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UNIVERSITY OF GHANA, LEGON 
COLLEGE OF HUMANITIES  
DEPARTMENT OF GEOGRAPHY AND RESOURCE 
DEVELOPMENT 
 
 
 
  
PUBLIC TRANSPORT AND THE   SPREAD OF 
INFECTIOUS DISEASES; A CASE OF GREATER ACCRA 
METROPOLITAN AREA (GAMA). 
 
BY 
ERIC SEPENU AFLI 
 
10392690 
 
 
 
 
 
This thesis is submitted to the University of Ghana, Legon in partial fulfilment of 
the requirement for the award of MPHIL Geography degree. 
 
 
July, 2018. 
  
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DEDICATION 
 
I dedicate this work to the Almighty God, my family, and friends. You impacted my life 
in diverse ways.  So if today this project has reached its successful completion, it should 
be dedicated to you. Thanks for bringing me this far. 
  
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DECLARATION 
 
I hereby declare that this research is my own work and to the best of my knowledge it 
contains no materials formerly published or written by another person, nor material which 
to a substantial extent has been accepted for the award of any other degree or diploma at 
the University of Ghana or any other educational institution. 
I also declare that the intellectual content of this research project is the product of my own 
work, except to the extent that assistance from others in conceptions or in style, 
presentation and linguistic expression as acknowledged. 
 
 
                                                                                         
    ERIC SEPENU AFLI                                                                         DATE 
            (STUDENT) 
 
 
            
PROF. JACOB SONGSORE                                                                 DATE 
(PRINCIPAL SUPERVISOR) 
 
 
            
DR. ERNEST AGYEMANG                                                                  DATE 
      (CO-SUPERVISOR) 
 
  
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ACKNOWLEDGEMENTS 
 
I wish to acknowledge various people who contributed to this research both directly and 
indirectly. To begin with, I thank my supervisors, Prof. Jacob Songsore and Dr. Ernest 
Agyemang for their professional guidance in this research. They have been committed and 
always made time to offer wise counsel on the direction and shape of this thesis even with 
their busy schedule. Their guidance aided me to broaden my understanding and appreciate 
the significance of research in identifying and addressing issues affecting the society. 
Secondly, I wish to express my deepest gratitude to Partners Enhancing Resilience for 
people Exposed to Risks (PERIPERI-U) for funding this thesis. 
I also wish to thank all my lecturers for imparting me with knowledge and skills in research 
methods. Their guidance in course work has helped me to gain a clearer understanding of 
various concepts and principles of research from both theoretical and practical viewpoints.  
Also, I wish to acknowledge all the respondents and institutions who participated in this 
research project especially: Mrs. Augusta Nyarko (Hospital Administrator- Cocoa Clinic, 
Bubiashie), Evelyn Dowuona (Head of Total Quality Management- La General Hospital, 
La), Mr. Joseph Anan ( Environmental Health Analyst- Metropolitan Public Health, 
Accra), Lawrence Henry Ofosu Appiah (Microbiologist/Principal Biomedical Scientist- 
Ghana National Public Health and Reference Laboratory- Korlebu), Beatrice Ayivor 
(Public Relation Officer- NADMO, Accra Metro), Mrs. Adjoa Agyeiwa Frimpong 
(Relieve and Re-construction Officer- NADMO, Accra Metro), Mr. Robert Darko 
(Industrial Relations Officer- GPRTU, Accra), Mr. Boniface Acheampong Yeboah 
(Research Officer- Gillman and Abbey Funeral Services, Darkuman), Mr. Isaac Kofi 
Oppong (Headmaster- St. Stephen Basic School, Darkuman), Rev. George Ofori Kwakye 
(Teacher- St. Stephen Basic School, Darkuman), Mr. Abdul Jalil Awal (Head Teacher- 
Jenesis Preparatory/JHS, Darkuman), and the entire people of Airport residential area, 
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Frafraha, Abokobi, Darkuman, Kaneshie, La, Nima, and Hatso. Their contributions has 
been invaluable especially in providing relevant data for the study. I am also grateful to 
Benedicta Naa Kwamah Ankrah, Rex Awuku, Nana Kwadwo Ampadu, Kwabena Offin 
Appiah, Florence Attipoe, Ernestina Amihere, Cecelia Naa Tsotsoo Laryea, Charles 
Acheampong Otoo, Paul Coleman-Dogbe, Jenifer Owusu, Lincoln Tei Nyade, and 
Priscilla Narkie Nuer Tei for their immense support. 
Finally, I acknowledge my Parents, friends and relatives for their contributions and 
support.  
  
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ABSTRACT 
 
Many are the challenges facing Emergency Medical Service (EMS) in the developing 
world including Sub-Saharan Africa. These challenges include insufficient resources in 
terms of vehicles (the ambulance itself), limited staff and equipment, poor communication 
and transportation network, just to mention a few. As a result, people resort to private and 
public transport (Taxis) in times of emergency health situations. It is however not certain 
that these public and private vehicles employ the standard protocols of disinfection 
afterwards, as infectious patients (passengers) may exude certain pathogens in the vehicle. 
This may leave other people (passengers) including the drivers exposed to the risk of 
contracting infectious diseases.  
This study, inspired by the philosophical underpinning of pragmatism, used the mixed 
method approach to examine and analyze public transport and the spread of infectious 
diseases in the Greater Accra Metropolitan Area (GAMA).  The environmental health 
hazard pathway by Corvalan and Kjellstrom (1995) was adapted and developed as an 
interpretative guide in analyzing the spread of infectious diseases through vehicles. 
Respondents were selected from households and health facilities in the High Income, 
Middle Income, and Low Income areas in GAMA. Respondents also included drivers who 
are dispersed across GAMA. The findings indicate that taxis are mostly used during 
emergency health situations, however drivers do not employ the right cleaning method 
after transporting patients, leaving passengers at risk as most people patronize public 
transport for their mobility. The study reveals that, there is a risk knowledge and awareness 
on public transport and infectious diseases among residents of GAMA, meanwhile both 
the people and authorities have come to live with it as an “acceptable risk” due to the 
ineffectiveness of emergency medical transport system delivery (Ambulance Service) in 
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Ghana. Both short term and long term recommendations were made to help reduce this 
everyday risk while ensuring the effectiveness of the Ghana Ambulance Service (GAS).  
  
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TABLE OF CONTENTS 
DEDICATION ................................................................................................................... i  
DECLARATION .............................................................................................................. ii 
ACKNOWLEDGEMENTS ............................................................................................ iii 
ABSTRACT ...................................................................................................................... v 
ABBREVIATIONS AND ACRONYMS ..................................................................... xiv 
CHAPTER ONE ............................................................................................................... 1 
1.0 GENERAL INTRODUCTION ............................................................................ 1 
1.1 Background of Study .............................................................................................. 1 
1.2 Statement of Problem ............................................................................................. 3 
1.3 Literature Review ................................................................................................... 5 
1.3.1 Emerging infectious diseases ........................................................................... 6 
1.3.2 Notifiable infectious diseases ........................................................................... 7 
1.3.2.1 Cholera ............................................................................................................ 7 
1.3.2.2 Hepatitis .......................................................................................................... 8 
1.3.2.3 Meningitis ........................................................................................................ 8 
1.3.2.4 Tuberculosis .................................................................................................... 8 
1.3.2.5 Typhoid Fever ................................................................................................. 9 
1.3.2.6 Severe Acute Respiratory Syndrome (SARS) .................................................. 9 
1.3.2.7 H1N1 Flu ......................................................................................................... 9 
1.3.2.8 Ebola ............................................................................................................. 10 
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1.3.2.9 Toxoplasmosis ............................................................................................... 11 
1.3.2.10 Measles/Rubella .......................................................................................... 11 
1.3.2.11 Bacillary Dysentery ..................................................................................... 12 
1.3.2.12 Amoebic Dysentery ..................................................................................... 12 
1.3.2.13 Schistosomiasis ........................................................................................... 12 
1.3.2.14 Soil-transmitted Helminthiasis .................................................................... 13 
1.3.3 Risk Perception of Diseases ........................................................................... 13 
1.3.4.1 Spreading Diseases with Transport .............................................................. 14 
1.3.4.2 Transporting Infectious Patients ................................................................... 14 
1.3.4.3 Using Public Transport as Hearse ................................................................ 15 
1.3.4.4 Emergency Medical Service Delivery ........................................................... 16 
1.3.4.5 Effectiveness of Vehicle fumigation .............................................................. 16 
1.3.4.6 Standard Protocols of Vehicle Disinfection .................................................. 17 
1.4 Conceptual Framework ........................................................................................ 19 
1.5 Research Objective .......................................................................................... 23 
1.6 Hypothesis ............................................................................................................. 24 
1.7 Research Questions ............................................................................................... 23 
1.8 Research Design .................................................................................................... 25 
1.8.1 Introduction .................................................................................................... 25 
1.8.2 Target Population .......................................................................................... 26 
1.8.3 Sampling Design for Questionnaire Survey ................................................. 26 
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1.8.4 Qualitative Research Methods ...................................................................... 30 
1.8.4.1 In-depth Key Informant Interviews ............................................................... 30 
1.8.4.2 Focus Group ................................................................................................. 30 
1.8.5 Secondary Source of Data ............................................................................. 32 
1.9 Ethical Considerations ......................................................................................... 33 
1.10 Limitation of Study ............................................................................................. 33 
CHAPTER TWO ............................................................................................................ 34 
2.0 STUDY AREA .......................................................................................................... 34 
2.1 Introduction........................................................................................................... 34 
2.2 Origin of Accra ..................................................................................................... 34 
2.3 Location of Study area ......................................................................................... 36 
2.4 Demographic Dynamics of Study area ............................................................... 37 
2.5 Health Care and Infrastructure in Accra ........................................................... 38 
2.6 Environment and Health in Accra Metropolitan Area ..................................... 38 
2.7 Emergency Medical Transport in Accra ............................................................ 39 
2.8 Summary ............................................................................................................... 39 
CHAPTER THREE ....................................................................................................... 40 
3.0 MAIN TRANSPORT MODE USED DURING EMERGENCY HEALTH 
SITUATIONS ................................................................................................................. 40 
3.1 Introduction........................................................................................................... 40 
3.2 Normality Test ...................................................................................................... 41 
3.3 Socio-Demographic Characteristics of Participants.......................................... 42 
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3.4 Mode of Transport during Emergency Health Situations ................................ 43 
3.4.1 Spatial variation of transport mode during emergency ................................. 45 
3.5 Summary ............................................................................................................... 46 
CHAPTER FOUR .......................................................................................................... 48 
4.0 PROTOCOLS/DISINFECTION PRACTICES EMPLOYED TO PREVENT 
VEHICLE INFECTION ................................................................................................ 48 
4.1 Introduction........................................................................................................... 48 
4.2 Transporting Infectious Patients ......................................................................... 50 
4.3 Standard Protocols of Transporting Infectious Patients and Disinfection ...... 52 
4.4 Effectiveness of emergency transport delivery .................................................. 54 
4.5 Summary ............................................................................................................... 56 
CHAPTER FIVE ............................................................................................................ 58 
5.0 RISK PERCEPTION AND EXPOSURE OF KEY ACTORS IN THE 
CHAIN ............................................................................................................................. 58 
5.1 Introduction........................................................................................................... 58 
5.2 Risk perception of key actors in the chain.......................................................... 58 
5.3 Spatial Variation of risk perception .................................................................... 59 
5.4 Relationship between Risk Perception and Gender/Age/Education/Religion. 61 
5.5 Risk Factor and Exposure of People Involved in Direct Infectious Patient 
Care .............................................................................................................................. 64 
5.6 Summary ............................................................................................................... 67 
CHAPTER SIX ............................................................................................................... 68 
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6.0 SUMMARY, CONCLUSION, RECOMMENDATIONS, AND DIRECTION 
FOR FURTHER STUDIES. .......................................................................................... 68 
6.1 Introduction........................................................................................................... 68 
6.2 Summary of Main Findings ................................................................................. 68 
6.3 Conclusion ............................................................................................................. 69 
6.4 Recommendations ................................................................................................. 70 
6.4.1 Education ......................................................................................................... 70 
6.4.2 Provision of Logistics to Various Health Facilities ......................................... 70 
6.4.3 Law Enforcement ............................................................................................. 71 
6.4.4 Equipping the Ambulance Service ................................................................... 71 
6.4.5 Expansion and demarcation of roads .............................................................. 72 
6.5 Direction for Further Studies .............................................................................. 72 
REFERENCES ............................................................................................................... 73 
APPENDIX 1 .................................................................................................................. 83 
APPENDIX 2 .................................................................................................................. 84 
APPENDIX 3 .................................................................................................................. 85 
APPENDIX 4 .................................................................................................................. 88 
APPENDIX 5 .................................................................................................................. 91 
 
 
  
  
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LIST OF TABLES 
 
Table 1.1Sampling Design for Household Questionnaire Survey ......................... 29 
 
Table 1.2 Sampling Design for Emergency Patients Questionnaire Survey......... 29 
 
Table 1.3 Sampling Design for Drivers Questionnaire Survey .............................. 30 
 
Table 1.4 Sampling Design for Focus Group Discussion ....................................... 32 
 
Table 3.1 Socio-Demographic Characteristics of Participants .............................. 43 
  
Table 3.2 Mode of transport during emergency health situations ........................ 44 
 
Table 4.1 Vehicle Disinfection Practice .................................................................... 49 
 
Table 4.2 Effectiveness of emergency transport delivery? ..................................... 55 
 
Table 5.1 Risk Perception of Key Actors in the Chain. .......................................... 59 
 
Table 5.2 Relationship between Risk Perception and Gender ............................... 62 
 
Table 5.3 Relationship between Risk Perception and Age. .................................... 63 
 
Table 5.4 Relationship between Risk Perception and Education. ......................... 64 
 
Table 5.5 Relationship between Risk Perception and Religion. ............................ 65 
 
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LIST OF FIGURES 
 
Figure 1.1 Environmental Health Hazard Pathway ............................................... 21 
Figure 1.2 Conceptual Framework .......................................................................... 22 
 
Figure 2.1 Study Area Map ....................................................................................... 37 
 
Figure 3.1 Which transport mode will you resort to during emergency? ............ 45 
  
Figure 5.1 Do you think vehicles can spread infectious diseases? ......................... 60 
  
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ABBREVIATIONS AND ACRONYMS 
 
AMA - Accra Metropolitan Assembly 
C D C - Center for Disease and Control 
CSM - Cerebrospinal Meningitis 
EMS - Emergency Medical service 
EVD - Ebola Virus Disease 
GAMA - Greater Accra Metropolitan Area 
GAS - Ghana Ambulance Service 
GPRTU - Ghana Private Road Transport Union 
HDIS - High Density Indigenous Sector 
HDLCS - High Density Low Class Sector 
HIV - Human Immune Virus 
LAS - Landon Ambulance Service 
LDHCS - Low Density High Class Sector 
LDMCS - Low Density Middle Class Sector 
LDNDS - Low Density Newly Developing Sector 
MDIS - Middle Density Indigenous Sector  
MDMCS - Medium Density Middle Class Sector 
MOH - Ministry of Health 
NADMO - National Disaster Management Organization 
PEDV - Porcine Epidemic Diarrhea Virus 
RF - Rural Fringe  
SARS - Severe Acute Respiratory Syndrome 
SOPs - Standard Operating Procedures 
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TB – Tuberculosis 
VP - Vehicle Preparation 
WHO - World Health Organization
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CHAPTER ONE 
1.0 GENERAL INTRODUCTION 
 
1.1 Background of Study 
There are particular health situations that need instant medical attention such that, a delay 
may lead to direct impact on one’s life. Such situations are called emergency situations 
(Kobusingye et al 2006). The World Health Organization (2018) identifies the five most 
common causes of death as ischemic heart disease, stroke, chronic obstructive pulmonary 
disease, lower respiratory infection and Alzheimer diseases and other dementias. Although 
these five most common causes of death did not capture communicable diseases, 
infectious diseases continue to be a danger to all persons, regardless of age, sex, ethnicity, 
and socioeconomic status (Mukherjee, 2017). Globally, infectious diseases play a major 
role in public health. This can be attributed to the fact that most regions in the world are 
yet to reach a level of modernization that is equivalent to the industrialized world status 
(Centers for Disease Control and Prevention, 2001). Pinheiro et al (2009) note that 
developing countries including countries that are in transition still face substantial burden 
posed by infectious diseases on their people’s health. In 2014 for instance, the prevalence 
of cholera affected over 25,000 people in Ghana with Accra metropolis as the epicenter 
(Cottavoz, 2014).  
However the means of transporting victims throughout emergency situations is ideally 
made by ambulances (Mohammed and Prabhu, 2015). According to Kobusingye et al. 
(2006), emergency transportation must be reachable within the shortest possible time 
proposing ambulance services as the best means. The ambulance services ought to have 
the apparatus, expertise and skilled staff in emergency intervention in different disaster 
settings (Gaston, 2013). This implies that the ambulance services basically are supposed 
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to provide a 24-hour response to health related emergencies and interventions. Ambulance 
could be a vehicle or an aircraft which is specially designed for transporting sick or injured 
people to or from medical facilities, or between medical facilities by land or air. Although 
ambulances play a critical role in emergency healthcare delivery, these services are 
undermined by many challenges in most developing countries including Ghana (Adamtey, 
2015). These challenges include insufficient resources in terms of vehicles (the ambulance 
itself), limited staff and equipment, poor communication network, amongst others. 
Consequently, the private sector is now a key stakeholder in providing rapid emergency 
response services to supplement the efforts of the ambulance service (Norman et. al., 
2007). In Ghana for instance, public and private transport have become the most 
convenient mode of transportation during emergency situations considering the challenges 
of the ambulance service. An evidence is the 70-year old man under trauma who was 
transported in his private vehicle to various hospitals in Accra but died as a result of 
unavailability of beds in the hospitals (Welsing, 2018).  In fact, motor bikes (Okada) have 
been a source of mobility in northern Ghana (Oteng-Ababio and Agyemang, 2012) where 
even sick and pregnant women rely on during emergencies (Atuoye et al, 2015). 
It is important to know that, infectious passengers and patients may cough, vomit, urinate 
or otherwise exude opportunistic and pathogenic microorganism into the vehicle in the 
process of transportation. Meanwhile it is possible for other passengers to absorb these 
microorganisms. There are also instances where infectious patients in the case of 
emergencies may die in the vehicle before arriving at the hospital. In Ghana most 
especially in the rural areas, people who die in their homes are usually conveyed to the 
mortuary via taxis or personal vehicles of relatives (Agyemang, 2014). Agyemang (2014) 
also found that some families even transport their deceased relatives from the mortuary 
for burial with taxis due to their inability to afford ambulance services. It is however not 
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certain that these vehicles are fumigated or disinfected with respect to standard protocols 
after delivering these services.  
As a matter of fact, most households and individuals in Ghana do not possess personal 
vehicles, thereby necessitating their reliance on public transportation such as taxis, buses, 
and vans (trotro). This is an indication that, the public most especially those who rely on 
public transport services including the service providers (drivers and conductors) are 
exposed to the risk of infectious disease transmission. 
 
1.2 Statement of Problem 
The Ministry of Health (MOH) in 2014 procured a number of new ambulances to augment 
the fleet of ambulances for the Ghana National Ambulance Service aimed at ensuring the 
establishment of an effective Emergency Medical Service and improved health care. 
Today, Emergency Health Service is on the verge of collapse as majority of the procured 
ambulances are grounded with just nine functioning in the entire Greater Accra region 
(Tawiah, 2017). This suggests that pre-hospital emergency care provided by the 
ambulance service is absent for mostly trauma victims. As a result, public transport 
continues to be the most preferable mode of transportation during emergencies with its 
own implications; as it is not certain whether the vehicles undergo the standard protocols 
of fumigation or disinfection afterwards.  
It is gratifying to know that, the worrying phenomenon of infectious diseases and their 
spread globally has led to various works by different researchers: 
Mohamed and Prabhu (2015) for instance relied on existing literature review which 
indicate a higher tendency of microbial load, in selecting three areas of ten ambulances 
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for specimen collection. The areas included: the stretcher handles, the meter knob of the 
oxygen flow, as well as interior handle of the rear door of the ambulances. Samples were 
collected before and after fumigation and specimens from all ten ambulances gave similar 
results. The study revealed that ambulances can perhaps be a possible source of diverse 
pathogenic microbes considering their role in transporting infectious patients. This creates 
a situation in which the patients, medical staff and relations of the patients may perhaps 
be exposed to several pathogens, which might cause diseases. 
Lowe et al (2014) also assessed the risks associated with transport vehicles in facilitating 
the eruption of novel disease organisms, by estimating the incidence of trailer pollution 
with Porcine Epidemic Diarrhoea Virus (PEDV) during the unloading process at harvest 
sites in the United States (US). They collected environmental samples from a number of 
livestock trailers at different harvest sites before and after pigs were unloaded. The study 
shows that collection points including harvest sites and livestock sale places, can be a 
source of infection of vehicles that revisit pig farms and could fast spread PEDV across 
large geographical areas after PEDV was first seen in US. 
Adamtey et al (2015) used in-depth qualitative interviews to explore the benefits of 
planning a reliable and active ambulance and emergency service towards healthcare 
delivery at the district level in Ghana. The study concluded that, the emergency service 
system in Ghana is ineffective and inefficient due to poor planning. 
All these studies amongst others indicate that the actual role public transport plays in 
transmitting communicable diseases has not been adequately dealt with. Mohamed and 
Prabhu (2015) narrowed the possible spread of diseases to only ambulances leaving other 
means of transport. Lowe et al (2014) also emphasized mainly on trailers meant for 
transporting pigs, while Adamtey et al (2015) focused on only emergency transport 
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delivery ignoring its role in spreading infectious diseases. Meanwhile in the field of social 
science, the focus and interest is not to test samples in laboratories, but rather on risk 
perception and risk knowledge of populations. 
As a result, there is little geographical means of analyzing risk perception and knowledge 
awareness on how public transport (vehicles) transmit infectious diseases. 
It is important to also know that, cases of infectious diseases in Ghana have seen 
fluctuations since the year 1970 (Opare et al., 2012), with the Greater Accra Metropolitan 
Area (GAMA) recording the highest cases. Gyimah (2017) for instance affirms that, 
GAMA consisted of 59.4% out of the 98.7% cholera cases recorded in the Greater Accra 
Region in the year 2014. 
This therefore calls for a study into public transport and the spread of infectious diseases 
in GAMA not only to fill the knowledge gap, but also help address the everyday risk 
associated with public transportation and infectious patient care, while ensuring the 
establishment of an effective Emergency Medical Service in Ghana.  
 
1.3 Literature Review  
Literature review involves a critical synthesis of already existing research information on 
a particular subject matter under study (Yaro, 2010; Bolderston, 2008; Ramdhani, A., 
Ramdhani, M. A., and Amin, A. S., 2014). In other words, literature review seeks to 
present the state of knowledge and theory on the set of issues examined. This section 
explores existing works on emerging infectious diseases, notifiable infectious diseases, 
risk perception of diseases, spreading diseases with transport, transporting infectious 
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patients, using public transport as hearse, emergency medical service delivery, and 
effectiveness of vehicle fumigation and the standard protocols of vehicle disinfection. 
 
1.3.1 Emerging infectious diseases 
Emerging infectious diseases are diseases that have occurred and affected people for the 
first time, or diseases that have existed earlier but are however increasing in terms of new 
cases or diffusing to new areas (Mukherjee, 2017). They also include infectious diseases 
that have affected a geographical area in the past and has declined within time or 
controlled, but again resurfaced. According to Mukherjee (2017), some old diseases 
reappear in new forms that may usually be severe or deadly. Example is the 2014 outbreak 
of the Ebola disease in West Africa. These are known as re-emerging diseases. 
Mukherjee (2017) notes that most of the emerging infectious diseases are caused by 
pathogens that are already present in the environment unnoticed. They tend to emerge 
when provided with favorable conditions and infect a new host. On rare instances, some 
of them evolve into a new variant and cause a new disease.  
According to the World Health Organization (2009), people traveling could be exposed to 
numerous infectious diseases depending on the presence of infectious agents in the visiting 
area. However the possibility of being infected will differ based on the purpose of the trip 
and the travel plan within the area, including the accommodation standards, sanitation and 
hygiene, as well as the conduct of the traveler (WHO 2010). 
 
  
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1.3.2 Notifiable infectious diseases 
Studies have shown that the control of infectious diseases is more complex than earlier 
perceived (WHO, 2012). The epidemiology of communicable disease is varying as new 
infectious diseases are emerging, while old infectious diseases are re-emerging (Bloom, 
Black, and Rappuoli, 2017). According to the Ghana Health Service (2017), notifiable 
infectious diseases in Ghana of which cases are reported include: HIV, Hepatitis, Syphilis, 
Toxoplasmosis, Measles/ Rubella, Yellow Fever, Dengue, Cholera, Bacillary Dysentery, 
Meningitis, Malaria, Amoebic Dysentery, Onchocerciasi, Lymphatic Filariasis, 
Schistosomiasis, Helminthiasis, Tuberculosis, and Buruli Ulcer. However Meningitis, 
Tuberculosis, Toxoplasmosis, Measles/Rubella, Bacillary Dysentery, Amoebic Dysentery, 
Schistosomiasis, Soil-transmitted Helminthiasis among the above mentioned diseases are 
the ones that are contagious and can spread through transport (WHO, 2012). It is also 
important to know that Typhoid Fever, Severe Acute Respiratory Syndrome (SARS), 
H1N1 Flu, and Ebola are also notifiable infectious diseases globally (WHO, 2012). 
Although Ebola in not a reported case in Ghana, it is a threat to public health (Ghana 
Health Service, 2015). 
 
1.3.2.1 Cholera  
Cholera is mainly spread through contaminated diet or water, and also through person-to-
person contact via the faecal-oral way. Environmental sanitation plays a crucial role in the 
contraction of Cholera since the bacterium lives and grows outside the body, and can 
quickly spread in crowded living environments (World Health, Organization, 2000).  
Cholera remains a key public health problem in Ghana especially, among the poor and 
vulnerable populations (Opare et al 2012).  Poor personal hygiene, lack of potable drinking 
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water, poor sanitation and open defecation are some of the root causes of cholera epidemic 
(Dzotsi et al 2014). 
 
1.3.2.2 Hepatitis 
Hepatitis B Virus contagion is a key public health problem worldwide as over 300 million 
people get infected annually, out of which 600,000 deaths are recorded (Ikobah et al, 
2016).  According to Ikobah et al (2016), Hepatitis B has a high prevalence in sub-Saharan 
Africa and East Asia as majority of the populace in these regions get infected during 
childhood, and up to about 10% of the adult population are constantly infected. 
1.3.2.3 Meningitis 
Cerebrospinal Meningitis (CSM) is characterized by inflammation of the protective 
membranes covering the brain and spinal cord known as the meninges, which give rise to 
multifaceted forms of symptoms including severe headache, rapid onset of fever, stiff 
neck, tenderness of the back, permanent damage to the brain and eventually death (Welch, 
& Nadel, 2003; MOH, 2010). The incidence of CSM, as it demonstrates itself in spatial 
and temporal patterns can be accredited to a constellation of factors (Apwah, 2013). These 
factors include the characteristics of the infecting organism, the opposition of the host, and 
the environment (Sultan et al., 2005).  According to Apwah (2013), most cases of 
meningitis is as a result of infections that are contagious. The germs regularly spread from 
person-to-person in minute drops of liquid from the throat and nose of an infected person. 
 
1.3.2.4 Tuberculosis 
Tuberculosis (TB) is caused by Mycobacterium Tuberculosis, and it is a prominent cause 
of mortality globally (Brooks et al., 2011). Usually, young adults in their most productive 
years get affected (WHO Fact Sheet 104, 2011). 700,000 women die from TB every year 
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globally (Marais, et al., 2010). Studies have shown that areas with higher incidence of TB 
are characterized with worsening housing conditions, crowding and high population 
densities which increase their risk to TB infection (Mangtani et al, 1995, Bhatti et al, 
1995). 
 
1.3.2.5 Typhoid Fever  
Typhoid Fever has been a major problem of public health in many developing countries 
including Ghana (Malisa and Nyaki, 2010). Globally, Typhoid fever has played an 
important role in morbidity and mortality, with about 12 to 33 million cases leading to 
between 216,000 and 600,000 annual loss of lives (Pang et al, 1995, DeRoeck, 2007). One 
can catch Typhoid fever through faecal-oral route via contaminated drinking water and 
food (Butter, 1992). 
 
1.3.2.6 Severe Acute Respiratory Syndrome (SARS) 
SARS is the new transmissible disease to appear in the 21st Century (Lau et al., 2004). 
SARS coronavirus is largely transmitted in droplets from the respiratory discharges of 
infectious people (Kamps and Hoffmann, 2003). As a matter of fact, the majority of new 
infections transpired in close contacts of patients with relations, healthcare workers which 
indicates that the virus is mostly spread through direct and indirect contact (Lau et al., 
2004). 
 
1.3.2.7 H1N1 Flu 
H1N1 influenza (Swine Influenza or Swine Flu) is a respiratory disease among pigs, 
caused by type ‘A’ influenza virus that frequently causes epidemics in pigs (Center for 
Disease Control, 2009). In 2009, human cases of pandemic influenza H1N1 had been 
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confirmed in over 214 countries with more than 18,449 mortalities (WHO, 2009), while 
in Africa alone, 35 countries officially reported 18,598 human cases and 168 deaths. 
(Ghana Health Service, 2010).  People are most likely to be infected if they are in close 
contact to infected pigs (CDC, 2009). According to the US Center for Disease Control 
(2009), one can contract swine flu from an infected person through coughing or sneezing, 
or when one touches an infected object and afterwards touches his or her mouth or nose. 
 
1.3.2.8 Ebola 
According to the World Health Organization (2014), “Ebola is a destructive pathogen that 
causes hemorrhagic fever syndrome in both humans and nonhuman primates, known as 
Ebola Virus Disease (EVD)”. Ebola is spread among populations through close contact 
with blood, secretions and other fluids of infected animals (WHO, 2014). Ebola however 
spreads in societies as a result of human-to-human diffusion through direct contact, such 
as contact between skin and mucous membranes like mouth, lips, genitals, and nostrils; 
with fluids from an infected individual (WHO, 2014 Fact Sheet). It is important to note 
that Ebola can also be contracted by indirect contact with items or things polluted by the 
virus (WHO Fact Sheet, 2014). When Ebola virus was detected in a medical student in 
Guinea, all intensive efforts to trace the roommate’s visitor and his relatives proved futile. 
Subsequently, the roommate’s visitor also contracted the virus, visited various doctors and 
health facilities by means of about 12 taxis, and transferred the virus to four different 
people including his cousin, his mother, a taxi driver, and another person (WHO, 
Morbidity and Mortality Weekly Report, 2015). The EVD caused a number of cases and 
deaths among healthcare workers as they were providing injection, placing intravascular 
device, providing medication, and emptying bed pans (Shannon, 2016), including Dr. 
Stella Ameyo Adadevoh, the Ghanaian doctor, who prevented the spread of Ebola and 
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paid with her life in Nigeria. This made it challenging for the World Health Organization 
to recruit adequate number of medical practitioners to work in areas highly affected by the 
outbreak. (WHO, 2015) 
 
1.3.2.9 Toxoplasmosis 
“Toxoplasmosis is a zoonotic disease caused by the protozoon Toxoplasma Gondii” 
(CDC, 2010). The distribution of postnatal infection varies worldwide due to 
environmental, socioeconomic, and cultural factors (Munoz Zanzi et al 2010). Postnatal 
infection is triggered by consumption of undercooked meat which contains tissue cysts, 
water, fruits, vegetables, and shellfish soiled with Oocytes (Jones et al 2009, De Moura et 
al 2006). Humans can become infected by direct contact with contaminated environmental 
samples (WHO, 2015).  
 
1.3.2.10 Measles/Rubella 
Measles is one of the most transmissible but vaccine-preventable diseases which is caused 
by the measles virus (Gyasi-Agyei, 2012). Measles is among the major infectious and 
severe ailments of childhood and plays a vital role in public health in developing countries 
(Levin et al, 2011). The World Health Organization (2011) reveals that in the year 2008, 
164,000 measles related mortalities were testified globally with almost 450 deaths daily 
or 18 deaths per hour. Over 95% mortalities take place in low-income nations with poor 
and inadequate health infrastructure (Gyasi-Agyei, 2012). Measles is diffused by the 
respiratory route and is highly infectious. This virus is found in droplets from the nose and 
mouth when an infectious person coughs or sneezes. One can contract measles by inhaling 
these droplets or by touching the object contaminated by the droplets, and then touching 
the mouth or nose with the hand. People carry the measles virus in their respiratory tract 
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before getting sick, which implies that they can transmit the virus unaware (Nettleman, 
2008). 
 
1.3.2.11 Bacillary Dysentery 
Bacillary Dysentery is caused by bacteria of the genus Shigella (Chang et al, 2016). 
Bacillary Dysentery is a major public health challenge in the developing world (Chang et 
al, 2016). Transmission is basically by the fecal oral route through polluted food and water, 
or person-to-person exchange. Annually, 1.1 million people die of bacillary dysentery out 
of 165 million cases globally, which mostly affect developing countries (Kotloff et al 
1999). 
 
1.3.2.12 Amoebic Dysentery 
“Amoebic dysentery is caused by the protozoan parasite Entamoeba histolytica, and it is 
transmitted in areas where poor sanitation allows contamination of drinking water and 
food with faeces” (WHO, 1997). Up to about 40% of diarrhoea cases in poor sanitation 
areas may have amoebic dysentery (Marie and Petri, 2013). Amoebic dysentery can spread 
from person to person, for example if someone doesn't wash his or her hands after visiting 
the toilet, and exchange hand shake or an object, or when you touch a contaminated object, 
amoebas could pass into your mouth when you eat without proper hand washing (WHO, 
1997). 
 
1.3.2.13 Schistosomiasis 
“Schistosomiasis, also known as Bilharziasis is caused by snail transmitted parasites of 
the genus Schistosoma that dwell in the human vasculature” (WHO 2011, Lier et al 2009). 
Globally, it is one of the most significant parasitic sicknesses, with a substantial socio-
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economic influence (WHO, 2011). Annually, over 200 million people get infected with 
the disease, out of which nearly 200,000 people may die. Globally, one out of thirty 
individuals has schistosomiasis (Chitsulo et al, 2004). About 779 million people with 
schistosomiasis live in the Middle East, South America, Caribbean, Southeast Asia and 
predominantly sub-Saharan Africa areas (Chitsulo et al, 2004). Risk factors of 
schistosomiasis include: extreme poverty, ignorance, inadequate or lack of public health 
infrastructure, and the unhygienic conditions in which people live. (Fenwick et al, 2003). 
 
1.3.2.14 Soil-transmitted Helminthiasis 
Soil-transmitted Helminths (STH) affect close to 2 billion people worldwide with children 
being the most vulnerable people (Montresor et al, 2013). An estimate of 870 million 
children are found in areas with high prevalence of Soil-transmitted Helminths. The most 
affected regions globally include: Africa, South Asia and South America (Lobo et al, 
2011). However STH infections seldom lead to death with diarrhoea, abdominal pain and 
low hemoglobin levels as the direct consequence of infections (Bethony et al, 2006). The 
long run impact of these infections are very dangerous since infected people exhibit 
reduced cognitive abilities and intellectual capacity, and low working productivity 
(Bethony et al, 2006). The prevalence and control of STH infections is associated with 
quality of water, cleanliness and socio-economic status in the affected zones (Strunz et al, 
2014). 
 
1.3.3 Risk Perception of Diseases 
Studies have shown that the socio-cultural orientation of a people could also inform their 
overall perception on the incidence of diseases and management efforts (Furnham et al., 
1999; Green, 1999; Madge, 1998). This means that, some people perceive the prevalence 
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of various health problems based on their religious, traditional, and cultural orientation. 
As a result, they may resort to ethno-medical methodologies to healthcare such as ritual 
cleansing and folk remedies (Apwah, 2013). Agyemang (2014) for instance indicates that 
some drivers who use their taxis as hearse buy bottles of schnapp and a fowl to perform 
ritual to cleanse the vehicle of any bad luck instead of fumigation. This therefore suggest 
the extent of risk exposure of both driver and passengers of that particular taxi, which is a 
clear indication of how cultural practices and believe can negatively influence risk 
perception (see Mase, Gramig, and Prokopy, 2017; Rimal and Juon, 2010; Bempah and 
Oyhus, 2017; Yoo, Kim, and Lee, 2018; Apwah, 2013) 
 
1.3.4.1 Spreading Diseases with Transport 
Transportation is a potential source of spreading infectious diseases if satisfactory hygiene 
measures are not considered (Lowe et al, 2014). According to Lowe et al (2014), the rapid 
spread of Porcine Epidemic Diarrhoea Virus Infection among pigs was as a result of how 
pigs were transported in vehicles that have not been cleaned and disinfected.  
This implies that transportation from one region to another is seen as a major factor which 
affects the outburst of infectious diseases (Cui et al, 2006). Therefore it is very crucial to 
toughen restrictions on passengers the minute an infectious disease pops up. 
 
1.3.4.2 Transporting Infectious Patients 
The Public Health Act 851 of Ghana is an act aimed at consolidating the public health 
laws to prevent and sustain diseases in order to protect the health of individuals and 
animals. It was passed by Parliament of Ghana and approved by the President of Ghana 
on the 9th of October, 2012. 
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According to the Act, an infectious patient, or a corpse suspected to be capable of diffusing 
infections may be taken out from the vehicle and detained until a health officer defines the 
person to be safe (Public Health Act, 2012). According to the Public Health Act (2012), 
recalcitrant drivers who fail to comply in such situations commits an offence and can be 
convicted or fined. 
The Director General of the Ghana Health Service (GHS) in March 2018 instructed health 
facilities not to refer Lassa fever patients to other health facilities to prevent spread of the 
disease (Tetteh, 2018). According to the director general of the Ghana Health Service, 
when patients are transported from one medical facility to another by commercial vehicles, 
the disease will spread as most commercial vehicles are not disinfected after transporting 
patients (Glover, 2018). This directive from the director general however will only get to 
health facilities and not commercial vehicle drivers due to the channel (newspaper) 
through which the directive came. Most drivers especially those far away from the cities 
may not get the opportunity to access the dailies. 
 
1.3.4.3 Using Public Transport as Hearse 
According to Agyemang (2014), taxis are used as hearse in some parts of Ghana. In 2014, 
Agyemang was right at the mortuary when a family brought in a deceased wrapped in a 
white bedspread in a Hyundai taxicab. Kwame Antwi (the deceased) who was 36 years 
died at a prayer camp at Edumfa in the Central Region. When he passed away, his family 
did not have the means to hire a hearse to convey his body from the Centre (Prayer Camp) 
to the mortuary. When the taxi driver was asked what steps he would take to ensure the 
safety of passengers who may board his taxi cab afterwards, he swore he wouldn’t `pick 
any passenger again because he had made a sale of GH¢170 and has closed for the day.  
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1.3.4.4 Emergency Medical Service Delivery 
Globally, the demand for Emergency Medical Services (EMS) in on the rise. According 
to Page et al (2013), EMS are grouped into two key models worldwide: the German-
Franco Model, where an ambulance is manned by physicians, and the Anglo-American 
Model, in which an ambulance is manned by Emergency Medical Technicians. Both 
German and American Models, make use of contemporary techniques and machineries to 
decrease medical uncertainties in order to achieve the utmost possible quality pre-hospital 
care (Page et al, 2013). Many countries around the world are using these ideas, however a 
lot of countries especially in the developing world, compromise on safety due to limited 
budgets and the size of available infrastructure. According to Page et al (2013), the 
deficiency of trained pre-hospital providers, modern apparatus and ambulance vehicles for 
instance has also led to poor quality emergency medical services. 
 
1.3.4.5 Effectiveness of Vehicle fumigation 
Studies made by Mohamed and Prabhu on microbiological spectrum in ambulances has 
revealed that there are high contamination rates with Staphylococcus and Pseudomonas 
(Mohamed and Prabhu. 2015). Their research identified shortfalls in the process of 
cleaning. These shortfalls comprised lack of designated cleaning apparatus, inadequate 
period for effective cleaning, and the lack of appropriate disinfection procedures for 
medical apparatus, which exposes both patients and those involved in direct patient care 
to variation of risk. Though saving the lives of patients in emergency situations is crucial, 
the hygienic safety of victims and ambulance staff are likewise significant.  
 
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1.3.4.6 Standard Protocols of Vehicle Disinfection 
According to the London Ambulance Service (LAS), cleaning procedures should be 
carried out as soon as possible after a patient has been conveyed and handed over. Below 
are vehicle cleaning procedures and methods used by the London Ambulance Service 
(LAS). 
Universal wipes are used to clean inner surfaces and patient contact surfaces of vehicle 
and subjected to air dry after every trip. Sporicidial wipes are also used to clean patient 
contact surfaces and equipments after transferring diahroea patients or vomiting patients. 
Sporicidial wipes enables LAS to disinfect body fluid discharges or any discharge with 
Sporicidal danger. In instances of large discharge of fluids like urine, vomit, or blood, spill 
wipes are used for decontamination. Antibak powder which is a high level of disinfectant  
is however used to clean and disinfect larger surfaces and vehicle floors. 
According to the Vehicle Cleaning Procedure manual (Ref. OP075) of LAS, cleaning 
procedures are grouped into four: Between Patient clean, Vehicle Preparation (VP) 
Contractor Nightly Clean and re-stock, Vehicle Preparation (VP) Contractor 6-weekly 
Deep Clean, and Unscheduled Deep Clean (Ad-hoc clean following significant 
contamination). 
Between Patient clean is done between each patient transference. It involves the cleaning 
of surfaces and medical apparatus which have been used in the treatment of patients and 
releases of body fluids as well as the safe dumping of disposable materials.  
Meanwhile, Vehicle Preparation (VP) Contractor Nightly Clean and re-stock is a 
systematic cleaning of defined areas of the vehicle, before re-stocking. This cleaning type 
focuses on flat surfaces and areas of the vehicle which are regularly touched. 
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The Vehicle Preparation (VP) Contractor 6-weekly Deep Clean is a method where 
ambulances are arranged for Deep Clean every six-weeks by Vehicle Preparation 
Operatives. This type of cleaning is aimed at ensuring that an ambulance is expansively 
cleaned at regular intervals. This is an in-depth cleaning of the ambulance, after all 
consumable items and medical apparatus have been unloaded. The ambulance is thereafter 
fumigated using moist heat or vapour. 
Moreover, Deep Clean (Ad-hoc clean following significant contamination) method is 
employed based on risk assessment of contamination, the vehicle may be taken off road 
anytime for emergency deep cleaning to be done, despite the regular cleaning routine.  
In the case of the Ghana Health Service (GHS) and Ministry of Health (MOH), the 
standard protocols for vehicle disinfection is guided by the second edition of “Standard 
Operating Procedures (SOPs) for the Prevention and Control of Cholera 2016”. It is 
important to know that the SOPs 2016 is cholera specific, but it applies to all related 
infectious diseases in Ghana. The SOPs 2016 outlines that seats must be covered with 
impermeable materials such as rubber that can easily be disinfected or destroyed (Ministry 
of Health, 2016). It further states that the receiving health facility should perform or 
supervise appropriate decontamination, cleaning and disinfection of the vehicle with 2% 
chlorine solution under the supervision of Disease Control Officers at various health 
facilities. 
 
  
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1.4 Conceptual Framework 
A conceptual framework provides a broad and pictorial understanding of the phenomena 
of interest, the assumptions and the philosophical views of the study (Polit and Beck, 
2004). The main focus of this study is to investigate the role of public transport in the 
spread of infectious diseases in the Greater Accra Metropolitan Area (GAMA). The 
interactions between land use and transportation system are characterized by causal 
relationships through series of forward and backward linkages as well as feedback 
mechanisms, as noted in the literature (Van Acker & Witlox, 2005; Wegener & Furst, 
1999). GAMA’s population is exposed to hazardous pollutants through a range of diverse 
pathways (Songsore, Nabila, Yangyuoru, Amuah, Bosque-Hamilton, Etsibah, Gustafsson, 
Jacks, 2001). This necessitated the adoption of the Environmental Health Hazard Pathway 
(Corvalan and Kjellstrom, 1995) considering the fact that, exposure may occur when 
individuals meet the pollutants in their surroundings or environment (Songsore et al., 
2005). The Environmental Health Hazard Pathway is originally noted for estimating 
pollution (air, water, food, and soil) and its environmental effects. According to the 
Environmental Health Hazards Pathway, the relationship between the environment and 
health functions through the exposure of individuals to environmental hazards as 
illustrated in Figure 1.1.  According to Crvalan and Kjellstrom (1995), these hazards may 
take various forms such that some are originated from natural phenomenon whereas the 
majority originate from human activities and interferences. In all circumstances, health 
consequences only arise if individuals are exposed, usually at a particular place and time, 
to the existing hazards (see Figure 1.1). 
However, the researcher modified the framework to suit the phenomenon (Public 
Transport and the Spread of Infectious Diseases) under study. Therefore, the study 
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narrowed the pathway’s “Hazard” and “Environmental Concentration” components to 
infectious patient and vehicle respectively. 
The framework starts from the point (hazard) where infectious patients may cough, vomit, 
urinate, or otherwise exude opportunistic and pathogenic microorganism in the vehicle 
(emission). The presence of these pathogens and microorganisms in the vehicle 
(environmental concentration) is then exposed. Persons that come into contact with the 
environment thereafter absorbs these pathogens and microbes (exposure) which will 
consequently lead to morbidity and death (health effect). Figure 1.2 illustrates the 
framework. 
This model however usually require the use of bio-markers and technologies that are costly 
which overshadows the gains particularly in developing countries like Ghana, where 
multiple and interrelated risks are usually pervasive (Songsore et al., 2005). 
  
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Figure 1.1 Environmental Health Hazard Pathway 
Source activities 
Industry         Transport       Domestic           Waste           Agriculture 
 and energy                              activities       management 
 
    
Emission 
 
Environmental Concentration 
             Air                       Water                    Food                        Soil 
 
 
Human distribution 
And activities 
 
 
 
Exposure 
External exposure 
 
 
Dose 
 
 
Health effects 
Early/Subclinical 
 
Moderate/Clinical 
 
Advance/Permanent 
 
 
Source: Corvalán and Kjellström (1995). Health and Environment Analysis for 
Decision Making.   
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Figure 1.2 Conceptual Framework  
 
 HAZARDS 
 Infectious Patient, Cough, Vomit, Urine, and 
Exude of pathogenic microorganism 
 
 
 EMISSION 
 
 
            ENVIRONMENTAL CONCENTRATION 
                             Vehicle                                                 Air                   
 
            EXPOSURE 
External Exposure 
 
Absorption 
 
 
 
Target Organ 
 
 
            HEALTH EFFECTS 
Subclinical Effects 
 
   
  Morbidity 
 
 
 Mortality 
 
Source: Author’s Construct (2018). Adapted with inspiration from Corvalán and 
Kjellström (1995). 
 
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1.5 Research Objectives 
The main aim of this study was to examine the role of public transport in the spread of 
infectious diseases in Greater Accra Metropolitan Area (GAMA). 
The specific objectives included the following: 
a) Assess the main transport modes used during emergency situations. 
b) Examine the protocols employed to prevent vehicle infection. 
c) Analyze risk factor and exposure of people involved in infectious patient care. 
d) Discuss the relationship between risk perception and socioeconomic 
characteristics among the key actors in the chain. 
e) Analyze the effectiveness of medical emergency delivery system in addressing 
these issues. 
 
1.6 Research Questions 
The research questions were as follows: 
1. Which mode of transport is mostly used during emergency health situations? 
2. Which protocols are employed to ensure vehicles are disinfected after delivering 
the service? 
3. Are the people involved in delivering emergency services exposed to risk? 
4. What is the relationship between risk perception and the socioeconomic 
characteristics among the key actors in the chain with respect to infection in 
transport systems? 
5. How effective is the emergency medical delivery system in Ghana? 
 
 
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1.7 Proposition 
a) Public transport does not provide emergency health delivery service. 
b) Public transport provides emergency health delivery service. 
 
1.8 Hypothesis 
Null Hypothesis (H0): There is no significant relationship between demographics 
(gender, age, education, and religion) and perceived risk that public transport can 
spread infectious diseases. 
Alternate Hypothesis (H1): There is a significant relationship between 
demographics (gender, age, education, and religion) and perceived risk that public 
transport can spread infectious disease. 
 
  
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1.8 Research Design 
1.8.1 Introduction 
Research design involves the planned ways and principles of doing a work. There are two 
main approaches to social research. These are quantitative and qualitative approaches. The 
quantitative approach is a formal, objective, systematic process in which numerical data 
are utilized to obtain information while the qualitative approach involves the generation 
of data in the form of words, images, impressions, gestures, or tones which represents real 
events (Yaro, 2010). This study employed both approaches (i.e. the Mixed Method). This 
was because given the merits and demerits of qualitative and quantitative methods, both 
approaches complement each other in terms of validity and authenticity (Teye, 2012). 
Moreover, inspired by the philosophical underpinning of pragmatism, the researcher had 
the opportunity to choose from both quantitative and qualitative approaches without 
restrictions (Creswell, 2014). Pragmatists claim that researchers must stress on the 
research problem and adopt multiple approaches to develop knowledge about the problem 
as cited in Agyemang (2015). This is because, there is no sole point of view that can ever 
give the perfect picture since there may perhaps be several realities (Saunders, Lewis, and 
Thornhill, 2007). Hence, the adoption of the mixed methods research approach in this 
study is vindicated, considering the fact that it provided the avenue to the researcher to tap 
into the strengths of both qualitative and quantitative research approaches.  
The study employed a cross- sectional survey design because cross-sectional survey is 
good for determining variation, patterns of associations, and indicate causation by 
examining relationships between variables (Mayoux, 2006). 
In-depth key informant interviews and focus group discussions were also employed. In-
depth key informant interviews and focus group discussions allowed for face- to- face 
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contact with the respondents and consequently provided in- depth data, while 
questionnaires also saved time of both the researcher and respondents (Bryman, 2016). 
Below are various components of research methodology that was applied. 
 
1.8.2 Target Population 
Data was collected at the same time (concurrently) within a short time frame from a large 
number of public transport drivers, ambulance drivers, and passengers/households who 
are dispersed across Greater Accra Metropolitan Area (GAMA). GAMA is a 
conceptualized area within the Greater Accra region of Ghana in earlier studies (Oteng-
Ababio, Melara Arguello & Gabbay, 2013; Yankson, Kofie & Moller-Jensen, 2005) as 
illustrated in Chapter 2.3.   
Stakeholder institutions like the Ghana Health Service, Ministry of Health, National 
Disaster Management Organization (NADMO), Ghana National Public Health, Ghana 
Red Cross Society, Environmental Health Department (AMA) and the Ghana Ambulance 
Service were also targeted. 
 
1.8.3 Sampling Design for Questionnaire Survey 
According to Songsore (2017), GAMA’s residential areas are classified into low income, 
middle income and a high income areas. The low income areas include the High Density 
Low Class Sector (HDLCS), High Density Indigenous Sector (HDIS), Middle Density 
Indigenous Sector (MDIS), and Rural Fringe (RF) (Songsore et al 2009). The middle 
income areas also includes the combination of the Medium Density Middle Class Sector 
(MDMCS) and the Low Density Middle Class Sector (LDMCS) while the high income 
areas also combine the Low Density High Class Sector (LDHCS) and the Low Density 
Newly Developing Sector (LDNDS), (Songsore et al 2009) (see figure 1.2). This study 
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therefore based on this classification in selecting the communities which include La, 
Nima, Darkuman, Abokobi (low income areas), Kaneshie, Hatso (middle income areas), 
Airport Residential Area, and Frafraha (high income areas) for the household survey.  
Figure 1.2 Classification of Residential Areas in the Greater Accra Metropolitan 
Area (GAMA). 
Source: Songsore et al (2009). Environmental Health Watch and Disaster Monitoring 
in the Greater Accra Metropolitan Area (GAMA), 2005. 
 
A total of 320 questionnaires were distributed. Out of the 320 questionnaires, 180 were 
distributed to households based on the classification of residential areas in the GAMA 
(Songsore et al, 2009), to appreciate the spatial variation of risk knowledge awareness 
based on class and income status. One community under each residential stratum was 
randomly selected for this survey. The study employed a systematic random sampling 
procedure, where household questionnaires were administered to one household member 
of every fifth house starting from a randomly selected household in each residential area. 
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The researcher based on the classification of residential areas in the Greater accra 
Metropolitan Area (Songsore et al, 2009) in selecting the residential locations for the 
study. This was aimed at appreciating the spatial variation of the problem under study. 
The apportioning of the questionnaires was based on the 2010 population census by the 
Ghana Statistical Service.  However, the apportioning in Abokobi, Hatso, Airport 
Residential Area, and Frafraha village base on the 2010 population census was minimal 
and could not have represented the views of residents in those areas. Therefore the 
apportioning was adjusted by reducing the numbers of La, Nima, Darkuman, and Kaneshie 
by 15% and were added to that of Abokobi, Hatso, Airport Residential Area, and Frafraha 
to raise the value of their apportioning for fair representation of views.  
Eighty questionnaires were also distributed randomly to drivers who are dispersed across 
GAMA, while sixty questionnaires were allocated to in-patients. All sixty questionnaires 
were administered to in-patients because the researcher’s interest was emergency 
situations but not on out-patients. Out of the 60 questionnaires allocated for in-patients, 
twenty were allocated to in-patients of one of the health facilities located in the low income 
areas (La Polyclinic Hospital), another set of twenty were administered to in-patients in a 
health facility located in the middle income areas (Cocoa Clinic), and then the remaining 
twenty were for in-patients in a health facility located in the high income areas in GAMA 
(Nyaho Medical Centre). Tables 1.1, 1.2, and 1.3 shows how the questionnaires were 
allocated. 
  
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Table 1.1Sampling Design for Household Questionnaire Survey 
 
STRATUM POPULATION SAMPLE SHARE SAMPLE SIZE ADJUST-
MENT 
( Songsore et al, 2009) (2010 Census) (Population of Area x 100) (No. of 
Questionnaire) 
289,119 
Low Income Areas     
La (HDIS) 98,683 (0.34) 34% 61 52 
Nima (HDLCS) 80,843 (0.28) 28% 50 43 
Darkuman (MDIS) 61,562 (0.21) 21% 38 32 
Abokobi (RF) 1,654 (0.01) 1% 2 7 
Middle Income Areas     
Kaneshie (MDMCS) 31,141 (0.11) 11% 19 16 
Hatso (LDMCS) 8,062 (0.03) 3% 5 10 
High Income Areas     
Airport Residential Area 5,696 (0.02) 2% 3 11 
(LDHCS) 
    
Frafraha (LDNDS) 
1,478 (0.01) 1% 2 9 
Total 289,119 100% 180 180 
 
 
Table 1.2 Sampling Design for Emergency Patients Questionnaire Survey 
 
Name of Health Facility Number of Questionnaire  
 
La Polyclinic (Low Income Area) 20 
 
Cocoa Clinic ( Middle Income Area) 20 
 
Nyaho Medical Center (High Income Area) 20  
 
Total 60 
 
 
 
  
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Table 1.3 Sampling Design for Drivers Questionnaire Survey 
 
Drivers Number of Questionnaire  
 
Taxi  20 
Van (Trotro)  20  
Private Car  20 
 
Motor Taxi (Okada) 20 
Total 80  
 
 
1.8.4 Qualitative Research Methods 
 
1.8.4.1 In-depth Key Informant Interviews 
 
This study conducted in-depth key informant interviews with the Principal Biomedical 
Scientist of the Ghana National Public Health Reference Laboratory (Ministry of Health), 
the Public Relations Officer of the National Disaster Management Organization 
(NADMO), an Environmental Health Analyst- Metropolitan Public Health Department-
AMA, the Greater Accra Industrial Relations Officer of the Ghana Private Road Transport 
Union (GPRTU), as well as a Research Officer of the Gillman and Abbey Funeral 
Services. 
1.8.4.2 Focus Group Discussion 
Focus Group discussions were also organized among a group of health personnel who are 
involved in direct patient care, and men and women from various households. Table 4 
shows the number of respondents and groups. In all, three different focus group 
discussions were organized. Each group comprised of 6 participants, since a lesser number 
tend to reveal less information and can be dull (Gibbs, 1997; Stewart & Shamdasani, 2004) 
as illustrated in Table 1.4.  
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The health workers directly involved in patient care comprised of two medical officers, 
two nurses, and two cleaners. Men and women from households were randomly selected 
form the various classified income areas in GAMA (see Songsore et al, 2009). Two each 
from the low (Nima) middle (Kaneshie), and high income areas (Airport Residential 
Area). All the three focus group discussions took place at Kaneshie. 
 
1.8.4.3 Observation 
According to Jorgensen (2015), scientific observation is the process of recording 
behavioral patterns of people, objects, and events as they occur. As adopted by various 
studies (see Von Baeyer and Spagrud, 2007; Weinberg, Mortonson, Eisentein, Hirata, 
Riess, and Rozo, 2013), the researcher utilized the observation method of data collection 
through observation checklist to gather information on disinfection practices at three 
different car washing bays in Airport residential area, Kaneshie, and Darkuman. This 
method was adopted because it provides an opportunity for the researcher to gather 
information that respondents may be reluctant to discuss in an interview, while firsthand 
experience with  a setting enables the researcher  to discover rather than guessing what the 
content looks like (Jorgensen, 2015). 
  
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Table 1.4 Sampling Design for Focus Group Discussion 
Group Number of Respondents 
Health Workers involved in direct patient 6 
care 
Men from households 6 
Women from households 6 
Total 18 
 
 
 
1.8.5 Secondary Sources of Data 
Written reports and already existing paper documents and policy frameworks from 
stakeholder institutions like the Ghana Health Service, Ministry of Health, School of 
Public Health, and Noguchi Memorial Institute for Medical Research, Ghana Red Cross 
Society, Environmental Health Department (AMA), and National Disaster Management 
Organization (NADMO) were consulted in this study to help augment the primary data. 
1.8.6 Data Analysis and Presentation 
Primary data collected from the field in this research were cross-checked to ensure there 
were no mistakes. Completed questionnaires were coded and imputed into the computer 
and analyzed using Statistical Package for the Social Sciences (SPSS version 23). A Chi 
Square test was also used to analyze and measure the relationship between dependents and 
independent variables in the study. Descriptive statistics such as percentages and 
frequencies were also included in the analysis via tables and charts, while qualitative data 
was analyzed and presented by reporting key findings under each main theme through 
appropriate verbatim quotes of respondents as employed by various studies (see Burnard, 
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Gill, Tewart, Treasure, and Chadwick, 2008; Colorafi and Evans, 2016; Denzin, 2008; 
Gyimah, 2017) 
1.9 Ethical Considerations 
Ethical considerations relate to the moral standards that the researcher should consider in 
all research methods and stages of the research design.  Trustworthiness is “the extent to 
which findings provide truth-value of data collected” (Lincoln & Guba, 1985). After the 
Department of Geography and Resource Development’s approval to conduct the study, 
permission was sought from the relevant authorities in the various communities and 
institutions. The consent of all participants were sought and they were assured that the 
information they provide would be treated confidentially. Participants were required not 
to include their identity or names to prevent recognition within the text of this report. This 
was done to ensure that the participants are completely candid in their responses.  
 
1.10 Limitations of the Study 
This study intended to collect information from the Ghana National Ambulance Service 
via a key informant interview on disinfection practices. However, all efforts to get 
approval for an appointment proved futile therefore the inability to get the needed 
information considering the timeline of the study. This however, to a large extent did not 
affect the findings of this study, as information that was needed from the Ghana National 
Ambulance Service was acquired from the National Public Health Reference Laboratory 
(Ministry of Health). 
Having discussed the background to the study, the next chapter provides an overview of 
the study area.  
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CHAPTER TWO 
2.0 STUDY AREA 
 
2.1 Introduction 
This chapter informs readers about the background of the study area. It talks about the 
genesis or origin of Accra and the origin and characteristics of Greater Accra Metropolitan 
Area (GAMA). Secondly, the chapter examines the location and of GAMA. Again, the 
demographic dynamics of the study area is further discussed, while the environmental 
health, healthcare infrastructure and emergency transport systems of Accra are also 
highlighted. 
 
2.2 Origin and Characteristics of Greater Accra Metropolitan Area (GAMA) 
Accra, the capital city of Ghana has fast grown both physically and economically. The 
origin of Accra has been linked to its development as a coastal fishing port during the late 
16th Century (Grant & Yankson, 2003). 
The Kpeshie people were the first settlers on the stretch of the coastline now called Accra. 
They included the Ga-speaking migrants from Niger into their communities. The east of 
the fishing village was the east of Korle Lagoon but later expanded to include places such 
as Jamestown and Ussher Town in the present day Accra. The latter part of the 15th 
Century witnessed the arrival of the Europeans along the coast of Gold Coast and most of 
them built their forts and castles along the coast including Accra. The Europeans had 
authority over areas with forts and castles and fought among themselves (Gutkind, 1989). 
The emergence of slave trade in the pre-colonial period led to the development of coastal 
trade centres which enhanced the building of many forts and castles. For example, the 
Ussher Fort was built by the Dutch in 1605, Christiansburg Castle by the Swedes in 1657 
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and James Fort by the British in 1673. These forts became foreign commercial enterprises 
in the pre-colonial periods. Gold and slave trade were dominant in Accra than any other 
place along the coast in the 1680’s (Acquah, 1958). In 1850 and 1872 when the Danes and 
the Dutch left the region respectively, Accra grew into a prosperous trading centre, and 
became the capital of the British Gold Coast colony (Agyemang, 2015). Consequently, 
municipal council was formed to improve the town. Gradually, Greater Accra 
Metropolitan Area (GAMA) developed following the emergence of peri-urban cities, 
which can be linked to urban sprawl and uncontrolled physical expansion from the 
metropolitan boundaries of Accra during the 1960s (Agyemang, 2015). 
It is important to know that, Greater Accra Metropolitan Area (GAMA) is not a known 
nomenclature in the administrative areas in Greater Accra. However, previous studies 
(Oteng-Ababio, Melara Arguello & Gabbay, 2013; Yankson, Kofie & Moller-Jensen, 
2005) have conceptualized GAMA as the much broader area of the Greater Accra region 
that was initially made up of the Accra Metropolitan Assembly (AMA), Tema Municipal 
Assembly (TMA) and Ga District Assembly (GDA). In fact, GAMA had transformed into 
twelve independent administrative divisions as at 2012 (Agyemang, 2015).  
These divisions have been induced by the rapid growth of population and Ghana’s 
decentralization policy aimed bringing governance from the central government to the 
local Metropolitan, Municipal and District Assemblies (MMDAs). Every administrative 
division is headed by a Chief Executive Officer appointed and endorsed by the President 
and local assembly members respectively. 
GAMA covers about 1,079 km2 (33%) of the Greater Accra region’s total land surface of 
3,245 km2 (Ghana Statistical Service, 2005) and shelters close to 3.7 million dwellers, 
that is near about 96 % of Greater Accra region’s entire population of about 4 million 
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(Ghana Statistical Service, 2012). This qualifies GAMA, or also referred to as Accra in 
the subsequent paragraphs as the most densely populous and distinct largest urban 
conurbation in the whole of Ghana (Agyemang, 2015) accompanied with associated risk 
such as outbreak of infectious diseases. In the year 2004 for instance, the Greater Accra 
Metropolitan Area (GAMA) recorded the highest cases of cholera with 59.4% out of the 
98.7% cholera cases recorded in the Greater Accra Region (Gyimah, 2017). Nevertheless, 
the emergency transport system in GAMA is challenged with inadequate pre-emergency 
care infrastructure such as ambulance services (Zakariah, Stewart, Boateng, Achena, 
Tansley, and Mock, 2017). In fact, transportation in GAMA is dominated by the informal 
transport service providers, generally known as “Trotro” (mini buses and vans) and taxis 
(Agyemang, 2015). Recently, motor-taxis services, popularly known as “Okada” have 
become the preferred public transport mode of transport in GAMA (Oteng-Ababio & 
Agyemang, 2012). The aforementioned situation in GAMA presents no option for the 
public other than compelling the general public to resort to taxi services during emergency 
health situations. 
This is what influenced the selection of GAMA as the study area. 
 
2.3 Location of Study area 
Greater Accra Metropolitan Area (GAMA) shares boundaries with the Central Region in 
the west (Upper West Akim and Awutu Senya districts), Eastern Region in the north 
(Ayensuano Akwapim South, Nsawam Kuwapim North district and municipalities), Shai 
Osudoko and Ningo Pampram districts in the east, and the Gulf of Guinea in the south. 
Hence, the operational definition of GAMA in this study includes the catchment area 
illustrated in Figure 2.1. 
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Figure 2.1 Study Area Map 
Source: Author, 2018. 
2.4 Demographic Dynamics of Study area 
The total population of the Metropolis is 1,665,086 (2010 census) with females 
constituting 51.9 percent while males formed 48.1 percent. The age distribution of the 
population shows that the population peaked at the age group 20-24, representing 12.4 
percent followed by the 25-29 age group (11.5%). Females constitute the higher 
proportion in almost all the age groups of the population. With regards to sex ratio, for 
every 100 females, there were about 93 males within the Metropolis. The sex ratio of the 
Metropolis is lower than the national ratio of 95.2 (GSS, 2012). This could be attributed 
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to male mortality being higher than that of females in the Metropolis or male out-migration 
from the Metropolis.   
The Accra Metropolis has a Total Fertility Rate of 2.2, which is lower than the regional 
average of 2.6 while crude death rate is 4.4 per 1000 population which is slightly higher 
than the regional average of 4.3 per 1000 population (GSS, 2012). 
 
2.5 Health Care and Infrastructure in Accra 
The city of Accra has over 20 government-run health facilities, and more than 800 private 
health facilities (Pehr, 2010).  New health facilities are also under construction. The first 
phase of the University of Ghana Medical Center (UGMC) for example is ready for use. 
Despite the availability of these health facilities in Accra, accessibility has been a 
challenge for the past years considering the rapid growth of the City’s population which 
does not correspond with health infrastructure. Many lives have been lost due to the 
unavailability of beds-the so called “no bed syndrome”. 
2.6 Environment and Health in Accra Metropolitan Area 
As a result of rapid increase in Accra’s population at a growth rate of 2.62% (GSS, 2012) 
and inadequate provision of facilities, majority of the residents live under deplorable 
environmental conditions which are detrimental to health (Boadi, 2004). Poor 
environmental and sanitary conditions in poor neighborhoods results in high cases of 
infectious diseases like cholera, diarrhoea, typhoid fever, and respiratory tract infections 
amongst others.   
 
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2.7 Emergency Medical Transport in Accra 
The Ghanaian National Ambulance Service (GNAS) originated following a soccer 
stadium disaster, at the Ohene Gyan Stadium in Accra on May 9, 2001 that saw about 123 
fatalities (Osei-Ampofo et al, 2013). The tragedy instigated a movement to improve 
Ghana’s emergency services. In 2009, Ghana’s medical emergency system consisted of 
49 government ambulances and a number of various private hospital ambulances (Boateng 
and Kratzer, 2010). Currently, Accra has the largest allocation of 9 out of 55 functioning 
ambulances. 
 
2.8 Summary 
The Greater Accra Metropolitan Area is an urban residential area with a youthful 
population.  It is characterized by rapid population growth (2.62%) and inadequate 
infrastructure leading to poor environmental conditions especially in poor communities. 
As a result, residents are exposed to a number of infectious diseases such as cholera, 
diarrhea, typhoid fever, respiratory tract infections amongst others. Emergency medical 
transport delivery in Accra is inadequate considering the population of the area and the 
available ambulance facilities in Accra. 
The next chapter discusses transportation mode during emergency health situations in 
Greater Accra Metropolitan Area (GAMA). 
  
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CHAPTER THREE 
3.0 MAIN TRANSPORT MODE USED DURING EMERGENCY HEALTH 
SITUATIONS 
 
3.1 Introduction 
The presentation of this research’s result begins in this chapter. The primary objective of 
this study was specifically to examine the role of public transport in the spread of 
infectious diseases in Greater Accra Metropolitan Area (GAMA). The research aimed at 
achieving the following objectives: 
1) Assess the main transport modes used during emergency situations. 
2) Examine the protocols employed to prevent vehicle infection. 
3) Analyze risk factor and exposure of people involved in infectious patient care. 
4) Discuss the perception of risk of the key actors in the chain 
5) Analyze the effectiveness of medical emergency delivery system in addressing 
these issues. 
The chapter discusses the demographic characteristics of respondents, and the mode or 
preferred mode of transportation during emergency health situations of respondents. 
A total of 320 participants/respondents were used in the research for the gathering data. In 
addition, information was also gathered from individuals involved in direct patient care as 
well as experts from key stakeholder institutions through focus group discussions and key 
informant interviews respectively.  
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3.2 Normality Test  
Before the analysis of the results, the researcher first of all run a normality test of the data 
collected to analyse its adequacy in making statistical inferences.  
According to the central limit theorem, as long as the sample size is 30 or more; the 
sampling distribution would tend to be normal irrespective of the population distribution. 
The sample size used in this study was large enough to satisfy the requirement of normality 
according to the central limit theorem (Ghasemi and Zahediasl, 2012). Besides, the study 
used 320 respondents which is representative enough to make generalization of the 
population. Meyer et al (2005) purported that the larger the sample size used in the study, 
the more precise and stable the estimates of the population parameter would be for 
statistical inferences.  
According to Kline (2011), a skewness level with absolute values greater than 3 are 
regarded as extreme, while a kurtosis level with absolute values greater than 8 are 
described as extreme. When the acceptable level of skewness (3) and that of kurtosis (8) 
are violated, it suggests a problem that should be addressed before performing any 
inferential statistical analysis. The result showed that the maximum value for skewness 
was 1.53 and the maximum value for kurtosis was 1.02. Since the skewness values are 
lower than the acceptable level (3) and kurtosis values were lower than the acceptable 
level (8), the data appeared to be normal related to each of the indicator variables used in 
the study.  
The skewness and kurtosis values of the respondents’ demographics are shown in Table 
3.1.   
 
  
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3.3 Socio-Demographic Characteristics of Participants. 
Out of the 320 participants, 189(59.1%) were males while 131(40.9%) were females. 
Those aged 0-14 years (Youth) were not interviewed since the research was targeted at 
responsible adults which explains why they constitute 0% (see Table 3.1). Respondents 
between the ages of 15-64 years (Economically Active) constituted 95.6% while those 
above 65 (Old Age) years represented 4.4%. With respect to level of education, 6.9% had 
no formal education. 34.9% of the respondents acquired basic education. 30.3% acquired 
O levels or SHS education, while 27.9% represented respondents who are enrolled in 
tertiary institution as well as those who have completed tertiary education. 
Regarding religious affiliation, Christians constituted the majority with 65.6% (210) while 
Muslims were made up of 18.1% (58). 9.4% (30) of the participants were Traditional 
Believers and 6.9% (22) were indifferent (Table 3.1). 
 
  
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Table 3.1 Socio-Demographic Characteristics of Participants 
Demographic Characteristics Frequency (%) Skewness Kurtosis 
Gender  0.37 -1.88 
Male 189 (59.1%)   
Female 131 (40.9%)   
Age of the Respondents  0.53 -0.60 
         0-14years 0 (0%)   
15-64years 306 (95.6%)    
65 and above 14 (4.4%)   
Educational Level  -0.13 -1.29 
Primary/JHS 112 (34.9%)   
O’Level/SHS 97 (30.3%)   
Tertiary 89 (27.9%)   
None 22 (6.9%)   
Religion  1.48 1.020 
Christianity 210 (65.6%)   
Islam 58 (18.1%)   
African Tradition 30 (9.4%)   
Other 22 (6.9%)   
Source: Field Survey, 2018. 
 
3.4 Mode of Transport during Emergency Health Situations 
Two hundred and forty (240) respondents made up of 60 emergency patients and 180 
responsible adults from various households were consulted on the mode of transport they 
used and will use during emergency respectively. 
Out of the 60 questionnaires that were administered to emergency patients in the selected 
health facilities, none resorted to ambulance. 85% resorted to taxis, 11.7% used a private 
vehicle, and 3.3% resorted to Uber as a means of transport to the hospital.  
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However, 72.8% of responsible adults from the various household in GAMA indicated 
that they will resort to taxis during emergency medical situations, while 13.9% of them 
said they will resort to a private vehicle. Meanwhile, those who intend resorting to 
ambulance constituted 7.8%, while 3.3% intend to request for Uber in case of emergency 
health situation. None of the respondents resorted or intend to resort to either Van (Trotro) 
or Motor Taxi (Okada) (Table 3.2). This therefore indicate that taxis are the most preferred 
mode of transport during emergency health situations (Table 3.2). The results therefore 
reject the first proposition of this study (Public transport does not provide emergency 
health delivery service) and accepts the second proposition (Public transport provides 
emergency health delivery service) which is consistent with Agyemang (2014) which has 
it that taxis are used as ambulance in Ghana. 
Table 3.2 Mode of transport during emergency health situations 
 
 N(60) N(180) TOTAL 
 
MEANS OF TRANSPORTATION Patients Household N (%) 
 
Ambulance 0 (0%) 14 (5.8%) 14(5.8%) 
 
Taxi 52 (85%) 131 (72.8%) 182 (75.8%)  
 
Personal Vehicle 7 (11.7%) 25 (13.9%) 32 (13.3%)  
 
Uber 2 (3.3%) 10 (5.5%) 12 (5%)  
 
Van (Trotro) 0 (0%) 0 (0%) 0 (0%)  
Motor Taxi (Okada) 0 (0%) 0 (0%) 0 (0%) 
Source: Field Survey, 2018. 
 
  
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3.4.1 Spatial variation of transport mode during emergency 
Data from the study shows that the preference for taxis during emergency health 
conditions do not vary across space in GAMA. Preference for taxis are high among the 
low and middle and high income areas (see Figure 3.1).   The minority who claim will 
resort to private vehicles and ambulances during emergency health conditions can be 
linked to the fact that they possess a private vehicle, or the fact that they can easily access 
ambulance through their influence in society or afford the services of ambulances from 
nearest private health facilities. 
Figure 3.1 Which transport mode will you resort to during emergency?  
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Low Income Middle Income High Income
Ambulance 64% 7% 29%
Taxi 79% 13% 8%
Van (Trotro) 0% 0% 0%
Bus 0% 0% 0%
Motor Bike (Okada) 0% 0% 0%
Private Vehichle 44% 32% 24%
 
Source: Field Survey, 2018. 
 
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3.5 Summary  
Education is one of the essential determinants of risk knowledge and awareness of 
infectious diseases which reflect in the outcome of the study. The results indicate that 6.9% 
of the respondents had no formal education. 34.9% have acquired basic education. 30.3% 
have also acquired O levels and Secondary education. 27.9% of the respondents 
constituted those who have both obtained tertiary education and those who are enrolled in 
tertiary institutions. This implies that 93.1% of the participants in this research are 
literates.  
Regarding the ages of respondents in this study, all of them are above 18years. This means 
that the views of respondents represent that of the responsible adults in GAMA. 
Christians formed 65.6% of the respondents. This is consistent with the 2010 Population 
and Housing Census which has it that Christianity is the major religion in Ghana.  
According to Agyemang (2014), taxis are used as ambulance and hearse in Ghana. This 
exposition is consistent with the primary data gathered in this study as 85% of the 
emergency patients (respondents) were transported to the hospital via taxis because that 
was the only available and fastest means, while 80% of the taxi drivers who participated 
revealed that they have ever conveyed dead bodies with their vehicles despite the Public 
Health Act 2012 which insists infectious patient, or a corpse suspected to be capable of 
diffusing infections should be taken out from a vehicle. However, 72.8% of household 
respondents noted that they will resort to taxis during emergency health situations due to 
its efficiency, reliability, and affordability. 
The 5.8% and 13.3% respondents who claim they will resort to ambulance and private 
vehicles respectively are mainly residents in the high and middle income areas. This shows 
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that although taxis are the main transport mode during emergency health situations in 
GAMA, a handful of the population also resort to ambulance and private vehicles. 
The next chapter therefore discusses cleaning practices that are employed to disinfect the 
vehicles after emergency health transport delivery.  
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CHAPTER FOUR 
4.0 PROTOCOLS/DISINFECTION PRACTICES EMPLOYED TO PREVENT 
VEHICLE INFECTION 
 
 
4.1 Introduction 
This Chapter discusses vehicle disinfecting practices of drivers who have ever transported 
patients and dead bodies. It further discusses the standard protocols of transporting 
infectious patients and disinfecting vehicles, and how respondents of this study perceive 
the effectiveness of the emergency transport delivery system in Ghana. 
Information on vehicle disinfection were sought from 80 respondents (drivers) made up 
of both private and public transport drivers. The results indicate that 40% have ever 
transported patients to a health facility. 5% out of the 40% have recorded a death case in 
the transportation process. However, 8% have either transported a dead body to or from 
the morgue. 
None of the above respondents fumigated the vehicle after delivering the service. But 24 
of them sent their vehicles to the washing bay while 16 cleaned the vehicle personally with 
detergents (see table 4.1). 
 
 
  
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Table 4.1 Vehicle Disinfection Practice 
VARIABLE YES NO 
Have you ever transported patients especially during   
emergencies? 
Private Vehicles 2 18 
Taxis 20 0 
Van (Trotro) 8 12 
Motor bike (Okada) 2 18 
TOTAL 32(40%) 48(60%) 
Have you ever recorded any death in your vehicle during   
transportation process? 
Private Vehicles 0 20 
Taxis 4 16 
Van (Trotro) 0 20 
Motor bike (Okada) 0 20 
TOTAL 4 (5%) 76(95%) 
Have you ever conveyed a dead body to or from the morgue   
with your vehicle? 
Private Vehicles 2 18 
Taxis 4 16 
Van (Trotro) 2 18 
Motor bike (Okada) 0 20 
TOTAL 8 (10%) 72(90%) 
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Which cleaning method did you employ after delivering the   
service 
Fumigation 0 0 
Washing Bay 24 60 
Detergent 16 40 
Airing 0 0 
Ritual Cleansing 0 0 
TOTAL 40 100 
 
Source: Field Survey, 2018. 
The findings indicate that majority (60%) of drivers clean their vehicles at the washing 
bay after transporting dead bodies or sick passengers. However, observations at three 
different car washing bays in Airport residential area (high income area), Kaneshie 
(middle income area), and Darkuman (low income area) indicate that, vehicles are cleaned 
with detergents. All the washing bay attendants noted that they use detergents just to keep 
vehicles clean and neat. Therefore there is no difference compared to the minority (40%) 
who personally cleaned their vehicles with detergents.    
 
4.2 Transporting Infectious Patients  
An interview with officials from stakeholder institutions including; the National Disaster 
Management Organization (NADMO), Ghana Private Road Transport Union (GPRTU), 
and Environmental Health Department of AMA indicate that there is no policy that 
regulates the transportation of infectious patients and dead bodies.  
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An official from the Environmental Health Department of AMA noted: 
“A policy is only a course of action to, let’s say, achieve a particular objective, so for us 
I don’t think that there is any policy that regulates the transportation of infectious patients 
and dead bodies within the metropolis. I have not come across any carved policy. But that 
is not to say that in the absence this policy we don’t really handle infectious cases as city 
authorities. We do handle them. We do transport them. When there is any case as in a 
dead body found somewhere as a result of neglect of family or flooding, we tend to handle 
them by sometimes giving them what we call sanitary burial. So basically if it is an 
infectious case then of course as city authorities we ensure that the burial becomes free. 
So we actually assume custody of the case and when the family is involved then we tend to 
break that link or that chain between the isolated case and the family in the case of 
infectious diseases like TB or cholera. So I will say that there is no clear cut policy that 
regulates the transportation of infectious patients or dead bodies. However, when it comes 
to an outbreak in the metropolis, definitely there is a mode of transporting these patients 
and dead bodies.” (Official 1- Key Informant Interview, April 16, 2018.) 
While an official from Accra Metro NADMO also noted: 
“We don’t have a law that regulates transporting infectious patients or dead bodies. I 
haven’t seen or come across any law like that”. (Official 2- Key Informant Interview, 
April 24, 2018.) 
Meanwhile, an official from the Greater Accra GPRTU noted: 
“I don’t know of any law. I have to be frank with you. But what I know is we as GPRTU, 
we operate trotros, taxis, long journey buses, tipper cars. That is what we operate. And 
basically we don’t transport dead bodies. Because I think transporting a dead body or a 
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corpse, may be the person dies in the house and you have to convey the body to the 
mortuary. That should be done by the ambulance that is why there is ambulance service 
available. So we don’t transport dead bodies. But I also know that sometimes a taxi can 
be asked to may be take a sick person to the hospital then unfortunately on the way the 
person will give up the ghost. For that it has been happening but it will be very difficult to 
tell that driver that when the person dies in the car because the person is dead because of 
that since it is a taxi I will stop on the way and call an ambulance. First of all, you are not 
a doctor to determine whether the person is dead or not” (Official 3- Key Informant 
Interview, May 14, 2018.) 
By contrast, information gathered from the Ghana National Public Health Reference 
Laboratory (Ministry of Health) revealed that there is a policy framework that regulates 
transportation of infectious patients and dead bodies as well as standard protocols for 
disinfections (SOPs 2016). 
This inconsistency could be attributed to lack of proper coordination among these 
stakeholder institutions. 
 
4.3 Standard Protocols of Transporting Infectious Patients and Disinfection 
The Second Edition of the Standard Operating Procedures for the Prevention and Control 
of Cholera in Ghana (SOPs), 2016 outlines how infectious patients and dead bodies should 
be transported and disinfections be carried out. It further explained that the SOPs is cholera 
specific because cholera remains a major public health challenge in Ghana, however it is 
useful with respect to other infectious diseases such as Ebola, Lassa Fever, amongst others. 
The Standard Operating Procedures for the Prevention and Control of Cholera in Ghana 
(SOPs), 2016 state emphatically that patients should be transported by national ambulance 
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services other than taxis or other public vehicles. According to the SOPs 2016, should it 
become necessary to use public transport, seats must be covered with impermeable 
materials such as rubber that can easily be disinfected or destroyed. It further states that 
the receiving health facility should perform or supervise appropriate decontamination, 
cleaning and disinfection of the vehicle with 2% chlorine solution. According to a 
Principal Biomedical Scientist, Disease Control Officers at various health facilities are to 
ensure the effectiveness of the SOPs at their facility.  
However, data gathered revealed that taxis and private vehicles do not adhere to these 
precautions and protocols for vehicle disinfection before, during, and after delivering 
emergency medical services (see Table 7). 60% of the drivers who indicated that they have 
ever transported infectious patients and dead bodies indicated that they sent their vehicles 
to the washing bay afterwards, while 40% also indicated that they personally cleaned their 
vehicles with detergents afterwards. It is surprising to also know that some private hearse 
drivers also clean their ambulance personally while others subscribe to the washing bay. 
However, observations and interviews at three different washing bays in Airport 
residential area, Kaneshie, and Darkuman revealed that no disinfectants are used apart 
from washing detergents in cleaning these vehicles. This can lead to a rapid spread of 
infectious diseases as Lowe et al (2014) established that the rapid spread of Porcine 
Epidemic Diarrhea Virus Infection among pigs was as a result of how pigs were 
transported in vehicles that were not cleaned and disinfected. This collaborates with the 
conceptual framework of this study (The Environmental Health Hazard Pathway) which 
shows that, when infectious patients cough, vomit, urinate, or releases microorganisms in 
the vehicle, passengers and drivers of that vehicle get exposed, and when there is a contact 
with these microbes, passengers and drivers absorb them and contract diseases which 
consequently will spread and may lead to death (see figure 1.1) as Mukherjee (2017) noted 
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that most infectious diseases are caused by pathogens that are already present in the 
environment unaware. 
It is gratifying to know that some funeral homes adhere to the standard protocols of 
disinfection and transportation of dead bodies according to information gathered from this 
study. A Research Officer at the Gillman and Abbey Funeral Services in Accra explained 
how their hearse transport dead bodies from health facilities to and from the morgue as 
well as the periodic fumigation of their premises, which is in line with the SOPs 2016. He 
revealed: 
“Normally they (dead bodies) are put in a water proof rubber bags at the origin (hospital) 
like as we have here then we seal it. Then the drivers who do the conveyance put on gloves 
then they put them on the stretcher and bring them. When they bring them, the stretcher is 
pulled out from the hearse then we use a lift (elevator) to send them to the morgue. 
Periodically, we do disinfection of the entire premises. Every three months, people come 
from the AMA to do it. You know that, excuse me to say, we deal with dead bodies. So we 
do that to safeguard us. But because the bodies are put in the waterproof bags, no liquid 
or anything comes out. However, we use chemicals to clean the hearse after conveyance”. 
(Official 4- Key Informant Interview, May 14, 2018.)  
 
4.4 Effectiveness of emergency transport delivery 
It is evident in chapter three that taxis are the most preferred mode of transport during 
emergencies (Table 3.2). Views were sought from 60 patients who were recovering from 
emergency trauma in various hospital wards on why they resorted to taxis during 
emergency. With respect to reasons why respondents (patients) resorted to their mode of 
transport other than ambulance, 23 out of the 60 respondents revealed that their mode of 
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transport was the only available means. 12 others indicated that it was the only convenient 
means, meanwhile 4 out of the 60 attributed their reasons to affordability, while 21 also 
noted all the above reasons. This is an indication that the public have confidence and trust 
in taxis during emergency situations than the ambulance, due to the deficiency of the 
Ghana Ambulance Service. This vindicates Page et al (2013), and Adamtey (2015) who 
noted that, inadequate ambulance, trained staff, and modern apparatus have led to poor 
quality emergency medical services in developing countries.  
All the 60 respondents expressed their satisfaction to the transport service they resorted to 
(see Table 4.2).  
 
Table 4.2 Effectiveness of emergency transport delivery? 
VARIABLE FREQUENCY PERCENTAGE 
Give a reason for your transport mode preference.   
That was/is the only available mode of transport 23 38.3 
It was/is affordable 4 6.7 
That was/is the only convenient mode for me 12 20 
All the above 21 35 
Did the mode of transport meet your needs   
satisfactorily?  
Yes 60 100 
No 0 0 
Source: Field Survey, 2018. 
 
  
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4.5 Summary  
The SOPs 2016 outlines how infectious patients and vehicles should be transported and 
disinfected respectively. However, data collected indicate that drivers do not adhere to the 
standard protocols before, during, and after transporting infectious patients. This leaves 
both drivers and passengers exposed to infectious diseases, which supports claims by the 
WHO (2009) that people travelling could be exposed to a number of infectious diseases 
based on the presence of infectious agents. However, the study found out that, there is 
inconsistency among stakeholder institutions with regards to policies that regulates the 
transportation of infectious patients and dead bodies. This may be attributed to the fact 
that, there is no proper coordination among these institutions. 
Findings of this study reveal that, respondents have trust in taxi services during emergency 
health situations other than ambulance services. This is due to the inability of the 
ambulance service to meet their demands adequately. All of them expressed their 
satisfaction with the services of taxis and private vehicles. This is consistent with Adamtey 
et al (2015) who indicate that emergency and ambulance service is ineffective in Ghana. 
Meanwhile, results of this study show that, taxis and private vehicles which provide 
emergency health delivery transport are not properly fumigated after service delivery. 
Drivers resort to personal cleaning with detergents or the washing bay where it was 
observed that, attendants also clean the vehicles with detergents. This leaves drivers, 
passengers, the washing bay attendants, and the public at risk considering the fact that 
infectious diseases can spread through direct and indirect contact. Although the findings 
of this study did not reveal evidence of people catching disease form vehicles, other studies 
like Lowe and Walker (2014) has it that, the spread of Porcine Epidemic Diarrhoea Virus 
in the United States was due to how pigs were transported in vehicles that were not 
properly cleaned and disinfected. This is an indication that, an epidemic may occur should 
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there be a single case of an infectious disease like Ebola. This is because, taxis are the 
preferred mode of transport during emergency health situations, meanwhile drivers do not 
employ or practice standard and effective cleaning protocols. Consequently, drivers, 
passengers, washing bay attendants and all those who come in contact with vehicles that 
are not properly disinfected may absorb certain microbes. They will in turn transfer these 
microbes to people they come in contact with (households), leading to a possible outbreak 
of infectious disease. 
Having discussed the standard protocols of vehicle disinfection and the vehicle 
disinfection practices among drivers, the next chapter highlights the risk perception among 
the key actors in the chain (drivers and passengers, households) with respect to vehicles 
and the spread of infectious diseases.  
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CHAPTER FIVE 
5.0 RISK PERCEPTION AND EXPOSURE OF KEY ACTORS IN THE 
CHAIN 
 
 
5.1 Introduction 
This chapter discusses one of the main subjects of this research thus, the perception of risk 
on public transport and infectious diseases. The chapter touches on five main sections. 
These include; the risk perception of key actors in the chain, the spatial variation of risk 
perception, relationship between risk perception and respondent’s demographics, and the 
risk factor and exposure of people involved in direct infectious patient care. 
 
5.2 Risk perception of key actors in the chain 
Perception of risk about transport and infectious diseases was sought from all the 320 
respondents/participants. 91.9% of the respondents indicated that they know about 
infectious diseases.86.6% think vehicles can spread infectious/communicable disease. 
However, 16.2% believe infectious diseases can spread via body to body contact with 
infectious passenger on board. 5.6 claim infectious diseases can spread via body contact 
with infected part of vehicle. 56.3% indicated one can contract infectious/communicable 
diseases from vehicles by breathing in contaminated air on board, while 21.9 percent 
believe that vehicles can spread diseases through all the above factors. Details are found 
in Table 5.1. 
  
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Table 5.1 Risk Perception of Key Actors in the Chain. 
 
VARIABLE FREQUENCY PERCENTAGE 
Do you know about infectious/communicable   
diseases? 
Yes 294 91.9 
No 26 8.1 
Do you think vehicles can spread   
infectious/communicable diseases? 
Yes 227 86.6 
No 43 13.4 
In what way(s) do you think vehicles can   
spread infectious/communicable diseases? 
Body to body contact with infectious patient on 52 16.2 
board 
Body contact with infected part of vehicle 18 5.6 
Breathing contaminated air on board 180 56.3 
All the above 70 21.9 
Source: Field Survey, 2018. 
 
5.3 Spatial Variation of risk perception  
This research sought the perception of risk among respondents (household individuals) 
in all three income areas (high, middle, and low income areas). Respondents were asked 
whether they think vehicles can spread infectious diseases (see Figure 5.1). 
 
  
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Figure 5.1 Do you think vehicles can spread infectious diseases? 
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Low Income Middle Income High Income
Yes 86% 100% 100%
No 14% 0% 0
Yes No
 
Source: Field Survey, 2018. 
 
The variation in Figure 5.1 indicates that risk knowledge is high among residents in the 
high and middle income areas compared to those in the low income areas. All respondents 
in the high and middle income areas think vehicles can spread infectious diseases. 
However, in the low income areas, 86% of the respondents think vehicles can spread 
infectious diseases, while 14% think vehicles cannot spread infectious diseases. The ‘No’ 
which represents 14% of the response in low income areas can be attributed to ignorant 
and faith considering the level of education, social status, and religious belief of the 
respondents, since these factors influence risk perception (Solvic and Peters, 2006; Anyan, 
2017). However, findings reveal that respondents have a risk knowledge that vehicles can 
spread infectious diseases. 
 
  
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5.4 Relationship between Risk Perception and Gender/Age/Education/Religion. 
 
Tables 5.2, 5.3, 5.4, and 5.5 present results on risk perception with respect to public 
transport and the spread of infectious diseases, in relation to the demographics (gender, 
age, educational level, and religion respectively) of respondents with a chi square test. The 
significant values indicate that all of them are statistically significant (p<0.05). This 
implies that there is a significant relationship between demography (gender, age, 
education, and religion) (independent variables) and risk perception on the spread of 
infectious diseases via vehicles (dependent variable). This is consistent with studies made 
by Furnham et al (1999), Green (1999), Madge (1998), and Apwah (2013) which reveal 
that religious, traditional, cultural orientation, and other demographic characteristics like 
age, gender, educational level of people influence risk perception. Therefore, the chi 
square test rejects the null hypothesis of his study (H0= There is no significant relationship 
between demographics and the perceived risk that public transport can spread infectious 
diseases) and accepts the alternate hypothesis (H1= There is a significant relationship 
between demographics and the perceived risk that public transport can spread infectious 
diseases).  
It is evident in the Tables (5.2, 5.3, 5.4, and 5.5) that correlation (r) for all demographic 
characteristics was positive. This implies that there is a positive relationship between 
respondent’s demographic characteristics (gender, age, education, and religion) and risk 
perception on transport and the spread of infectious diseases. 
Table 5.2 shows that perception of risk among males are higher than females. This is 
inconsistent with earlier studies (see Flynn et al, 1994; Savage, 1993) which have it that 
risk perception among females are higher than males. The results of this study may be 
attributed to the fact that men attain higher education than women in Ghana (GSS, 2012), 
and therefore have higher risk perception than women as argued by Seale et al., (2010) 
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that there is a linkage between education and risk perception. It is however worrying 
because women are those who usually take care of the home, children and sick relatives 
(Messing and Ostlin, 2006). This implies that, they are mostly in direct contact with the 
entire household compared to the men. This increases their vulnerability considering their 
low risk perception leaving the entire household especially children also at risk. 
 
Table 5.2 Relationship between Risk Perception and Gender 
Demographic Do You Think Vehicles Correlation Chi Significant 
Characteristic Can Spread Infectious (r) Square (p) 
Diseases? 
Gender  Yes No 0.565 102.2 0.001 
Male 163(86.2%) 26 (13.8%)    
Female 99 (42.9%) 32 (57.1%)    
 
Source: Field Survey, 2018. 
 
The findings of this study also indicate that, there is a mix risk perception among various 
age groups (see Table 5.3). However, the economically active respondents (15-64 years) 
seem to be more risk conscious. This therefore integrates the various different assumptions 
of relationship between age and risk perception (see Flynn et al, 1994; Savage, 1993). This 
is because risk perception may differ across different age domains considering different 
motivations (Bonem et al, 2015; Slovic and Peters, 2006) like experience, education, 
religion, amongst others. Table 5.3 shows the relationship between age of respondents and 
their risk perception. 
  
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Table 5.3 Relationship between Risk Perception and Age. 
 
Demographic Do You Think Vehicles Correlation Chi Significant 
Characteristic Can Spread Infectious (r) Square (p) 
Diseases? 
Age of the Respondents   0.771 276.5 0.001 
0-14years 0 (0%) 0 (0%)    
15-64years 252(82.4%) 54 (17.6%)    
65 and above 10 (71.4%) 4 (28.6%)    
Source: Field Survey, 2018. 
 
Table 5.4 indicates that there is a high risk perception among educated respondents. This 
risk knowledge trickles down with a decreasing effect to those who have no form of formal 
education. This suggests that, there is a link between education level and risk perception 
(Seale et al., 2010). Therefore the higher the education level of a person, the higher the 
risk perception and consciousness of the person, while the lower the education level of a 
person, the lower the risk perception and consciousness of the person (see Table 5.4).   
  
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Table 5.4 Relationship between Risk Perception and Education. 
 
Demographic Do You Think Vehicles Correlation Chi Significant 
Characteristic Can Spread Infectious (r) Square (p) 
Diseases? 
Educational Level   0.578 175.5 0.001 
Primary/JHS 97 (79.5%) 25 (20.5%)    
SHS/ O’Level 82 (84.5%) 15 (15.5%)    
Tertiary 85 (95.5%) 4 (4.5%)    
None 8 (36.4%) 14 (63.6%)    
Source: Field Survey, 2018. 
 
Risk perception among members of the three main religions in Ghana (Christian, Muslims, 
and Traditionalists) are higher than those who belong to other religious bodies and those 
who are indifferent when it comes to religion (Others) (see table 5.5). This may be due to 
the recent series of education and awareness on environmental health by Non-
Governmental Organizations (NGOs) targeted at these religious bodies. It is important to 
also know that, most religious bodies includes programs like health talks and screenings 
in their calendar which has led to the high risk perception and consciousness of their 
members. Table 5.5 shows the relationship between religion and risk perception of 
respondents. 
  
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Table 5.5 Relationship between Risk Perception and Religion. 
 
Demographic Do You Think Vehicles Correlation Chi Significant 
Characteristic Can Spread Infectious (r) Square (p) 
Diseases? 
Religion   0.871 283.8 0.001 
Christian 190(90.5%) 20 (9.5%)    
Muslim 46 (79.3%) 12 (20.7%)    
African Tradition 16 (53.3%) 14 (46.7%)    
Other 10 (45.5%) 12 (54.5%)    
Source: Field Survey, 2018. 
 
5.5 Risk Factor and Exposure of People Involved in Direct Infectious Patient Care 
Three series of focus group discussions were organized to analyse the risk factor and 
exposure of people who are directly involved in direct care of infectious patients. The first 
group was made up of a group of six health workers (doctors, nurses, and cleaners), while 
the second group was made up of men form various households, and the third group was 
also made up of women from various households. The findings revealed that health 
workers adhere to safety rules and precautions to reduce their risk level due to their risk 
knowledge and awareness. Discussants noted: 
“Before I attend to a patient, I think about my safety first. That is what I was taught in 
school. So I make sure am in my protective gear all the time when am attending to 
infectious patients.” (Health Worker 1- Focus Group Discussion, May 14, 2018.) 
 
“As a lab technician, I always protect myself with gloves to prevent contact with samples 
I take in the laboratory.” (Health Worker 2- Focus Group Discussion, May 14, 2018.) 
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“I adhere to all the safety measures to the highest degree when administering health care 
to infectious patients because I know the least negligence may cause me a lot.” (Health 
Worker 3- Focus Group Discussion, May 14, 2018.) 
 
On the other hand, there were mixed perception of risk exposure among the men and 
women’s groups. The discussants noted: 
“As a Catholic, my faith mandates me to take care of the sick. We call it the Corporal 
Works of Mercy. So I don’t think I can get infected since it is a religious mandate. God 
protects me.” (Man 1- Focus Group Discussion, May 16, 2018.) 
“God is not wicked to look on for me to get infected when I am taking care of a sick relative 
and helping him to get well.” (Woman 2- Focus Group Discussion, May 16, 2018.) 
 
“I believe I can get infected when I relate with a sick person because I don’t have gloves 
and stuffs. Sicknesses like chicken pox and cough are contagious so I can also get it from 
the person.” (Man 2- Focus Group Discussion, May 16, 2018.) 
 
“Infectious diseases are contagious so I stand the chance of getting infected when 
someone I live with is a victim. Because air has no boundaries. Example, when the person 
is suffering from TB” (Woman 2- Focus Group Discussion, May 16, 2018.) 
   
A portion of them believe taking care of their sick relatives brings blessings and not a 
curse, therefore they cannot be infected. On the other hand, others also believe they are 
exposed, considering the fact that they do not have access to water proof gloves and 
disinfectants. This is consistent with the quantitative data that was gathered. 
  
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5.6 Summary  
91.9% of respondents in this study have knowledge of infectious diseases. However, 
86.6% believe they can contract infectious diseases from vehicles while 13.4% don’t think 
they can contract infections from vehicles. Drivers among the 13.4% respondents claim 
they keep their vehicles neat all the time so they do not stand the chance of contracting 
infections from the vehicle. Others made up of household individuals also think they are 
not at risk because they always sanitize their hands and also cover their mouth and nose 
when a passenger coughs or sneezes. A handful of the respondents also noted that they are 
immune to infectious diseases by faith which is consistent with Anyan (2017) who 
observed that religious faith and beliefs play a role in health coping strategies. However, 
there is a significant relationship between risk perception and demographic characteristics 
(see Tables 5.1, 5.2, 5.3, and 5.4). 
 
 
 
  
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CHAPTER SIX 
6.0 SUMMARY, CONCLUSION, RECOMMENDATIONS, AND DIRECTION 
FOR FURTHER STUDIES. 
 
6.1 Introduction 
This chapter contains the summary of the study with the topic: “Public Transport and the 
spread of infectious diseases; a case of Greater Accra Metropolitan Area (GAMA)”. Based 
on the presentation and analysis of data in the previous chapters, it further draws 
conclusions on all the studies conducted and provide recommendations. 
 
6.2 Summary of Main Findings 
This study was aimed at achieving five specific objectives. The first was to assess the main 
transport modes used during emergency situations. The second was to examine the 
protocols employed to prevent vehicle infection. The third was to analyze risk factor and 
exposure of people involved in infectious patient care. The forth objective was to discuss 
the perception of risk of the key actors in the chain, while the fifth and last objective was 
to analyze the effectiveness of medical emergency delivery system in addressing these 
issues. The Environmental Health Hazard Pathway model of Corvalan and Kjellstrom 
(1995) was adopted and modified to explain the phenomenon under study.  
From the primary data gathered, the main transport modes used during emergency health 
situations are taxis due to their availability, affordability, reliability, convenience, and 
effectiveness. However, these taxis do employ only normal cleaning methods such as 
detergents and resorting to the washing bay rather than the standard protocols for vehicle 
disinfection.  
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Analysis from previous chapters indicate that all the people (Nurses and Doctors) involved 
in infectious patient care are at risk but not vulnerable to infectious diseases as they adhere 
to safety precaution in the cause of carrying out their duties. All the key actors in the chain 
including: household individuals, drivers, passengers, health workers and patients are 
aware of the everyday risk associated with transporting patients with public transport. This 
findings therefore rejects the null hypothesis of the study. However the use of public and 
private transport as ambulance has become an acceptable risk due to the deficiency of the 
emergency medical transport delivery system (ambulance service) in Ghana.  
Meanwhile the standard protocols of vehicle disinfection are not adhered to. This leaves 
both drivers and passengers at risk of infectious diseases because, patients being 
transported may cough, vomit, urinate, or exude pathogenic microorganisms in vehicle. 
And since effective protocols are not employed in disinfecting vehicles afterwards, 
persons who come into contact with vehicle may absorb these microbes. This may lead to 
infection which will lead to sickness or loss of life as illustrated in conceptual framework 
(see figure 1.1). 
 
6.3 Conclusion 
Every individual will want the best pre-hospital care and timely intervention during 
emergency health situations. It is however not the wish for anyone to resort to vehicles 
(taxis) that are not designed for such purpose in times of emergency, but it only happens 
because the system provides no option. This therefore has become an “acceptable risk” to 
both authorities and individuals.  
In this case, should there be a single case of an infectious disease like Ebola in Ghana, one 
can imagine the rate at which it will spread and the losses considering the mode of 
transportation used during emergencies, and the cleaning methods employed by drivers 
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after service delivery. It is therefore crucial for the government and relevant stakeholders 
to put in the necessary measures to curb the spread of infectious diseases through transport, 
while ensuring the effectiveness of emergency medical transport delivery across the 
country because “prevention is better than cure”. 
 
6.4 Recommendations 
Based on the findings of the study, the following short term and long term 
recommendations are proposed in preventing the spread of infectious disease via public 
transport; 
 
6.4.1 Education 
The research findings have is that, majority of the people have the risk knowledge of public 
transport and infectious diseases which is welcoming. However, a handful of the 
population do not have the risk knowledge. This indicates that there is the need to eradicate 
the ignorance of the few people in the respective population. Therefore the ministry of 
health and the Ghana Health Service should target stakeholder institutions especially the 
GPRTU and religious bodies, to educate their members and congregation respectively. 
This will go a long way to add up to the risk knowledge and ensure the abolition of 
attributing faith and belief to risk. 
 
6.4.2 Provision of Logistics to Various Health Facilities 
Both government and Non-Governmental Organizations should help the Ministry of 
Health and the Ghana Health Service to provide the various health facilities with adequate 
logistics (disinfectants/fumigants, gloves, amongst others), so that any vehicle that 
conveys an infectious patient is fumigated at the facility (destination) before leaving the 
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facility. This will help address the problem of inadequate logistics at the health facilities 
due to financial constraints. Moreover, there will be no excuse for both healthcare 
providers and drivers for not adhering to the SOPs 2016. 
 
6.4.3 Law Enforcement 
This study revealed that people including key stakeholder institutions are unaware of the 
SOPs 2016 which outlines the standard protocols of transporting infectious bodies. The 
SOPs 2016 on transporting and translocation of infectious patients and dead bodies should 
be made available to all stakeholders. Recalcitrant individuals and institutions should be 
punished to serve as deterrence.  This will help ensure the effective enforcement of the 
law.    
 
6.4.4 Equipping the Ambulance Service 
Majority of respondents in this research used or prefer to use other means other than the 
ambulance during emergency health situations due to the ineffectiveness of the Ghana 
Ambulance Service. This is because the Ghana Ambulance Service is unable to timely 
meet the demands of victims considering the challenges facing the Ambulance Service in 
Ghana which includes inadequate ambulances, equipment, and staff. Therefore 
Government should add emergency service delivery to its priority by equipping the Ghana 
Ambulance Service with adequate ambulances and staff, to make the service efficient and 
effective. This will help reduce the reliance on public and private transport during 
emergency health situations and also curb the possible spread of infectious diseases. 
 
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6.4.5 Expansion and demarcation of roads 
The Ministry of Roads and Highways as well as the Ministry of Transport with the support 
from government must construct new roads and expand already existing roads. Emergency 
lanes should be demarcated on our roads like the Bus Rapid Transport (BRT). This will 
help facilitate efficient transportation and timely response of the Ambulance Service 
during emergencies. 
 
6.5 Direction for Further Studies 
This study revealed that motor bikes are not used to transport sick patients during 
emergencies. However it can still play a role in spreading infectious diseases especially 
via the helmet that is being used by different people who patronize commercial motor taxi 
(Okada) services. As illustrated in the conceptual frame work (see Figure 1.1), 
concentration of microorganism in the helmet from an infectious person can be absorbed 
by another person who wears it. Although motor taxi service is illegal in Ghana, it still 
remains a lucrative transport business in the country (Oteng-Ababio and Agyeman, 2012) 
as some people patronize the service. Therefore, new and further studies should be directed 
towards the area of motor taxi and infectious diseases. 
 
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org. au. Accessed: 10th February. 
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Ghana Health Service (2015). 2014 Annual Report. 
 
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Yoo, S.W., Kim, J., & Lee, Y. (2018). The effect of health beliefs, media perceptions, and 
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communication.33(1), 32-4.  
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APPENDIX 1 
KEY INFORMANT INTERVIEW GUIDE 
 
AMA Environmental Health, NADMO, GPRTU 
1. Is there a policy that regulates the transportation of infectious patients and 
dead bodies? 
2. How does your institution ensure the effectiveness of the policy? 
3. What are the challenges you face in enforcing the law? 
 
Ghana National Public Health Reference Laboratory (Ministry of Health) 
1. How can public transport (vehicles) spread infectious diseases? 
2. What precautions and cleaning protocols should be employed to prevent vehicle 
infections? 
3. How are those involved in direct patient care at risk of infectious diseases? 
4. What precautions and protocols should those involved in direct patient care employ 
to reduce risk of infection? 
Ambulance Drivers/Hearse 
1. What precautionary measures do you put in place when transporting patients to 
reduce risk of infection? 
2. What protocols do you employ in cleaning vehicles after transporting patients? 
3. Do you think the precautions and protocols are effective in preventing disease 
spread? 
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APPENDIX 2 
FOCUS GROUP DISCUSSION GUIDE 
 
Health Personnel 
1. Can you be infected when attending to infectious patients? 
2. What precautionary measures do you put in place when attending to infectious 
patients? 
3. Do you think these measures are effective in protecting you from getting infected? 
 
Men and Women from Households 
1. Can you catch infectious diseases through public transport patronage? 
2. What measures do you adopt to reduce risk of infection? 
3. What do you consider before opting for a transport mode during emergency health 
situations? 
4. Is the emergency medical transport system in Ghana effective? 
5. What should be the way forward?  
  
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APPENDIX 3 
DEPARTMENT OF GEOGRAPHY AND RESOURCE DEVELOPMENT 
UNIVERSITY OF GHANA, LEGON 
 
 
RESEARCH QUESTIONAIRE FOR HOUSEHOLDS 
 
INTRODUCTORY REMARKS 
I am Eric Sepenu Afli, a student at the University of Ghana, Legon, department of 
Geography and Resource Development. I am currently undertaking my research project 
as a requirement for the award of Master of Philosophy of Geography and Resource 
Development. The study is on Public Transport and the Spread of Infectious Diseases; 
A Case of Accra Metropolitan Area.  
The findings and recommendations of the study will help reduce the everyday risk 
associated with transportation, contribute to the knowledge base in the education sector 
and also ensure appropriate policy interventions. Therefore, I would like to collect data 
that will assist in accomplishing the objectives of this study.  Your contribution will be 
much appreciated and the information provided will be treated with utmost confidentiality.  
Kindly answer the questions in this questionnaire. 
NB: Kindly answer the question by ticking and/or explaining. 
 
A. RISK PERCEPTION 
 
1. Do you know about infectious/communicable diseases? 
 Yes     No 
 
2. Do you think transportation can spread infectious/communicable disease? 
 Yes    No 
 
3. If you answered Yes in question 2, in what way(s) do you think transport can 
spread infectious/communicable diseases? 
 Body contact with infectious passenger on-board 
 Body contact with infected part of vehicle 
 Breathing contaminated air on-board 
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 Other (specify)         
     
 
 
4. Do you think you can contract infectious/communicable diseases through 
transport? 
 More likely     Likely     Less likely      Not likely 
 
5. Give reason(s) for your answer in question 4.     
          
          
          
          
          
          
   
 
 
B. EMERGENCY TRANSPORT DELIVERY 
 
6. Which transport mode do you patronize often? 
 Taxi         Van (Trotro)        Bus        Motor bike       Personal/Private 
vehicle 
 
7. Which transport mode will you resort to in case of emergency health situation? 
 Ambulance   Taxi  Van (Trotro)  Bus  Motor bike   Personal/Private 
vehicle 
 
8. Give reason(s) for your preference in question 7.    
          
          
          
          
           
 
C. RESPONDENT’S DETAILS 
 
9. Gender: 
    Male     Female 
 
10. Age: 
 18-24       25-29      30-34      35-39       40-49       50-59        60 and 
above  
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11. Level of Education: 
 Primary     JHS/JSS      O level      SHS/SSS      Tertiary      None 
 
12. Religion 
 Christian     Islam     African Tradition    Other    
   
 
  
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APPENDIX 4 
DEPARTMENT OF GEOGRAPHY AND RESOURCE DEVELOPMENT 
UNIVERSITY OF GHANA, LEGON 
 
 
RESEARCH QUESTIONAIRE FOR DRIVERS 
 
INTRODUCTORY REMARKS 
I am Eric Sepenu Afli, a student at the University of Ghana, Legon, department of 
Geography and Resource Development. I am currently undertaking my research project 
as a requirement for the award of Master of Philosophy of Geography and Resource 
Development. The study is on Public Transport and the Spread of Infectious Diseases; 
A Case of Accra Metropolitan Area.  
The findings and recommendations of the study will help reduce the everyday risk 
associated with transportation, contribute to the knowledge base in the education sector 
and also ensure appropriate policy interventions. Therefore, I would like to collect data 
that will assist in accomplishing the objectives of this study.  Your contribution will be 
much appreciated and the information provided will be treated with utmost confidentiality.  
Kindly answer the questions in this questionnaire. 
NB: Kindly answer the question by ticking and/or explaining. 
 
A. PROTOCOLS/DISINFECTION PRACTICE 
 
13. What type of vehicle do you use/drive? 
 Personal Vehicle     Taxi      Van (trotro)     Ambulance 
 
14. Have you ever transported patients (sick passengers) especially during 
emergencies? 
 Yes      No  
 
15. Have you ever recorded any death in your vehicle in the process of transporting 
patients? 
      Yes      No  
 
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16. Have you ever conveyed a dead body to or from the morgue? 
      Yes      No  
 
17. If your answered ‘Yes’ to any of the questions from 2-4, did you clean the 
vehicle after delivering the services? 
      Yes      No  
 
18. If you answered Yes in question 5, what cleaning method did you use? 
 
 Fumigation    Washing Bay     Detergents      Airing    Ritual Cleansing  
 
             Other (specify)          
 
19. Give reason(s) for your method in question 6.     
          
          
          
          
          
          
   
 
 
B. RISK PERCEPTION 
 
20. Do you know about infectious/communicable diseases? 
 Yes     No 
 
21. Do you think your vehicle can spread infectious/communicable disease? 
 Yes    No 
 
22. If you answered Yes in 9, in what way(s) do you think your vehicle can spread 
infectious/communicable diseases? 
 Body contact with infectious passenger on-board 
 Body contact with infected part of vehicle 
 Breathing contaminated air on-board 
 Other (specify)         
     
 
 
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23. Do you think you and/or passengers can contract infectious/communicable 
diseases from your vehicle? 
 More likely     Likely     Less likely      Not likely 
 
24. Give reason(s) for your answer in 11.      
          
          
          
          
          
          
   
 
 
C. RESPONDENT’S DETAILS 
 
25. Gender: 
    Male     Female 
 
26. Age: 
 18-24       25-29      30-34      35-39       40-49       50-59        60 and 
above  
 
27. Level of Education: 
 Primary     JHS/JSS      O level      SHS/SSS      Tertiary      None 
 
28. Religion 
 Christian     Islam     African Tradition    Other (specify)   
   
  
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APPENDIX 5 
DEPARTMENT OF GEOGRAPHY AND RESOURCE DEVELOPMENT 
UNIVERSITY OF GHANA, LEGON 
 
 
RESEARCH QUESTIONAIRE FOR PATIENTS (PASSAENGERS) 
 
INTRODUCTORY REMARKS 
I am Eric Sepenu Afli, a student at the University of Ghana, Legon, department of 
Geography and Resource Development. I am currently undertaking my research project 
as a requirement for the award of Master of Philosophy of Geography and Resource 
Development. The study is on Public Transport and the Spread of Infectious Diseases; 
A Case of Accra Metropolitan Area.  
The findings and recommendations of the study will help reduce the everyday risk 
associated with transportation, contribute to the knowledge base in the education sector 
and also ensure appropriate policy interventions. Therefore, I would like to collect data 
that will assist in accomplishing the objectives of this study.  Your contribution will be 
much appreciated and the information provided will be treated with utmost confidentiality.  
Kindly answer the questions in this questionnaire. 
NB: Kindly answer the question by ticking and/or explaining. 
 
A. ACCESS TO EMERGENCY TRANSPORT 
 
29. Have you ever been under emergency health situation? 
 Yes      No 
 
30. Which mode of transport did you use? 
 Ambulance    Taxi     Van (Trotro)    Private Vehicle   Motor Bike 
(Okada)  
 
31. What made you use the transport mode in question 3? 
 That was the only available mode of transport  
 It was affordable     
 That was the only convenient mode for me 
 All the above 
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 Other (specify)         
   
 
32. Did the transport mode in question 3 meet your need satisfactory? 
 Yes    No 
 
33. Give reason(s) for your answer in question 5.     
          
          
          
          
          
          
   
 
B. RISK PERCEPTION 
 
34. Do you know about infectious/communicable diseases? 
 Yes     No 
 
35. Do you think you can contract infectious/communicable disease from vehicle 
you board? 
 Yes    No 
 
36. If you answered Yes in 9, in what way(s) do you think you can contract 
infectious/communicable diseases from the vehicle board? 
 Body contact with infectious passenger on-board 
 Body contact with infected part of vehicle 
 Breathing contaminated air on-board 
 Other (specify)         
     
 
 
37. How likely do you think you can contract infectious/communicable from the 
vehicle you board? 
 More likely     Likely     Less likely      Not likely 
 
38. Give reason(s) for your answer in 11.      
          
          
          
          
          
          
   
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C. RESPONDENT’S DETAILS 
 
39. Gender: 
    Male     Female 
 
40. Age: 
 18-24       25-29      30-34      35-39       40-49       50-59        60 and 
above  
 
41. Level of Education: 
 Primary     JHS/JSS      O level      SHS/SSS      Tertiary      None 
 
42. Religion 
 Christian     Islam     African Tradition    Other (specify)   
   
 
 
 
 
 
 
 
 
 
  
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APPENDIX 6 
WASHING BAY OBSERVAION CHECKLIST 
 
1. Is the attendant wearing protective gear?   
     Yes        No 
 
 
 
2. Did the attendant apply disinfectant? 
     Yes         No 
         
 
3. Is the attendant’s cleaning procedure in line with the 
Ghana Health Service SOPs 2016? 
        Yes      No 
 
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