focus on this instead of waste
treatment
● Consider sustainable land-use for current land-fills
Unreliable and underdeveloped waste collection ● Assess the development of the current situation
● Informal sector integration
● Road network improvements
● Consider alternative waste business models
Indiscriminate burning & dumping by informal ● Informal sector integration
collection providers ● Incentivize disposal at formal sites
● Create decentralized discharge points
Limitations
No focus group was conducted in a high-income, low-density neighbourhood such as EL. While this
type of neighbourhood represents a minority of the population in Accra, it would have been helpful to
pre-test the survey in this type of neighbourhood in order to check wording and relevance of questions
for the target group. However, both the organization and the compensation of participants in these
neighbourhoods were outside the time and financial restrictions of this research.
Limitations of the survey process that need to be considered are that while data in JT, NM
and AD were collected on one weekday each, the data collection process in EL took 5 days, on both
weekdays and weekends. The reason for this is that private household security is common in EL,
leading to difficulty getting in contact with the actual residents of the house in order to collect data.
Although the priority was to survey the household head’s wife this restriction in EL led to a slight
shift in the target group, as in EL either the household head or his wife were surveyed, depending on
availability. Additionally, the participants in the other three neighbourhoods most likely did not
commute to work, as they were available for surveys during the week and daytime, while the same
cannot be said for participants from EL.
Unfortunately, the survey results do not allow any conclusions on whether there are households
who instead of organizing waste collection, directly dump or bury parts or all of their waste. It can
14 G. KANHAI ET AL.
be assumed that this applies to a number of households surveyed, as households also burn parts of
their waste even when waste is collected on schedule. Regarding health literacy, the risk of over- or
understating household health outcomes increases when respondents report on household mem-
bers who are not present during the interview. Nonetheless, as the respondent is the household head
or the household head’s wife, knowledge about the health status of other household members can be
expected.
Conclusion
The results show that population awareness and risk perception of waste-related health hazards are
similarly low throughout all neighbourhoods disproving the second hypothesis that it would be
lowest in low-income high-density areas. Regarding the connection between specific diseases and
waste, awareness of the relationship between cholera and waste is the greatest. While households do
appear to know that they can potentially fall ill due to poor waste management, they do not yet
realize that this is likely already the case, or what measures can be taken to reduce exposure. While
our results did show that formal waste collection capacity is lowest in low-density high-income
areas, differing from our hypothesis, this does not seem to lead to increased indiscriminate dumping
and waste burning at the household level as the informal waste management sector fills this gap. The
opposite of our initial hypothesis held to be true, as there were indiscriminate dumping and waste
burning at household level in middle and low-density high-income neighbourhoods where the
formal collection is unreliable and this leads to higher health hazards related to waste.
Our findings add to the risk perception literature by demonstrating that in an area with high
exposure to non-catastrophic risk, many households nevertheless do not perceive themselves to be
at risk from waste management. The findings suggest that where diseases related to waste manage-
ment with lower fatality rates are commonplace, people come to see them as a regular aspect of daily
life.
In order to increase the waste collection capacity in Accra, further analysis is needed on informal
sector integration and on alternative financing mechanisms or viable business models. Further
discussions are needed to address the question of how to motivate households to dispose of their
waste in a safer way and how to provide infrastructure for the safe disposal of household waste.
Acknowledgments
Particular thanks go to the University of Ghana, with a special thanks to Dr. Mawuli Dzodzomenyo from the
School of Public Health for his formal support in Accra. We also want to thank Dr. Ralf Aschemann for his
suggestions during the entire research and Thiago Hérick De Sá for his support in feed-backing the household
survey and suggestions regarding the focus groups. Additionally, thanks go to all of the participants of the focus
groups and the households for their openness to contribute to this research. We also thank Wendy Williams for
her suggestions to improve the English narrative of the text. This paper reflects the authors’ views. Thanks also to
Michael Hinsch for assistance on different logistical aspects of the work.
Declaration of Interest
The authors report no conflict of interest.
References
Abul S. 2010. Environmental and health impact of solid waste disposal at Mangwaneni dumpsite in Manzini:
swaziland. J Sustain Dev Africa. 12(7):64–78.
Agyei-Mensah S, Oteng-Ababio M. 2012. Perceptions of health and environmental impacts of e-waste management
in Ghana. Int J Environ Health Res. 22(6):500–517. doi:10.1080/09603123.2012.667795.
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 15
Alfaro d’Alençon P, Smith H, Álvarez de Andrés E, Cabrera C, Fokdal J, Lombard M, Mazzolini A, Michelutti E,
Moretto L, Spire A. 2018. Interrogating informality: conceptualisations, practices and policies in the light of the
New Urban Agenda. Habitat Int. 75:59–66. doi:10.1016/j.habitatint.2018.04.007.
Al-Khatib I, MonouM, Abu Zahra AS, Shaheen H, Kassinos D. 2010. Solid waste characterization, quantification and
management practices in developing countries. A case study: nablus district – palestine. J Environ Manag. 91
(5):1131–1138. PMID: 20116162. doi:10.1016/j.jenvman.2010.01.003.
Almazán-Casali S, Alfaro JF, Sikra S. 2019. Exploring household willingness to participate in solid waste collection
services in Liberia. Habitat Int. doi:10.1016/j.habitatint.2019.01.001.
Amegah AK, Jaakkola JJ, Quansah R, Norgbe GK, Dzodzomenyo M. 2012. Cooking fuel choices and garbage burning
practices as determinants of birth weight: a cross-sectional study in Accra, Ghana. Environ Health. 11(1):78.
doi:10.1186/1476-069X-11-78.
Anaman KA, Nyadzi WB. 2014. Analysis of improper disposal of solid wastes in a low-income area of Accra, Ghana.
Appl Econ Finance. 2(1):66–75. doi:10.11114/aef.v2i1.633.
Arku G, Luginaah I, Mkandawire P, Baiden P, Asiedu AB. 2011. Housing and health in three contrasting neighbour-
hoods in Accra, Ghana. Soc Sci Med. 72(11):1864–1872. doi:10.1016/j.socscimed.2011.03.023.
Arku R, Dionisio KL, Hughes AF, Vallarino J, Spengler JD, Castro MC, Agyei-Mensah S, Ezzati M. 2014. Personal
particulate matter exposures and locations of students and locations of students. J Expo Sci Environ Epidemiol.
1–10. Epub 2014 Aug 27. doi:doi.10.1038/jes.2014.56.
Asibey MO, Amponsah O, Yeboah V. 2019. Solid waste management in informal urban. Occupational safety and
health practices among tricycle operators in Kumasi. Ghana Int J Environ Health Res. 1–16. doi:10.1080/
09603123.2019.1569211.
Basel Convention. 1989. The basel convention on the control of transboundary movements of hazardous wastes and
their disposal. s.l.: UNEP.
Bel G, Fageda X, Warner ME. 2010. Is private production of public services cheaper than public production?
A meta-regression analysis of solid waste and water services. J Policy Anal Manag. 29(3):553–577. doi:10.2307/
40802088.
Boadi KO, Kuitunen M. 2003. Municipal solid waste management in the Accra Metropolitan Area, Ghana. Environ.
23:211–218. doi:10.1023/B:ENVR.0000017283.09117.20
Boadi KO, Kuitunen M. 2005. Environmental and health impacts of household solid waste handling and disposal
practices in third world cities: the case of the Accra Metropolitan Area, Ghana. J of Environ Health. 68(4):32–36.
PMID: 16334095.
Chalfin B. 2014. Public things, excremental politics, and the infrastructure of bare life in Ghana’s city of Tema. Am
Ethnol. 41(1). doi:10.1111/amet.12062.
Coffey M, Coad A. 2010. Collection of municipal solid waste in developing countries. Malta: UN-HABITAT.
Cohen B. 2006. Urbanization in developing countries: current trends, future projections, and key challenges for
sustainability. Technol Soc. 28:63–80. doi:10.1016/j.techsoc.2005.10.005.
Dhar-Chowdhury P, Haque CE, Driedger SM. 2015. Dengue disease risk mental models in the city of Dhaka,
Bangladesh: juxtapositions and gaps between the public and experts. Risk Anal. 36(5):874–891. doi:10.1111/
risa.12501.
Diener E, Seligman M. 2004. Beyong money - toward an economy of well-being. Psychol Sci Public Interest. 5
(1):1–31. doi:10.1111/j.0963-7214.2004.00501001.x.
Dionisio K, Rooney MS, Arku RE, Friedmann AB, Hughes AF, Vallarino J, Agyei-Mensah S, Spengler JD, Ezzati M.
2010. Within-neighborhood patterns and sources of particle pollution: mobile monitoring and geographic
information system analysis in four communities in Accra, Ghana. Environ Health Perspect. 118(5):607–613.
doi:10.1289/ehp.0901365.
Dzotsi E, Odoom JK, Opare JK, Davies-Teye BB. 2016. Outbreak of cholera, Greater Accra region Ghana 2014. J Sci
Res Rep. 9(3):1–12. doi:10.9734/JSRR/2016/21461.
Engstrom R, Ofiesh C, Rain D, Jewell H, Weeks J. 2013. Defining neighbourhood boundaries for urban health
research in developing countries: A case study of Accra, Ghana. J Maps. 9(1):36–42. doi:10.1080/
17445647.2013.765366.
Ezeah C, Roberts C. 2012. Analysis of barriers and success factors affecting the adoption of sustainable management
of municipal solid waste in Nigeria. J Environ Manag. 103:9–14. doi:10.1016/j.jenvman.2012.02.027.
Finn S, O’Fallon L. 2015. The emergence of environmental health literacy—from its roots to its future potential.
Environ Health Perspect. 125(4):495–501. doi:10.1289/ehp.1409337.
Fischhoff B, Bostrom A, Jacobs Quadrel M. 1997. Risk perception and communication. In: Detels R, Holland WW,
McEwen J, Omenn GS, editors. Oxford textbook of public health: vol. 2. the methods of public health. 3rd ed.
New York: Oxford University Press; p. 987–1002.
Flynn J, Slovic P, Mertz CK. 1994. Gender, race, and perception of environmental health risks. Risk Anal.
14:1101–1108. PMID: 7846319.
16 G. KANHAI ET AL.
Fobil J, Armah N, Hogarh J, Carboo D. 2008. The influence of institutions and organizations on urban waste
collection systems: an analysis of waste collection system in Accra, Ghana (1985–2000). J Environ Manag.
86:262–271. doi:10.1016/j.jenvman.2006.12.038.
Fobil J, May J, Kraemer A. 2010. Assessing the relationship between socioeconomic conditions and urban environ-
mental quality in Accra, Ghana. Int J Environ Res Public Health. (7). doi:10.3390/ijerph7010125.
Ghana Statistical Service. 2012. 2010 population & housing census: summary report of final results. Accra: Ghana
Statistical Service. doi:10.1094/PDIS-11-11-0999-PDN
Ghana Statistical Service. 2014. 2010 population & housing census. Urbanisation: Ghana Statistical Service.
Grasmück D, Scholz RW. 2005. Risk perception of heavy metal soil contamination by high-exposed and low-exposed
inhabitants: the role of knowledge and emotional concerns. Risk Anal. 25(3):611–622. doi:10.1111/j.1539-
6924.2005.00628.x.
Greenberg MR, Schneider D. 1995. Gender differences in risk perception: effects differ in stressed versus non-stressed
environments. Risk Anal. 15:503–511. PMID: 7480950.
Guerrero L, Maas G, Hogland W. 2013. Solid waste management challenges for cities in developing countries. Waste
Manag. 33(1):220–232. doi:10.1016/j.wasman.2012.09.008.
Hoornweg D, Bhada-Tata P. 2012. What a waste: A global review of solid waste management; knowledge papers no.
15. Washington (DC): World Bank.
Konteh F. 2009. Urban sanitation and health in the developing world: reminiscing the nineteenth century industrial
nations. Health Place. 15(1):69–78. doi:10.1016/j.healthplace.2008.02.003.
Kretchy J-P, Dzodzomenyo M, Rheinländer T, Ayi I, Konradsen F, Fobil JN, Dalsgaard A. 2015. Exposure, protection
and self-reported health problems among solid waste handlers in a Coastal Peri-urban community in Ghana.
Int J Public Health Epidemiol. 4(2):121–128.
Krueger RA. 1988. Focus Groups: A practical guide for applied research. Newbury Park (California): SAGE
Publications, Inc.
Marshall R, Farahbakhsh K. 2013. Systems approaches to integrated solid waste management in developing countries.
Waste Manag. 33:988–1003. doi:10.1016/j.wasman.2012.12.023.
Mattiello A, Chiodini P, Bianco E, Forgione N, Flammia I, Gallo C, Pizzuti R, Panico S. 2013. Health effects associated
with the disposal of solid waste in landfills and incinerators in populations living in surrounding areas:
a systematic review. Int J Public Health. 58(5):725–735. doi:10.1007/s00038-013-0496-8.
McIntyre D, Thiede M, Dahlgren G, Whitehead M. 2006. What are the economic consequences for households of
illness and of paying for health care in low- and middle-income country contexts? Soc Sci Med. 62(4):858–865.
doi:10.1016/j.socscimed.2005.07.001.
Medina M 2010. Solid wastes, poverty and the environment in developing country cities: challenges and
opportunities. Working Paper//World Institute for Dev Economics Research, 2010(23).
Miezah K, Obiri-Danso K, Kádár Z, Fei-Baffoe B, Mensah MY. 2015. Municipal solid waste characterization and
quantification as a measure towards effective waste management in Ghana. Waste Manag. 46:15–27. doi:10.1016/j.
wasman.2015.09.009.
Modak P. 2011. Chapter 5 - municipal solid waste management: turning waste into resources. In: United Nations
Bureau International des Expositions. Shanghai manual - a guide for sustainable urban Dev in the 21st century. s.l.:
UN. Chapter 5.
Moore SA. 2012. Garbage matters: concepts in new geographies of waste. Prog Hum Geog. 36(6):780–799.
doi:10.1177/0309132512437077.
Morua AR, Halvorsen KE, Mayer AS. 2011. Waterborne disease-related risk perceptions in the Sonora river basin,
Mexico. Risk Anal. 31(5):866–878. doi:10.1111/j.1539-6924.2010.01570.x.
National Climate Change Committee (NCCC) of Ghana. 2015. Ghana national climate change master plan action
programmes for implementation: 2015–2020. Republic of Ghana: Ministry of Environment, Science, Technology
and Innovation.
Nyametso JK. 2010. Improvement of squatter settlements: The link between tenure security, access to housing and
improved living and environmental conditions (Thesis, Doctor of Philosophy). University of Otago. http://hdl.
handle.net/10523/1681
Oteng-Ababio M. 2010. Private sector involvement in solid waste management in the Greater Accra Metropolitan
Area in Ghana. Waste Manag Res. 28:322–329. doi:10.1177/0734242X09350247.
Oteng-Ababio M. 2011. The role of the informal sector in solid waste management in the Gama, Ghana: challenges
and opportunities. Tijdschr Econ Soc Geogr. doi:10.1111/j.1467-9663.2011.00690.x.
Oteng-Ababio M, Arguello J, Gabbay O. 2013. Solid waste management in African cities: sorting the facts from the
fads in Accra, Ghana. Habitat Int. 39:96–104. doi:10.1016/j.habitatint.2012.10.010.
Oteng-Ababio M, Grant R. 2019. Ideological traces in Ghana’s urban plans: how do traces get worked out in the
Agbogbloshie, Accra? Habitat Int. 83:1–10. doi:10.1016/j.habitatint.2018.10.007.
Oteng-Ababio M, Owusu-Sekyere E, Amoah S. 2017. Thinking globally, acting locally: formalizing informal solid
waste management practices in Ghana. J Dev Soc. 33(1):75–78. doi:10.1177/0169796X17694517.
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 17
Owusu-Sekyere E. 2014. Scavenging for wealth or death? Exploring the health risk associated with waste scavenging
in Kumasi. Ghana J Geogr. 6:63–80.
Oyinlola M, Whitehead T, Abuzeinab A, Adefila A, Akinola Y, Anafi F, Farukh F, Jegede O, Kandan K, Kim B, et al.
2018. Bottle house: A case study of transdisciplinary research for tackling global challenges. Habitat Int. 79:18–29.
doi:10.1016/j.habitatint.2018.07.007.
Petts J. 2000. Municipal waste management: inequities and the role of deliberation. Risk Anal. 20(6):821–832.
doi:10.1111/0272-4332.206075.
Pongrácz E, Phillips PS, Keiski RL. 2004. Evolving the theory of waste management: defining key concepts. WIT
Transact Ecol Environ. 78:471–480.
Porta D, Milani S, Lazzarino AI, Perucci CA, Forastiere F. 2009. Systematic review of epidemiological studies on
health effects associated with management of solid waste. Environ Health. 8(1). doi:10.1186/1476-069x-8-60.
Rockson G, Kemausuor F, Seassey R, Yanful E. 2013. Activities of scavengers and itinerant buyers in Greater Accra,
Ghana. Habitat Int. 39:148–155. doi:10.1016/j.habitatint.2012.11.008.
RooneyMS, Arku RE, Dionisio KL, Paciorek C, Friedman AB, Carmichael H, Zhou Z, Hughes AF, Vallarino J, Agyei-
Mensah S, et al. 2012. Spatial and temporal patterns of particulate matter sources and pollution in four commu-
nities in Accra, Ghana. Sci Total Environ. 435–436:107–114. doi:10.1016/j.scitotenv.2012.06.077.
Rushton L. 2003. Health hazards and waste management. Br Med Bul. 183–197. doi:10.1093/bmb/ldg034.
Sasu S, Kümmerer K, Kranert M. 2011. Assessment of pharmaceutical waste management at selected hospitals and
homes in Ghana. Waste Manag Res. 30(6):625–630. doi:10.1177/0734242x11423286.
Satterhwaite D. 2005. The scale of urban change worldwide: 1950–2000 and its underpinnings. London: International
Institute for Environment and Development.
Sekito T, Prayogo TB, Dote Y, Yoshitake T, Bagus I. 2013. Influence of a community-based waste management
system on people’s behavior and waste reduction. Resour Conserv Recy. 72:84–90. doi:10.1016/j.
resconrec.2013.01.001.
Seo S, Aramaki T, Hwang Y, Hanaki K. 2004. Environmental impact of solid waste treatment methods in Korea.
J Environ Eng. 130(1):81–89. doi:10.1061/(ASCE)0733-9372(2004)130:1(81).
Sinthumule NI, Mkumbuzi SH. 2019. Participation in community-based solid waste management in Nkulumane
Suburb, Bulawayo, Zimbabwe. Resour. 8(1):30. doi:10.3390/resources8010030.
Songsore J. 2017. The complex interplay between everyday risks and disaster risks: the case of the 2014 cholera
pandemic and 2015 flood disaster in Accra, Ghana. Int J Disaster Risk Reduct. 26:43–50. doi:10.1016/j.
ijdrr.2017.09.043.
UN, Department of Economic and Social Affairs. 2005. Designing household survey samples: practical guidelines.
New York: UN.
UN-Habitat. 2010. Solid waste management in the world’s cities: water and sanitation in the world’s cities 2010.
London: Earthscan.
UN-Habitat. 2015. UN-Habitat Global Activities Report 2015: Increasing Synergy for greater national ownership,
Nairobi: UN-Habitat.
Vandermoere F. 2008. Hazard perception, risk perception, and the need for decontamination by residents exposed to
soil pollution: the role of sustainability and the limits of expert knowledge. Risk Anal. 28(2):387–398. doi:10.1111/
j.1539-6924.2008.01025.x.
Wilson D. 2007. Development drivers for waste management. Waste Manag Res. 25:198–207. doi:10.1177/
0734242X07079149.
Wittsiepe J, Fobil J, Till H, Burchard GD, Wilhelm M, Feldt T. 2015. Levels of polychlorinated dibenzo-p-dioxins,
dibenzofurans (PCDD/Fs) and biphenyls (PCBs) in blood of informal e-waste recycling workers from
Agbogbloshie, Ghana, and controls. Environ Int. 79:65–73. doi:10.1016/j.envint.2015.03.008.
World Bank. 1996. Ghana - Urban Environmental Sanitation Project. World Development Sources, WDS 1996.
Washington, DC: World Bank. http://documents.worldbank.org/curated/en/797301468770981963/Ghana-
Urban-Environmental-Sanitation-Project
Zhou Z, Dionisio K, Veríssimo TG, Ezzati M. 2013. Chemical composition and sources of particle pollution in
affluent and poor neighborhoods of Accra. Ghana Environ Res Lett. 1–9. doi:10.1088/1748-9326/8/4/044025.