ABSTRACT
This research was done using multiple methods case study to determine if
environmental sanitation conditions affect malaria infection rates in children of two
communities; one urban area and one rural area. Fasari settlement in Kuje Area
Council was the rural case study while Wuse zone 6-, Abuja was the urban case
study. The specific aim of this research was to investigate the incidence of malaria in
children under 5- in relation to environmental sanitation conditions in the two
communities. Fasari and Wuse Zone 6- was used because of the different
environmental conditions.
vii
The research was done within the months of February and April 2015, also
the study made use of all available records at the Federal Staff Hospital, Abuja.
Information was obtained from design questionnaire, a total of 50 cases notes were
studied and analysed.
My research didn’t specifically show that environmental sanitation is
responsible for different malaria rates in the two study areas. This was because the
respondents in Wuse Zone 6 were using prophylaxis for their children and the
respondents in Fasari rural settlement had no records of malaria incidence of their
children.
Conclusively, malaria is a treatable ailment that continues to cause death to
children under the age of five years. Environmental factors such as stagnant water,
bushy environment and poor environmental sanitation play an important role in
spreading the disease.
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TABLE OF CONTENTS
Title page ……………………………………………………………………………………. i
Certification ……………………………………………………………………………….. ii
Readers’ approval ………………………………………………………………………. iii
Dedication ………………………………………………………………………………… iv
Acknowledgement ……………………………………………………………………….. v
Abstract ……………………………………………………………………………….. vi-vii
Table of contents…………………………………………………………………… viii-ix
List of figures …………………………………………………………………………….. x
Introduction …………………………………………………………………………………………………………. 1
Background ………………………………………………………………………………………………………. 1
Research Rationale (Importance of the Study) ………………………………………………………… 2
Environmental Sanitation ……………………………………………………………………………………. 3
Water-Related Diseases ………………………………………………………………………………………. 5
Malaria…………………………………………………………………………………………………………….. 8
Malaria Impact on Children’s Health …………………………………………………………………… 10
Statement of problem ……………………………………………………………………………………….. 12
Specific aim ……………………………………………………………………………………………………. 12
Objectives ………………………………………………………………………………………………………. 12
Null Hypothesis (H0) ………………………………………………………………………………………… 13
Research Hypothesis (H1) ………………………………………………………………………………….. 13
Study Area ……………………………………………………………………………………………………… 13
Methodology ………………………………………………………………………………………………………. 13
Study Sites ……………………………………………………………………………………………………… 13
Rural Area………………………………………………………………………………………………………. 13
Urban Area …………………………………………………………………………………………………….. 15
Research Design ………………………………………………………………………………………………. 16
Comparative Case Study …………………………………………………………………………………… 16
Prospective Case Study …………………………………………………………………………………….. 16
Cross Sectional Case Study ……………………………………………………………………………….. 16
Data Analysis ………………………………………………………………………………………………….. 17
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Research Challenges ………………………………………………………………………………………… 17
Result …………………………………………………………………………………………………………….. 18
Result from Comparative Study ………………………………………………………………………….. 18
Result from prospective Study ……………………………………………………………………………. 26
Result From Cross Sectional Study ……………………………………………………………………… 28
Discussion …………………………………………………………………………………………………………. 31
The poor environmental sanitation of Fasari community …………………………………………. 31
From the comparative case study ………………………………………………………………………… 31
From the prospective and cross-sectional case studies …………………………………………….. 33
Conclusion …………………………………………………………………………………………………………. 34
Recommendations ……………………………………………………………………………………………….. 35
References …………………………………………………………………………………………………………. 37
Appendix……………………………………………………………………………………………………………. 40
x
List of Figures
Figure 1: How environmental sanitation can reduce malaria in children of Fasari……………. 19
Figure 2: How environmental sanitation can reduce malaria in children of Wuse Zone 6….. 20
Figure 3: Environmental Conditions of Fasari and Wuse Zone 6. …………………………………. 20
Figure 4: How often environmental sanitation is carried out in Fasari and Wuse Zone 6…… 21
Figure 5: Awareness of traditional medication in Fasari and Wuse Zone 6 for curing malaria
in children. …………………………………………………………………………………………………………. 22
Figure 6: Respondent in Fasari and Wuse Zone 6 with children. ………………………………….. 22
Figure 7: Respondents children in Fasari and Wuse Zone 6 that have had malaria infection.23
Figure 8: Frequency of medical check-up of children in Fasari and Wuse Zone 6. …………… 24
Figure 9: Distance of health facilities in Fasari and Wuse Zone 6 ………………………………… 25
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CHAPTER ONE
Introduction
Background
Living in a clean environment, access to sanitation facilities and good health
is every child’s right. However, many children in developing countries such as
Nigeria lack safe and clean environment sanitation and good health (IRC
International Water and Sanitation Centre, 2001). School-going children also lack
environment sanitation facilities, leading to possible health effects. Lack of proper
maintenance and preservation of the environment causes potential danger to the
health of children at home and in schools. Provision of sanitation facilities does not
make healthy physical learning environment sustainable, but utilization of such
facilities and related hygiene behaviors that lead to accrued health benefits. In
schools, hygiene education aims to boost sustainable environment sanitation
practices that will help in preventing water and environmental sanitation-related
diseases. In practice, the sanitary situation in many schools and many homes in
Nigeria is unacceptable. Water supply and sanitation practices are inadequate to
many school-going children in schools and at home. Children use non-functional
toilets and latrines that lack water for flushing whereas some are open with freely
flowing sewage. These conditions make schools and homes unsafe places for
children where waterborne infectious diseases such as diarrhea and cholera and
water-related vector-borne diseases such as malaria are rampant (WHO, 1997).
Nigeria experiences high child mortality rates from malaria (30%) as one of
the water-related vector-borne diseases. Other diseases that kill include diarrhea and
dysentery. Carrier mosquitoes that breed in stagnant water cause malaria. Therefore,
poor environmental sanitation practices that result to stagnant water provides such
2
breeding grounds for mosquitoes. Consequently, the rates at which children are
infected by the deadly disease tend to increase. The millennium development goals
(MDGs) adopted by the United Nations in 2000 aimed at reducing such diseases and
poverty. Accordingly, the first MDG’s objective was eliminating and reversing the
effects of malaria and other main diseases by 2015. Despite the fact that the MDGs
were set and adopted worldwide, many African countries failed to initiate the
strategies to combat malaria. The MDGs and the Malaria Declaration in Abuja in
2000 have had minimal impact on the spread of the disease and related death cases.
Additionally, Nigeria recorded a growing resistance of the malaria disease to first
line drugs. As such, infected people use the expensive ACT combination therapy.
Malaria in children is a prevalent issue in Nigeria, where more than half of the
population lives below the poverty line. Living under such conditions condemns
majority of the children to living in poorly preserved physical environment. Lack of
basic environmental sanitation practices leads to increased malaria cases.
Research Rationale (Importance of the Study)
Many diseases, including malaria are not only the result of malnutrition and
poverty, but also the result of environmental risk factors. As such, it is important to
consider environmental health issues that affect a child’s health. In addition, it is
paramount to discuss water-related diseases that pose danger to a child’s survival
especially in malaria-stricken areas. This study uses a case-study approach to
examine the relationship between environmental sanitation and malaria incidence in
rural and urban sites in Abuja; Nigeria. In order to attain sustainable results, there is a
need to improve preventive measures directed towards children’s health.
Additionally, preventive measures such as improving environmental sanitation are
3
successful in reducing children’s exposure to disease agents thus averting latent
infections. This literature review looks at the correlation between environmental
sanitation and malaria among children in Nigeria.
The main objective of this review is to provide required information to
decision-makers on the possible and appropriate policies to aid in the reduction of
children infections and deaths from malaria. The information will also help in
protecting the health and well-being of young children through providing sustainable
environment sanitation practices. This entails the reduction of the environmental risk
factors by offering suitable interventions that prevent exposure. In addition, this
review will also help in understanding the environmental risk factors, ways in which
the children are exposed, and how to alleviate the potential health impact.
Accordingly, the study will also provide a better understanding of the relationship
between environmental sanitation and malaria among children in Nigeria.
Environmental Sanitation
According to the WHO, environmental sanitation entails the control or
modification of the physical environment in order to avert the transmission of
diseases to humans. This involves access to a safe and adequate water supply-, and
sanitary disposal, free of human excreta. It also involves household waste
management and changing individuals’ behavior through hygiene education. The
International Drinking Water Supply Decade of 1981-1990 recorded a remarkable
increase in water supply and sanitation across the globe. As a result, over 1.6 billion
people could access safe water for drinking. However, in 2001, over 1.1 billion
people were without adequate sanitation and safe drinking water in the globe.
Further, in 2000, about 80% of Africans lacked improved sanitation and clean water.
4
In rural areas in China and India alone, over 1.3 billion people had inadequate
sanitation especially in rural areas. According to the WHO (2001), approximately
40% of the world’s population lacked adequate sanitation. Since 1990 to date,
efforts to achieve global coverage of sanitation and clean water have been
unsuccessful. This is attributed to rapid population growth that overwhelms the
improvements made and the extent of resources required to achieve the set goal. In
2011, about 2.5 billion people in the world use inadequate sanitation facilities and
approximately 1 billion people practice open defecation. In the same year, 64% of
the world’s population relies on improving sanitation amenities.
The situation in Africa alone is worse than other parts of the world. Africa
experiences the poorest environmental sanitation practices. According to 2000
statistics, only 62% of Africa’s population had access to improved sanitation and
clean water supply. The situation in rural areas in Africa was worse with only 47% of
the population enjoying adequate sanitation. Urban areas portray a different statistic
with about 85% of residents enjoying improved sanitation and clean water supply
(World Health Organizations, 2002). In 2012, sub-Saharan Africa recorded 44% of
the population that experience low sanitation coverage. An estimated 26% of the
population practices open defecation in this region (United Nations, 2011).
In Nigeria, the water situation and environment sanitation are also
unacceptable. The country’s population grows rapidly, with about 54% of the people
living in abject poverty. Even though the country has enough water to meet the
current drinking demand, lack of ability to distribute the water leads to inadequate
supply in some areas. Additionally, the population also suffers poor sanitation
amenities that pose public health problems to children. Efforts by the Minister of
Water Resources in the country initiated a program to improve water supply and
5
environmental sanitation. The efforts were successful where the country recorded an
improvement of 30% during 1999-2004 periods. In 2012, the country recorded
estimated improvements to 32% for improved sanitation. Despite these
improvements, the country still faces major challenges in achieving the Millennium
Development Goals.
The inability to achieve the MDGs through providing clean water and
environmental sanitation to its population is attributed various reasons. Bad
governance practices lead to poor environmental sanitation and inadequate of clean
water to the population. Numerous funds directed to sanitation and water sector from
the government and foreign aid are misappropriated and stolen through corruption.
This problem affects Nigeria and many other African countries. Consequently,
sanitation goals become difficult to achieve. Government officials also frustrate civil
society groups’ efforts in providing environmental sanitation practices. Secondly,
lack of political will and commitment by the government, civil societies and donors.
These stakeholders lack the commitment to ensure that environmental considerations
are implemented in order to achieve improved sanitation amenities. Such lack of
commitment is evident in health centers and schools that are built without toilets and
good drainage systems.
Water-Related Diseases
Water-related diseases are key barriers to sustainable development.
According to Toepfer (2004), disease statistics are especially tragic in the developing
countries such as Nigeria. Diarrhea and malaria are the largest causes of death in
children below the age of 5 years in Africa. Most of the deaths experienced are
preventable. Increased population, growing water demands and climate change have
6
led to vulnerability of water-related diseases. According to the WHO (2008), waterrelated
diseases can be categorized into, 1) waterborne infectious diseases such as
diarrhea and cholera and 2) water-related vector-borne diseases such as malaria.
Recent outbreaks of water-related diseases in parts of West Africa and especially
Nigeria have prompted different organizations towards establishing appropriate
methods to eliminate and prevent the spread. In earlier years, health and sanitation
education in Nigeria concentrated on teaching theory and memorization of facts on
water-related diseases. The official curriculum ignored the practical implementation
of sanitation through strengthening hygiene practices. Nigeria government offered
formal, non-specific civic and school education that failed in enabling people on how
to eliminate and prevent the spread of water-related diseases. The most affected parts
of the country are the rural areas where majority of residents lack basic water
sanitation practices. Additionally, schools topics on sanitation have been disregarded
because the curricula fail to accommodate adequate teachings on water sanitation and
hygiene. Nigerians also experience water shortages and water infrastructure
problems in the some urban and rural areas leading to difficulties in maintaining
water sanitation (Wright et al., 2004). Many people collect water for daily survival
from any available water collection points rendering the fight against water-related
diseases even more difficult (Newsom, 2006). In spite of all the efforts made by the
Nigerian government agencies, the non-governmental organizations, and local
interest groups, basic sanitation in schools and major cities remains poor. Both urban
and rural areas, schools and health centers have limited access to appropriate sanitary
facilities.
The majority of Nigerians in rural areas and poor urban settlements lack basic
requirements such as latrines and hand washing amenities The few available sanitary
7
facilities are poorly managed and periodically non-functional (UNEP, 2008).. Failed
efforts in eliminating and preventing water-related diseases are attributed to lack of
prioritizing environmental sanitation in rural and urban areas by the local authorities.
Consequently, the majority of the cities and schools do not have access to proper
sewerage systems. The pit latrines used especially in the rural areas serve as the only
sanitation facilities. However, the pit latrines are also poorly maintained, especially
in public places and schools leading to unhygienic conditions. Other sections of
urban areas experience burst and open sewers that flow across residential areas,
creating pools of stagnant water that form breeding grounds for mosquitoes (UNEP,
2008).- Under such conditions, the cities, schools and other public areas have
become hazardous where the water-related diseases such as cholera, dysentery,
malaria, and diarrhea originate and spread. Suffering from either of these waterrelated
diseases affect the ability to partake any economic activities to improve the
people’s living standards. As such, the families continue living in the same poor
sanitation areas leading to the continuous challenges in containing the diseases.
Additionally, the government uses many funds in treating the diseases leading to
lesser focus on improving sanitation and preventing them. In schools, affected
children suffer from poor health, causing the inability to learn.
Many water-related disease interventions have been successful. However, the
results have not been sustainable over the years. Efforts in parts of the country have
failed to attain the set targets with the diseases reemerging. The Nigerian
government also lacks appropriate systems that can be used in educating and
facilitating water sanitation in all the affected areas.
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Malaria
Malaria is a vector-borne disease caused by parasites of the genus
Plasmodium. Scientifically, four main Plasmodium species infect humans with
malaria. These species include Plasmodium falciparum, P. ovale, P. malariae and P.
vivax. Of the four species, P. falciparum, transmitted by the female Anopheles
mosquito, is the most common and deadly. If untreated, malaria caused by P.
falciparum can cause cerebral malaria. Infected humans experience fever pain in the
joints, nausea and continuous vomiting, shivering, and severe abdominal pains. At
and advanced disease level, victims experience convulsions, coma, and extreme
fatigue and diminished immunity to other diseases. In Nigeria, human malaria is a
major threat to children. According to Miller (2000), if untreated, malaria caused by
P. falciparum may lead to severe malaria and eventual death.
Malaria incidences vary according to the weather that affects the ability of the
survival of Anopheles mosquitoes. Nigeria experiences tropical climate described by
a combination of high rainfall, temperature, and humidity, especially in the South of
the country that encourages breeding of the mosquitoes. As such, Nigeria has a large
inhabitant at risk of malaria. Consequently, malaria poses a major health issue in the
country with constant transmission across the country. According to National
Malaria Control Plan of Action (1996 & 2001), malaria accounted for about 50% of
the outpatient consultations in all hospitals. In addition, 15% of the hospital
admissions made were patients suffering from malaria. The disease is also
considered as an economic and social problem because of the funds dedicated to
solving the endemic. According to WHO (2005), Nigeria government spent over
US$3.5 million and additional US$ 2.3 million from other stakeholder sectors in
attempts to control the malaria menace in 2003. Additionally, about 50% of the
9
population in Nigeria experience at least one malaria episode annually (WHO, 1995:
WHO, 2002). Alarmingly, the situation is getting worse because of the increased
malaria resistance to the cheap and readily available first line anti-malarial drugs
(WHO, 2002). The resistant malarial infections constitute over 90% of the reported
cases of all tropical diseases in the country (Alaba, 2005). Evidence from the
Nigerian malaria report in 2005 shows an increase in infections from 1.12 million in
1990 to 2.25 million in 2000 and 2.61 million by the end of 2003 (WHO, 2005).
Malaria is a treatable ailment that continues to cause death to children under
the age of five years in rural areas of Nigeria. Statistically, malaria causes over a
million deaths in the world and 90% of these deaths occur in Africa. The disease is
common and occurs approximately three to four times annually in young children. It
is also responsible for about 25% of infant deaths and 30% of childhood death in the
country, UNICEF, 1998: Federal Ministry of Health, 2008). The disease causes
severe anemia and cerebral infections among other complications in children under
the age of five. Annually, Nigeria records approximately 100 million episodes of
malaria infections in children below the age of five years (Federal Ministry of
Health, 2008). The childhood mortality rate is 143 deaths per 1,000 live births in
Nigeria due to malaria (WHO, 2012). Most of these deaths occur a few days after
developing symptoms of malaria. Some deaths occur due to self-treatment at home.
This is where a child does not receive early treatment from hospitals, but instead,
self-medication is administered from anti malarial from medicine sellers. In
appropriation or delay of proper treatment also causes death in children (Goodman et
al, 2007).
Malaria transmission depends on the prevalence of the infection in man,
seasonal incidence, the characteristics of the indigenous mosquito, and vulnerability
10
to infection. The overall biological cycle of a mosquitoes’ life is identical with the
egg, larval and pupae stages. Nigeria’s weather is conducive for the breeding of all
species of mosquitoes. The eggs are deposited in particular aquatic habitats and other
stagnant, water-containing structures, natural or artificial. In most cases, poor
environmental sanitation practices lead to formation of artificial breeding grounds for
the mosquitoes. For example, presence of poorly drained surface water and open
sewers in urban and rural areas provide mosquitoes with suitable breeding
environment. Additionally, poorly serviced water system infrastructure and
abandoned projects in cities and rural areas provide aquatic habitats for mosquitoes’
breeding. Poor governance activities and corruption has resulted in incomplete water
infrastructure such as cisterns, canals, ditches, reservoirs and water-filled potholes all
over the country provide artificial breeding grounds for mosquitoes. After
approximately 3 days, an adult mosquito emerges from the pupae. A female adult
mosquitoes feed on blood and in the process may infect humans with malaria.
Children in Nigeria are vulnerable to potential malaria infections since most of the
breeding grounds are close to the playing grounds. The increase in malaria infections
is largely influenced by the distribution of the mosquito’s population that is
influenced by environmental conditions.
Malaria Impact on Children’s Health
Epidemiological studies propose that health shocks in children may result to
serious long-term health consequences. For example, young children may undergo
slowed brain development because of insufficient oxygen and nutrients caused by
suffering from malaria. Consequently, long-term impairment of mental abilities and
brain functions may follow. In addition, children who suffer from malaria are likely
11
to experience lower lifetime educational attainment and deteriorating health
outcomes in old age. Early exposure to malaria is also associated with lower
economic status in adulthood. This accrues from possible educational setbacks and
loss of important school days during the sick period. Small school-going children fail
to attend school whenever they are suffering from malaria. Treating the disease to
full recovery may take significantly longer time in children below the age of 10
years. As such, they end up losing many school days. Additionally, as
aforementioned, children in Nigeria are likely to experience 3 to 4 episodes of
malaria infection annually. This consumes most of their school time in hospitals
during treatment and recovery. In such cases, a child misses a significant number of
lessons in school. A continuation of this trend will have severe long-term educational
and economic effects in childhood and adulthood.
Other studies show that malaria causes lack of adequate hemoglobin
concentration in a child leading to anemia. Anemia is a widespread health problem,
especially in developed countries such as Nigeria. Majority of the anemia cases in
children are found in malaria-endemic areas in Sub-Saharan Africa. According to
WHO (2005) 30-90% of children under the age of 5 years from malaria infested
regions suffer from anemia. Of this, 5-15% suffers from severe anemia that result to
death because of malaria. Malaria contributes significantly to poor nutritional status
leading to possible malnutrition. Consequently, small children lack the essential iron
nutrient leading to anemia. Suffering from malaria eventually causes death if
untreated. Children and adults equally succumb to malaria in case the disease reaches
its last stages.
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Statement of problem
It is known that malaria is a deadly infectious disease which is common
especially in children below the age of five. Recent study shows that Nigeria holds
25% of malaria disease burden in Africa, contributing to the one million lives lost
each year in the region, most of which are children and pregnant women. Even
though malaria is a curable disease, it is an endemic and a major public health issue.
“In Nigeria, malaria-related deaths account for up to 11 percent of maternal
mortality. Additionally, they contribute up to 25 percent of infant mortality and 30
percent of under-5 mortality, resulting in about 300,000 childhood deaths annually”
(cite). Poor environmental sanitation conditions, such as pools of stagnant water,
promote the breeding of mosquitos, which are the vectors for malaria.
Specific aim
To investigate the incidence of malaria in children under 5- in relation to
environmental sanitation conditions in two sites, on rural (Fasari) and one urban
(Wuse Zone 6), in the Federal Capital Territory (FCT), Abuja, Nigeria.
Objectives
• To identify ways that local residents contribute to environmental conditions
around their homes.
• To evaluate medical records of malaria cases in children from urban hospitals
in Abuja.
• To determine the availability of health facilities in Fasari.
• To determine typical malaria prevention and control strategies used in urban
hospitals in Abuja, Nigeria.
13
• To make recommendations regarding environmental sanitation as it pertains
to child health.
Null Hypothesis (H0)
Environmental sanitation conditions have no effect on the incidence of
malaria in children.
Research Hypothesis (H1)
The incidence of malaria in children is higher in areas with poor
environmental sanitation conditions than areas with better sanitation conditions.
Study Area
This research was conducted in the Federal Capital Territory, Abuja a central
part of Nigeria. FCT Abuja has six local government areas namely; Abaji, Abuja
municipal council (AMAC), Bwari, Kuje, Kwali, and Gwagwalada local
government. This research was conducted in the Abuja Municipal Council (AMAC)
and Kuje Local Government Area.
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