ENSIGN GLOBAL COLLEGE, KPONG FACULTY OF PUBLIC HEALTH DEPARTMENT OF COMMUNITY HEALTH POST-FLOOD HEALTH RISKS AND CHALLENGES TO HEALTHCARE ACCESSIBILITY IN SELECTED DISTRICTS IN GHANA: CASE STUDY OF THE AKOSOMBO DAM SPILLAGE By GLADSTONE ELIKEM DOH (237100256) SEPTEMBER 2024 ENSIGN GLOBAL COLLEGE, KPONG FACULTY OF PUBLIC HEALTH DEPARTMENT OF COMMUNITY HEALTH POST-FLOOD HEALTH RISKS AND CHALLENGES TO HEALTHCARE ACCESSIBILITY IN SELECTED DISTRICTS IN GHANA: CASE STUDY OF THE AKOSOMBO DAM SPILLAGE BY DOH GLADSTONE ELIKEM gladstone.doh@st.ensign.edu.gh (237100256) A THESIS SUBMITTED TO THE DEPARTMENT OF COMMUNITY HEALTH, SCHOOL OF PUBLIC HEALTH IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE MASTER OF PUBLIC HEALTH DEGREE September 2024 mailto:gladstone.doh@st.ensign.edu.gh i DECLARATION I hereby declare that this thesis has been the result of my own research, except references cited that have been duly acknowledged. It has never been submitted in part or full for any award of my intended degree. Name of Student Doh Gladstone Elikem ……………………….. September ………, 2024 Signature Date Supervisor Dr Millicent Ofori Boateng ………………………... September ………, 2024 Signature Date Head of Academics Dr Stephen Manortey ………………………… September ………., 2024 Signature Date 22 30 ii DEDICATION This thesis is dedicated to the resilient people of the Central Tongu and Ada East Districts who endured the devastating impacts of the Akosombo Dam spillage in October 2023. Your courage and perseverance in the face of adversity serve as a profound source of inspiration. This work is especially dedicated to the families who lost properties and livelihoods but continue to rebuild their lives with unwavering strength. To the frontline rescue teams and community volunteers who selflessly helped during the floods, your commitment and dedication are invaluable. You are the unsung heroes who, despite the immense challenges, ensured that help reached the most vulnerable. I also dedicate this work to my family for their endless support and encouragement throughout this academic journey. Your unwavering belief in my abilities gave me the strength to persevere through this challenging project. Finally, to the future generations of researchers and public health professionals, may this work serve as a catalyst for more in-depth studies on post-flood health risks and healthcare accessibility challenges. I hope it inspires continuous efforts to develop sustainable solutions that improve the resilience of communities facing similar disasters. iii ACKNOWLEDGEMENT I am deeply grateful to the Almighty God for His divine guidance, protection, and inspiration throughout this academic journey. Without His grace, this work would not have been possible. I extend my deepest appreciation to my supervisor, Dr. Millicent Ofori Boateng, for her invaluable mentorship, insightful guidance, and unwavering support throughout the course of this research. Your dedication and critical feedback were instrumental in shaping this work. Special thanks to Dr. Sandra Kushitor, whose support and presence during data collection were invaluable. Your expertise and encouragement were crucial in navigating the challenging aspects of fieldwork, and your contributions greatly enriched the quality of this research. This thesis is a product of the Mepe Project, which examined the post-flood health risks and healthcare accessibility challenges following the Akosombo Dam spillage. I am immensely grateful to Sister Lynette Gay, whose generous funding made this project possible. I also extend my sincere gratitude to "Engage Now Africa" for their support and commitment to community development, which greatly facilitated this study. I am also grateful to the faculty members of Ensign Global College for their daily critiques and corrections that helped refine this thesis. To my family, I say "Ayekoo" (Well-done) for your unwavering support, encouragement, and love. iv DEFINITION OF TERMS Fluvial Floods – Where rivers/streams overflow their banks and water flows out onto the adjacent low-lying areas. Dam-mediated Floods – Flooding events caused by the release of water from a dam. Large Dam – A dam with a height of 15 metres or greater from lowest foundation to crest or a dam between 5 metres and 15 metres impounding more than 3 million cubic metres. Functional Health Facilities – A functional health facility is one that is fully operational, well- staffed, and equipped to provide essential healthcare services, including preventive, diagnostic, curative, and emergency care, while maintaining access to medical supplies, ensuring patient safety, and delivering quality care (Kruk et al., 2018). v LIST OF ABREVIATIONS ICLOD - International Commission on Large Dams IFRC – International Federation of Red Cross and Red Crescent LI – Legislative Instrument ABSTRACT Background: Floods are devastating natural disasters that have significantly impacted global public health, with dam-mediated flood events increasingly contributing to these public health concerns. Africa faces unique challenges in managing the health impacts of these dam-related floods. This study focuses on the health risks and healthcare access challenges faced by communities along the lower Volta River of Ghana following the Akosombo Dam spillage. Methods: A community-based cross-sectional survey was conducted involving 381 residents from three purposively selected communities. Participants were selected using a systematic random sampling technique. Data collection was done through structured questionnaires. The data were analysed using Stata version 17, with descriptive statistics, chi-square tests, and logistic regression employed to determine the significance of various factors, with a p-value set at 0.05. Results: The study found that a significant portion of the population (33.3%) reported experiencing health issues due to the flood, with skin infections being the most common, followed by vector-borne diseases and gastrointestinal issues. Access to healthcare services was significantly hindered, with 64% of respondents reporting the unavailability of functional health facilities during and immediately after the flood. Additionally, factors such as age, employment status, and pre-existing health conditions were identified as significant determinants of post-flood health risks. Conclusion: The Akosombo Dam spillage has highlighted the health risks and challenges in healthcare accessibility in the affected communities. The findings emphasize the need for improved disaster preparedness, better healthcare infrastructure, and community resilience- building to mitigate the impacts of such flooding events in the future. vi vii Keywords: Post-flood health risks, Healthcare accessibility challenges, Dam-mediated floods, Akosombo Dam spillage, Resilience-building practices. viii TABLE OF CONTENTS DECLARATION ........................................................................................................................................... i DEDICATION .............................................................................................................................................. ii ACKNOWLEDGEMENT ........................................................................................................................... iii DEFINITION OF TERMS .......................................................................................................................... iv LIST OF ABREVIATIONS ......................................................................................................................... v ABSTRACT ................................................................................................................................................. vi TABLE OF CONTENTS ........................................................................................................................... viii LIST OF TABLES ....................................................................................................................................... xi LIST OF FIGURES .................................................................................................................................... xii LIST OF MAPS ..........................................................................................................................................xiii 1 CHAPTER 1 ........................................................................................................................................ 1 INTRODUCTION ................................................................................................................................... 1 1.1 Background information ............................................................................................................ 1 1.2 Problem statement ...................................................................................................................... 3 1.3 Rationale for the study ............................................................................................................... 5 1.4 Conceptual framework .............................................................................................................. 6 1.5 Research Questions ..................................................................................................................... 8 1.6 General Objective ....................................................................................................................... 8 1.7 Specific Objectives ...................................................................................................................... 8 1.8 Profile of Study Areas ................................................................................................................. 9 1.8.1 Central Tongu District ........................................................................................................ 9 1.8.2 Ada East District ............................................................................................................... 10 1.9 Scope of Study ........................................................................................................................... 12 1.10 Organisation of Report ............................................................................................................. 12 2 CHAPTER 2 ...................................................................................................................................... 14 LITERATURE REVIEW .................................................................................................................... 14 2.1 Introduction ..................................................................................................................................... 14 2.2 Dam-Mediated Floods .................................................................................................................... 14 ix 2.3 Health Risks Associated with Post-Flooding ................................................................................ 16 2.4 Determinants of Post-Flood Health Risks ..................................................................................... 19 2.5 Challenges in Accessing Healthcare Facilities and Services Post-Flooding ............................... 20 2.6 Post-Flood Resilience-Building Practices ...................................................................................... 23 3 CHAPTER 3 ...................................................................................................................................... 25 METHODOLOGY ................................................................................................................................... 25 3.1 Research Methods and Design (Study methods and design) ................................................. 25 3.2 Data Collection Techniques and Tools .................................................................................... 25 3.3 Study Population ....................................................................................................................... 26 3.4 Study Variables ......................................................................................................................... 26 3.5 Sampling .................................................................................................................................... 29 3.6 Pre- Testing ................................................................................................................................ 31 3.7 Data Handling ........................................................................................................................... 31 3.8 Data Analysis ............................................................................................................................. 32 3.9 Ethical Considerations .............................................................................................................. 33 3.10 Limitations of Study ................................................................................................................. 33 3.11 Assumptions ............................................................................................................................... 33 4 CHAPTER 4 ...................................................................................................................................... 34 RESULTS .............................................................................................................................................. 34 4.1 Introduction ............................................................................................................................... 34 4.2 Sociodemographic Characteristics of Respondents ............................................................... 34 4.3 Variation in Sociodemographic Features across Districts .................................................... 38 4.4 Post-Flood Health Risks Assessment ....................................................................................... 38 4.5 Determinants of Post-Flood Health Risks ............................................................................... 40 4.6 Challenges in Accessing Healthcare Facilities and Services Post-flooding .......................... 42 4.6.1 Availability of Healthcare Facility during Floods .......................................................... 42 4.6.2 Variation in Respondents’ Views on the Availability of Functional Health Facility across the Districts ............................................................................................................................ 44 4.6.3 Access to Healthcare Services Post-flood ........................................................................ 45 4.6.4 Variation in Respondents’ Views on Access to Healthcare Services Post-flood across the Districts ........................................................................................................................................ 47 4.7 Resilience Building Practices and Post-Flood Preparedness................................................. 47 4.7.1 Resilience Building Practices ........................................................................................... 47 x 4.7.2 Variation in Resilient Building Activities Employed by Respondents across the Districts 49 4.7.3 Post-flood Preparedness Measures Implemented in the Community .......................... 51 5 CHAPTER 5 ...................................................................................................................................... 53 DISCUSSIONS ...................................................................................................................................... 53 5.1 Introduction ............................................................................................................................... 53 5.2 Post-Flood Health Risks Assessment ....................................................................................... 53 5.3 Determinants of Post-Flood Health Risks ............................................................................... 55 5.4 Challenges in Accessing Healthcare Facilities and Services Post-Flooding. ........................ 57 5.5 Post-Flood Resilience-Building Practices Among Residents ................................................. 58 6 CHAPTER 6 ...................................................................................................................................... 60 SUMMARY, CONCLUSION AND RECOMMENDATIONS ......................................................... 60 6.1 Summary .................................................................................................................................... 60 6.2 Conclusions ................................................................................................................................ 61 6.3 Recommendations ..................................................................................................................... 62 References .................................................................................................................................................. 64 Appendices ................................................................................................................................................. 68 Appendix 1 ............................................................................................................................................. 68 ETHICAL CLEARANCE ................................................................................................................ 68 Appendix 2 ............................................................................................................................................. 69 INFORMED CONSENT (PARTICIPANTS)................................................................................. 69 Appendix 3 ............................................................................................................................................. 72 QUESTIONNAIRE ........................................................................................................................... 72 xi LIST OF TABLES Table 3.1 Study Variables ............................................................................................................ 28 Table 3.2 Populations in the Selected Communities and Required Sample Sizes. ....................... 31 Table 4.1 Sociodemographic Features of Respondents ................................................................ 36 Table 4.2 Pearson Chi-square Test of Variation in Socio-demographic Features across Districts ....................................................................................................................................................... 38 Table 4.3 Distribution of Post-Flood Health Risks ....................................................................... 39 Table 4.4 Logistic Regression Analysis of the Determinants of Health Risks among Flood Victims ....................................................................................................................................................... 41 Table 4.5 Distribution and Accessibility of Healthcare Facilities ................................................ 44 Table 4.6 Pearson Chi-squared Test of Variation in Availability of Functional Health Facility across the Districts. ....................................................................................................................... 44 Table 4.7 Access to Healthcare Services Post-Flood .................................................................... 46 Table 4.8 Pearson Chi-squared Test of Variation in Responses across Districts on Access to Healthcare Services. ...................................................................................................................... 47 Table 4.9 Resilient Building Practices During and After the Flood ............................................. 49 Table 4.10 Pearson Chi-squared Test of Variation in Resilience Building Practices ................... 50 xii LIST OF FIGURES Figure 1.1 Conceptual Framework, Adapted from (Zhong et al.,2018) ........................................ 6 Figure 1.2 Map of Central Tongu District ( Ghana Statistical Service,2014) .............................. 10 Figure 1.3 Map of Ada East District (Ghana Statistical Service,2014) ........................................ 11 Figure 4.1 Respondents who reported having a functional health facility in their community (total sample) .......................................................................................................................................... 42 Figure 4.2 Respondents who reported having a functional health facility in their community, by district. .......................................................................................................................................... 43 Figure 4.3 Post-Flood preparedness and measures implemented by respondents ........................ 51 Figure 4.4 Post-Flood preparedness measures implemented by respondents, by districts ........... 52 file:///C:/Users/glads/Desktop/ENSIGN%20GLOBAL%20COLLEGE/THESIS%20FOLDER/Final%20%20working%20thesis%20project/Final%20Thesis%20Gladstone(1-6)%20(Autosaved).docx%23_Toc175361153 xiii LIST OF MAPS Figure 1.2 Map of Central Tongu District ( Ghana Statistical Service,2014) .............................. 10 Figure 1.3 Map of Ada East District (Ghana Statistical Service,2014) ........................................ 11 1 1 CHAPTER 1 INTRODUCTION 1.1 Background information Floods are recognized as one of the most catastrophic natural disasters globally, and have affected 2.3 billion people worldwide in the last 20 years (Suhr and Steinert, 2022). Global data from 2019 suggests that floods are responsible for 43.5% of all deaths from natural disasters (CRED, 2019), and they pose significant threats to public health, particularly in rural communities and can result in a range of health risks, including vector-borne diseases such as malaria (Watts et al., 2018). The aftermath of floods often leads to contaminated water sources, compromised sanitation infrastructure, and limited access to healthcare services, exacerbating the risk of disease transmission (UNDRR, 2022). Infrastructure damage, transportation disruptions, and overwhelmed healthcare systems hinder the delivery of essential medical care to affected populations (Hosseini, Barker and Ramirez-Marquez, 2016), particularly vulnerable groups such as the elderly, children, and individuals with pre-existing health conditions, who face heightened barriers in accessing timely healthcare interventions (WHO, 2014). According to the International Commission on Large Dams (ICOLD), a dam is defined as an artificially created barrier across a river, stream, or watercourse for the purpose of confining and controlling the flow of water, and thereby storing, diverting, or regulating water. And according to current estimates, there are now around 62,000 dams worldwide (International Comminsion on Large Dams, 2019) with an estimated cumulative storage capacity of between 7,000–8,300 km3 (Zarfl et al., 2015). Currently 37,600 dams are higher than 15 meters or greater from lowest foundation to crest (classified as large Dams) worldwide and a further 3,700 are planned or under construction (International Comminsion on Large Dams, 2019). Dams are constructed for many purposes, including reservoir creation, flood prevention, 2 irrigation, and hydroelectric power generation. But fluvial flood regimes (where rivers overflow their banks) are increasingly being mediated by dams (Dotse-Gborgbortsi et al., 2022). These Dam mediated floods usually occur when water holding capacities of dams are exceeded as a result of heavy rainfalls. Consequently, this leads to the controlled spillage of the dam to retain its integrity but causing flooding in low-lying communities along the watercourse (Atubiga et al., 2023). In Africa, the impact of dam mediated floods on public health is particularly pronounced due to various socio-economic and environmental factors such as poverty and climate change. In September 2020, small and medium scale floods affected millions of people in 15 countries across the continent (IFRC, 2021). Nearly seven million people were affected and 1,273 deaths occurred, the highest figure since 2006 (IFRC, 2021) . The Bagre Dam Spillage (in Burkina Faso), which occurs annually during the rainy season, often leads to widespread flooding in villages along the river course in Burkina Faso and in the northern regions of Ghana, displacing thousands of people, posing health risks, disrupting livelihoods and destroying about 196 km² of farmland in northern Ghana each year (Kansuk and Chimbar, 2021) (Baah-Kumi and Ward, 2020). The continent's susceptibility to the brunt of climate change, coupled with inadequate infrastructure and resource constraints, exacerbates the health risks associated with flooding (Jia et al., 2022). Moreover, the prevalence of waterborne diseases, such as cholera and typhoid fever, is significantly higher in African countries, further amplifying the disease burden in flood-affected communities (Legros, 2018). In Ghana, recent flooding incidents, including those resulting from the Bagre Dam spillage have highlighted the vulnerability of rural communities to post flood health risks and healthcare accessibility challenges. Similarly, the Weija Dam spillage in 2018 resulted in flooding in 3 communities along the Densu River, causing property damage and posing health risks to residents (Asare, 2020). 1.2 Problem statement The recurring occurrences of flooding events in Ghana, particularly those stemming from dam spillages like the Bagre Dam and the Weija Dam, have long posed significant health consequences to affected communities (Asare, 2020; Atubiga et al., 2023). The recent Akosombo Dam spillage emerged as the most devastating man-made disaster, affecting communities in North Tongu, Central Tongu, South Tongu districts in the Volta Region, Ada East district in the Greater Accra Region and some communities in the Eastern Region. Communities in these districts have over the years endured recurrent flooding events as a result of the spillage of the Akosombo Dam, primarily triggered by heavy rainfall, dam maintenance activities, or operational decisions, leading to minimal but consequential flood occurrences (Miescher, 2021). The last recorded spillage was in 2010 (Miescher, 2023). The severity of the issue became evident in October 2023, when an estimated 35,857 individuals, including children who are particularly vulnerable, were displaced due to flooding induced by the Akosombo dam spillage (Kobina, 2023). The resultant evacuation from homes and overcrowding at shelters following such flood event sets a fertile ground for outbreaks of various illnesses, including respiratory, skin and soft tissue, zoonotic, and gastrointestinal diseases (Paterson, Wright and Harris, 2018). Communities such as Bakpa Awadiwoekome, Kebegodo, and Pediatorkope in the Central Tongu and Ada East Districts, situated downstream along the Volta River, bear the brunt of these flood impacts, perpetuating a cycle of heightened post-flood health risks and healthcare accessibility challenges. 4 While existing literature acknowledges the occurrence of flooding events and their associated health consequences in Ghana (Asare, 2020; Atubiga et al., 2023), there remains a paucity of in-depth studies focusing specifically on the Akosombo Dam spillage and its impacts on affected communities. Predominantly, existing research highlights the immediate aftermath of flood events, such as displacement figures and basic health risks (Kobina, 2023). However, there is limited exploration into the ongoing challenges in healthcare accessibility, and resilience-building practices unique to the circumstances of the communities in the Central Tongu and Ada East Districts. Furthermore, while global statistics emphasize the prevalence of waterborne diseases like cholera linked to flood events (Ntajal et al., 2022), there is limited local research examining the specific vulnerabilities and health outcomes within the context of the selected districts. This research gap underscores the pressing need for a comprehensive study that not only quantifies the extent of post-flood health risks but also delves into the underlying factors exacerbating these risks and identifies effective resilience-building practices. Assessing the post-flood health risks faced by selected communities within the Central Tongu and Ada East Districts, specifically Bakpa Awadiwoekome, Kebegodo, and Pediatorkope, is imperative to inform evidence-based public health policies, disaster preparedness, and effective management strategies. 5 1.3 Rationale for the study Despite the increasing frequency of dam mediated flooding events and their detrimental effects on public health globally, limited research has been conducted to assess the specific post-flood health risks and healthcare accessibility challenges faced by the impacted communities in the Central Tongu and Ada East Districts in the context of the October 2023 spillage of the Akosombo Dam. By evaluating the post-flood health risks and healthcare accessibility challenges faced by Bakpa Awadiwoekome, Kebegodo and Pediatorkope, the study aims to provide evidence-based insights that can inform healthy public policy formulation, adequate healthcare provision, effective disaster preparedness and management, and community resilience-building efforts in flood-prone areas in Ghana. This study will also fill the literature gap on post flood health risks in Ghana and serve as a reference point for future studies. 6 1.4 Conceptual framework This conceptual framework recognizes at its core the intricate connections between environmental hazards such as floods, post-flood health risks such as waterborne diseases and their determinants, accessibility to healthcare facilities and services and post-flood resilience building practices in the context of the Akosombo Dam spillage. Akosombo Dam Spillage (Dam mediated flood) Healthcare facilities and services accessibility challenges (Damage to health facility, Damage to road leading to health facility) Determinants of Post- Flood Health Risks. (Health status, Socio- economic, Demography) Post-flood resilience building practices (community education/training , community participation) Post-Flood Health Risks. (waterborne diseases, vector-borne diseases) Figure 1.1 Conceptual Framework, Adapted from (Zhong et al.,2018) 7 Flood, resulting from the dam spillage introduce contaminants into water sources and also disrupt sanitation infrastructure and practices, increasing the risk of waterborne diseases (Few et al., 2004). This direct impact on water quality and sanitation practices serves as a primary pathway for health risks in flood-affected communities. In parallel, limited access to healthcare facilities and services, exacerbated by damage to health infrastructure and logistics is a key effect of the flood and influences post-flood health risks (Paediatric Society of Ghana, 2023). The determinants of post-flood health risks encompass environmental, individual, socioeconomic and community factors that influence the likelihood and severity of post-flood health risks following the flood event. Community resilience practices influence and emerges as a critical factor in shaping post-flood health risks. Resilient communities exhibit adaptive capacities to withstand and recover from adverse events, often fuelled by local initiatives, social networks, and resource mobilization (Aldrich, 2012). Assessing the post-flood resilience building practices among residents of Baka Awadiwoekome, Kebegodo and Pediatorkope can inform effective interventions aimed at mitigating post-health risks and promoting recovery in flood-affected areas. By assessing these interrelated factors within the context of the Akosombo Dam spillage in the selected communities, this research seeks to provide insights into post-flood health risks and inform evidence-based strategies for disaster preparedness, response, and resilience-building in flood-affected areas in Ghana and beyond. 1.5 Research Questions 1. What are the post-flood health risks in the selected communities of the Central Tongu and Ada East Districts? 2. What are the determinants of post-flood health outcomes among residents of the Central Tongu and Ada East Districts? 3. What are the challenges in accessing healthcare facilities and services in the selected communities post-flooding? 4. What are the post-flood resilience building practices among residents in the Central Tongu and Ada East Districts? 1.6 General Objective To assess post-flood health risks, healthcare accessibility challenges and resilience building practices in the Central Tongu and Ada East Districts in the aftermath of the Akosombo dam spillage. 1.7 Specific Objectives 1. To assess the post-flood health risks in the selected communities of the Central Tongu and the Ada East Districts. 2. To investigate the determinants of post flood-health outcomes among residents of the Central Tongu and Ada East Districts. 3. To identify the challenges in accessing healthcare facilities and services in the selected communities post-flooding. 4. To explore the post-flood resilience building practices among residents in the Central Tongu and Ada East Districts. 8 9 1.8 Profile of Study Areas 1.8.1 Central Tongu District Central Tongu District Assembly is one of the 18 District Assemblies in the Volta Region and among the Two Hundred and sixty (260) administrative districts created in Ghana. The District was carved out of the former North Tongu District Assembly with Legislative Instrument (LI) 2077 of 2012. Its administrative Capital is at Adidome. The District shares common borders with South Tongu to the South, Ada East District in the Greater Accra Region to the West, Akatsi South District to the East with North Tongu and Adaklu Districts to the North. Central Tongu District covers a total land area of about 682.22km² and it is dominated by mix of high lands, valleys and plain grounds making an undulating topography. The District lies within the Tropical Savannah Grassland zone and the Volta River runs through the district with many communities dotted along the banks of the river. This makes the district a suitable place for large scale farming. Agriculture is the leading employment sector in the District engaging 78.3 percent of the total households in the district (Ghana Statistical Service, 2014). The district has three hundred and three (303) communities including Bakpa Awadiwokome and Kebegodo, (which are the selected communities from the district), and 26 health facilities dotted across the 303 communities according to the 2021 Population and Housing Census. The District population figure as at the 2021 Population and Housing Census was 83,803 (https://ctda.gov.gh/). The growth rate is higher than both the Regional and National growth rates of 2.5%. This indicates that there will be a rapid increase in the pressure exerted on socio- economic services and resources in the District (Busia, 2023). https://ctda.gov.gh/ 10 Figure 1.2 Map of Central Tongu District ( Ghana Statistical Service,2014) 1.8.2 Ada East District The Ada East District is situated in the Eastern part of the Greater Accra Region. The total land area of the District is 289.78 (square km). The District shares common boundaries with the Central Tongu District to the North, South Tongu District and Ada West to the East and West respectively. It is bounded to the south by the Gulf of Guinea, which stretches over 18 kilometers from Kewunor to Totope. It is also bounded by the Volta River South–Eastwards extending to the Gulf of Guinea southwards thereby forming an Estuary, about 2 kilometers away from the District capital, Ada-Foah (https://aeda.gov.gh/) . https://aeda.gov.gh/ 11 The district is divided into three administrative sub-districts as follows: Ada-Foah sub-district, Kasseh sub-district, Pediatorkope sub-district. It has thirteen health facilities comprising of twelve government facilities and one private facility. Pediatorkope Sub district which is an Island with about 22 communities has Pediatorkope Health Centre(https://aeda.gov.gh/)and the major activities of the people in the district are fishing and farming(Sandqvist, 2019). Figure 1.3 Map of Ada East District (Ghana Statistical Service,2014) https://aeda.gov.gh/ 12 1.9 Scope of Study The scope of this study encompasses an assessment of post-flood health risks and healthcare accessibility challenges faced by communities affected by the spillage of the Akosombo Dam in the Central Tongu and Ada East Districts of Ghana. The research focuses on Bakpa Awadiwoekome, Kebegodo, and Pediatorkope, aiming to quantify the exposure to health risks and measure the accessibility challenges to healthcare services. This study employed a cross- sectional survey design to gather numerical data from residents aged 18 years and older, providing insights on health risks and healthcare accessibility challenges they faced post- flooding that could inform public health policy, disaster preparedness, and community resilience strategies in their communities and other flood-prone areas. 1.10 Organisation of Report This thesis report is organized into six chapters. Chapter 1 briefly introduces the subject matter of the study, provides a problem statement, justification and states the objectives of the study. In addition, it states and describes the conceptual framework, as well as gives a narration on the study site. Chapter two discusses relevant peer-reviewed literature on the topic of this thesis. In chapter three, the methodology employed in this study, the study design, the analysis of the data and the limitations of the study are discussed. Chapter four summarizes the findings of the study in prose and tables and appropriate figures. In chapter five, the findings of the study are discussed; whilst in chapter six, conclusions; and recommendations are provided for the appropriate bodies they are targeted to. References based on the Harvard referencing style are provided both in-text and at the end of the study report; and an appendix at the tail end of the study provides administrative documents like ethical clearance certificates, letters of introduction and correspondence, and extra tables and charts as well as statistical tests’ 13 calculations. At the beginning of the study report, there is a title page; followed with acknowledgements, foreword, a list of abbreviations, table of contents, and a list of abbreviations, figures and tables; as well as a structured abstract; all forming the front-matter of the thesis report. 14 2 CHAPTER 2 LITERATURE REVIEW 2.1 Introduction Floods are among the most frequent and devastating natural disasters globally, with significant impacts on human health and well-being. These events can occur due to various factors, including heavy rainfall, river overflow, dam spillages, and storm surges, leading to the inundation of land areas that are typically dry. The impacts of floods on human health are multifaceted, affecting physical, mental, and social dimensions of health. Over the last 20 years, it was estimated that floods have affected 2.3 billion people globally (Douben, 2006; Suhr and Steinert, 2022). The World Health Organization (WHO) reports that floods account for 40% of all-natural disasters worldwide, affecting an average of 250 million people annually (World Health Organization(WHO), 2013). The impacts on public health can be severe, encompassing a range of physical, mental, and social health issues often resulting in immediate physical injuries and fatalities. The global mortality rate from floods is substantial; between 1980 and 2016, over 2.5 million people were killed by floods (Debarati Guha-Sapir, Philippe Hoyois and Below Regina, 2016). 2.2 Dam-Mediated Floods Dam-mediated floods occur when the release of water from dams, either planned or accidental, leads to downstream flooding. These events can have severe impacts on communities, human health, infrastructure, and ecosystems. The controlled release of water from dams is often necessary to prevent structural failure, but can still result in significant flooding downstream. 15 According to the International Commission on Large Dams (ICOLD), a dam is defined as an artificially created barrier across a river, stream, or watercourse to confine and control the flow of water, thereby storing, diverting, or regulating water and according to current estimates, there are now around 62,000 dams worldwide (International Commission on Large Dams, 2019) with an estimated cumulative storage capacity of between 7,000–8,300 km3 Zarfl et al., (2015). 37,600 dams are higher than 15 meters (classified as large Dams) worldwide and a further 3,700 are planned or under construction. Dams are constructed for many purposes, including reservoir creation, flood prevention, irrigation, and hydroelectric power generation, but fluvial flood regimes (where rivers overflow their banks) are increasingly being mediated by dams (Dotse-Gborgbortsi et al., 2022). This phenomenon usually occurs when the water-holding capacities of dams are exceeded as a result of heavy rainfalls. Consequently, this leads to the controlled spillage of the dam to retain its integrity but causes flooding in low-lying communities along the watercourse (Atubiga et al., 2023). In Africa, the impact of dam-mediated floods on public health is particularly pronounced due to various socio-economic and environmental factors such as poverty and climate change. In September 2020, small and medium-scale floods affected millions of people in 15 countries across the continent. Nearly seven million people were affected and 1,273 deaths were caused, the highest figure since 2006 (IFRC, 2021). The Bagre Dam Spillage (in Burkina Faso), which occurs annually during the rainy season, often leads to widespread flooding in villages in Burkina Faso and the northern regions of Ghana, displacing thousands of people, posing health risks, disrupting livelihoods and destroying about 196 km² of farmland (Kansuk and Chimbar, 2021) (Baah-Kumi and Ward, 2020). 16 The continent's susceptibility to the brunt of climate change, coupled with inadequate infrastructure and resource constraints, exacerbates the health risks associated with these flooding events (Jia et al., 2022). Moreover, the prevalence of waterborne diseases, such as cholera and typhoid fever, is significantly higher in African countries, further amplifying the disease burden in flood-affected communities (Legros, 2018). In Ghana, recent flooding incidents, including those resulting from the Bagre Dam spillage have highlighted the vulnerability of rural communities to post-flood health risks and healthcare accessibility challenges. Similarly, the Weija Dam spillage in 2018 resulted in flooding in communities along the Densu River, causing property damage and posing health risks to residents (Asare, 2020). 2.3 Health Risks Associated with Post-Flooding Flooding can lead to a wide range of health issues, both immediate and long-term. Immediate health risks include physical injuries, hypothermia, and drowning. Some long-term health risks which often emerge in the aftermath of flooding include waterborne diseases (e.g., cholera, typhoid fever) and vector-borne diseases (e.g., malaria and dengue fever). The stagnation of water creates breeding grounds for mosquitoes, leading to outbreaks of diseases like malaria and dengue fever (Wellcome, 2022). Injuries can occur from drowning, debris, and collapsing structures. For example, the 2015 flood in Chennai, India, resulted in over 300 deaths and thousands of injuries due to collapsing buildings and electric shocks (Bureau, 2016). A systematic review of health outcomes related to floods in sub-Saharan Africa identified significant increases in the incidence of diseases such as cholera and malaria following flooding events (BMC Public Health, 2023). For instance, a study in Uganda found a high incidence of 17 cholera during flood periods compared to non-flood periods, with an incidence rate ratio of 144 (Rieckmann et al., 2018). Also, after the 2010 floods in Pakistan, there were over 200,000 reported cases of acute watery diarrhoea, primarily due to contaminated drinking water (Kouadio et al., 2014). After the 2017 floods in Bangladesh, there was a notable rise in malaria cases, with health officials reporting a 30% increase compared to the previous year (Willford, Roelofs and Leifman, 2019). Additionally, the disruption of water supply systems and the overflow of sewage systems during floods significantly contribute to the spread of various diseases (Qadri et al., 2017). Studies have shown that children under five are especially vulnerable to such diseases during flood events due to their weaker immune systems and the increased likelihood of coming into contact with contaminated water (Dewan, 2015). The damp and mouldy conditions following floods can lead to respiratory infections. Exposure to mould spores and the proliferation of bacteria in flooded homes contribute to respiratory issues such as asthma and bronchitis. In the aftermath of Hurricane Harvey in 2017, the incidence of respiratory illnesses in Texas significantly increased due to mould exposure (Paterson, Wright and Harris, 2018). Common mental disorders such as anxiety and depression are likely to affect certain subgroups of the population, particularly those with low incomes. The psychological effects of these disorders can persist for months or even years after flood events (Asian, 2002). Flood disasters can be especially traumatic for vulnerable groups, including children, women, and the elderly (Hamidazada et al., 2019). In some cases, there is a need to relocate people when their homes or communities have been destroyed, impacting their well-being and stability In a study conducted in the UK, flood victims were found to be between 4 to 8.7 times more at risk of long-term mental health problems compared to those who had not experienced flooding 18 (Paranjothy et al., 2021). Displacement from one's home, loss of property and livelihoods, and disruption of economic and social activities can cause ongoing stress. The stress of overcoming these losses can be overwhelming and produce lasting psychological impacts (Fernandez et al., 2015). The emotional cost of flooding can be long-lasting. Follow-up studies found that about one-quarter of affected individuals could not recover from the emotional trauma of the event (Emergency Management Australia, 2020). Factors contributing to this non-recovery included the severity of the flooding, the extent of resulting financial hardship, age, and socio-economic status. Elderly people on low incomes whose houses were flooded were the most severely affected (Flood Management in Australia, 2018). According to Songsore (2017), the health conditions suffered by the poor can be attributed to disaster risks such as floods. Using flood disaster events from 2014 to 2015, Songsore observed that the outbreak of cholera in many parts of Accra, including Weija, was a result of floods. Personal interviews at the household level revealed that communities affected by the floods experienced disruptions in services such as safe drinking water, which increased health risks due to water contamination. A study conducted by Asare (2020) on the effects of water spillage on residents in Weija, Accra, also found that the post-flood health effects observed included infections and outbreaks of cholera and typhoid. Furthermore, in the Philippines, increases in leptospirosis, a bacterial infection spread through water contaminated with rodent urine, have been documented following heavy rainfall and flooding events (World Health Organization, 2018). Similarly, in India, the incidence of dengue fever and chikungunya has been observed to rise during monsoon seasons when flooding is more common (Mishra et al., 2020). These diseases pose serious public health challenges, particularly in areas with inadequate healthcare infrastructure. Floods can destroy crops and food supplies, leading to food insecurity and malnutrition, especially in vulnerable populations such as children and the elderly. A study by Musah et al. 19 (2013) showed that recurrent floods in Tolon-Kumbungu in the Northern Region of Ghana, caused by the opening of the Bagre Dam in Burkina Faso, destroy farmlands in the district every year, washing away vital soil nutrients. Consequently, leading to low yields and the resultant surges in food prices, increasing the vulnerability of poor households to malnutrition and food insecurity. This, in turn, contributes to adverse health outcomes, including higher rates of illness and poor physical development. A study in Mozambique found that children in flood-affected areas were more likely to suffer from acute malnutrition compared to those in non-affected areas (WFP, 2019). According to Fewtrell & Kay, (2018), floodwaters can contain hazardous chemicals and pollutants from industrial sites, agricultural fields, and residential areas. Exposure to these contaminants can cause a range of health problems, including skin rashes, respiratory issues, and long-term diseases such as cancer. In Haiti, the displacement following the 2010 earthquake and subsequent floods led to rise in skin infections, respiratory diseases and gastrointestinal diseases such as cholera that claimed thousands of lives (Cravioto et al., 2012). 2.4 Determinants of Post-Flood Health Risks The determinants of post-flood health risks are multifaceted, encompassing environmental, social, and economic factors. Environmental factors include the extent and duration of flooding, which influence the likelihood of water contamination and the proliferation of disease vectors. For instance, prolonged flooding can lead to stagnant water, which becomes a breeding ground for mosquitoes and other vectors, thereby increasing the risk of vector-borne diseases such as malaria and dengue fever (Fewtrell & Kay, 2018; WHO, 2018). A study conducted in Pakistan highlighted the importance of sanitation in reducing post-flood health risks, showing that communities with better access to clean water had significantly lower rates of diseases 20 (Qadri et al., 2017). A review of health outcomes in Bangladesh following severe flooding events found that timely public health interventions were critical in preventing large-scale outbreaks of infectious diseases (Islam et al., 2014). Loss of livelihoods and financial instability can lead to poor nutrition and delayed medical care, further increasing vulnerability to diseases (IPCC, 2022). The economic strain on families often forces them to prioritize immediate survival needs over health care, leading to increased morbidity and mortality rates. The economic impacts of flooding were particularly evident in Mozambique, where the destruction of agricultural land led to food shortages and malnutrition among flood-affected communities (WFP, 2019). Displaced individuals frequently experience anxiety, depression, and post-traumatic stress disorder (PTSD) due to the loss of their homes and livelihoods. A study in Haiti following the 2010 earthquake and subsequent flooding found high levels of PTSD among displaced populations, highlighting the need for mental health support in disaster response efforts (Cravioto et al., 2011). A study in Nigeria found that urban areas with poor drainage infrastructure experienced more severe flooding and higher rates of waterborne diseases compared to areas with better infrastructure (Adelekan, 2010). This underscores the importance of investing in resilient infrastructure to mitigate the health risks of flooding. 2.5 Challenges in Accessing Healthcare Facilities and Services Post-Flooding Access to healthcare facilities and services is often severely disrupted in the aftermath of flooding. Infrastructure damage, loss of medical supplies, and displacement of healthcare professionals can significantly impede the delivery of essential health services (Cravioto et al., 21 2011). A study on the health effects of flooding in developing countries highlighted that healthcare systems often struggle to cope with the increased demand for services following a flood, leading to delays in treatment and care (Wellcome, 2022). A report from South Sudan indicated that immunization coverage for children under five continues to drop due to limited access to supplies and communities being cut off mostly by floods (Whande,2022). According to the report, flooding has isolated pregnant women and children under one year from antenatal care and immunization services, particularly those in villages and swamp islands. As a result of missed doses, an increasing number of children are growing up without immunizations, posing a significant public health risk (Whande,2022). A study in Bangladesh found that healthcare facilities in flood-prone areas often suffer severe structural damage, leading to prolonged closures and a significant reduction in healthcare availability (Shimi et al., 2010). This damage disrupts health services and poses as a major risk of developing complications from contaminations and infections due to floods. Also, a study in rural India highlighted that the destruction of transportation infrastructure during floods significantly increased travel times to healthcare facilities, resulting in delayed treatment and higher mortality rates (Kar, 2013). Floodwaters can wash away roads and bridges, isolating communities and making it difficult for residents to access healthcare facilities. This isolation is particularly problematic for rural areas where transportation options are already limited (Kar, 2013). Another study in Bangladesh found that healthcare facilities in flood-prone areas often suffer severe structural damage, leading to prolonged closures and a significant reduction in healthcare service availability (Shimi et al., 2010). Additionally, flooding can lead to the displacement of healthcare professionals (WHO, 2019). Health workers may be forced to evacuate their homes and workplaces, resulting in a shortage 22 of medical personnel during critical periods. This shortage can delay emergency response efforts and reduce the overall capacity of healthcare systems to manage post-flood health crises. Research in Mozambique after severe flooding showed that the displacement of health workers was a major barrier to providing timely and effective medical care to affected populations (WHO, 2019). Studies highlight the significant economic impact of floods, which includes the loss of income and property, often leaving families with limited financial resources to seek medical care. This financial strain frequently results in delays in treatment, exacerbating existing health conditions. For instance, research conducted in the Philippines demonstrated that the economic consequences of flooding, such as reduced household income and increased healthcare costs, significantly hinder access to medical services (Porio, 2011). The economic impact of floods, including loss of income and property, can leave families with limited financial resources to seek medical care. This financial strain often leads to delays in seeking treatment, exacerbating health conditions. Research in the Philippines demonstrated that the economic consequences of flooding, such as reduced household income and increased healthcare costs, significantly hindered access to medical services (Porio, 2011). Moreover, the psychological impact of flooding on affected populations can also impede access to healthcare. The trauma and stress associated with flooding can lead to mental health issues such as anxiety, depression, and post-traumatic stress disorder (PTSD), which may go untreated due to a lack of mental health services and the stigma associated with seeking help. A study in Pakistan found high levels of PTSD among flood survivors, highlighting the need for mental health support in disaster response and recovery efforts (Norris et al., 2022). A study conducted in the United States after Hurricane Katrina found that healthcare facilities faced significant challenges in maintaining quality care due to increased patient loads and resource shortages 23 (VanDevanter et al., 2017). During flooding events, the quality of healthcare services can be compromised as overwhelmed facilities may struggle to maintain standard care procedures, leading to suboptimal treatment outcomes (VanDevanter et al., 2017). 2.6 Post-Flood Resilience-Building Practices Building resilience to post-flood health risks involves a combination of community-based and institutional strategies. Community-based practices include public health education, which can improve awareness and preparedness, and community-led initiatives to improve water and sanitation infrastructure. Institutional strategies involve strengthening healthcare systems, improving early warning systems, and implementing effective response plans (Whande,2022). Research has shown that community involvement is crucial in building resilience (Jahan et al.,2010). A study in Northern Ghana demonstrated that community-based water, sanitation, and hygiene (WASH) programs were effective in preventing diarrheal diseases after floods. These programs, which include the distribution of water purification tablets and the promotion of handwashing, have proven to be cost-effective measures in reducing health risks (Armah et aL,2010). Strengthening healthcare infrastructure is another critical component of resilience- building. In Mozambique, the establishment of flood-resistant healthcare facilities and the training of healthcare workers in emergency response significantly improved the health outcomes of flood-affected communities (WHO, 2019). These facilities were equipped with emergency medical supplies and were designed to remain operational during and after flood events. A review of flood early warning systems in South Asia found that timely alerts and effective communication strategies significantly reduced mortality and morbidity rates during flood 24 events (Hagenlocher et al., 2018). These systems enable communities to evacuate in a timely manner and take preventive measures to protect their health. The psychological impact of flooding, including anxiety, depression, and post-traumatic stress disorder (PTSD), can have long-lasting effects on affected populations. A study in the Philippines after Typhoon Haiyan highlighted the importance of providing mental health services as part of disaster relief efforts (Porio, 2011). Community-based mental health programs, including counselling and support groups, have been effective in addressing these issues and promoting long-term resilience. Strong social networks and community cohesion can enhance collective action and resource sharing during and after flood events. Research in the United States after Hurricane Katrina demonstrated that communities with higher levels of social capital were better able to cope with the aftermath of the disaster and recover more quickly (Aldrich & Meyer, 2015). These findings underscore the importance of fostering social connections and community engagement in resilience strategies. A study in Vietnam found that community-based disaster preparedness training significantly improved residents' knowledge and readiness to respond to flood events (Pham et al., 2011). Moreover, economic resilience is a key factor in mitigating post-flood health risks. Providing financial support and livelihood recovery programs to affected communities can help them rebuild and reduce vulnerability to future floods. Microfinance schemes and cash transfer programs have been effective in supporting recovery efforts and promoting economic stability (Schipper et al., 2015). These initiatives enable families to repair their homes, restore their livelihoods, and access healthcare services, thereby enhancing overall resilience. 25 3 CHAPTER 3 METHODOLOGY 3.1 Research Methods and Design (Study methods and design) A cross-sectional survey was employed in this study to allow for the collection of numerical data, making it easier to quantify and measure the number of people in the selected communities exposed to post-flood health risks and had healthcare accessibility challenges. This study design was used because members of the selected communities were engaged at only one point in time. The main advantage of this research design is that it allows for gathering a relatively large data within a short period of time. 3.2 Data Collection Techniques and Tools Data was collected using a structured questionnaire which has been categorized into 8 (Eight) sections, i.e. Participant socio-demographic characteristics, Post-flood health risks and determinants, Psychological distress scale, Water quality and sanitation practices, Healthcare facility and services accessibility, Resilience building practices. Food security, and Chronic illnesses Section 1 (Participant socio-demographic characteristics), Section 2 (Post-flood health risks and determinants), section 3 (Psychological distress scale), section 4 (Water and sanitation practices), section 5 (Healthcare facility and services accessibility) and section 7 (Food security) of the questionnaire were adapted from (Paterson, Wright and Harris, 2018; United Nations Office for the Coordination of Humanitarian Affairs, 2021) which are studies on health risks of flood disasters and floods rapid needs assessments respectively. Section 6 (Resilience 26 building practices) was adapted from (Manandhar et al., 2023), a Post-Flood Resilience Assessment of July 2021 Flood in Western Germany and Henan, China. Research assistants were trained to administer the questionnaire in the local dialects. A Multi-stage sampling technique was used in this study. Purposive sampling was used to sample the districts and communities affected by the flood and a Systematic random sampling technique was used to sample respondents from every second household. 3.3 Study Population The study included individuals aged 18 years and older, residing in the selected communities affected by the spillage from the Akosombo Dam. Both males and females who are mentally sound were included in the study population. 3.4 Study Variables The following were the variables that were employed to carry out the empirical investigation in the study: 1. Post-flood health risks assessment: This assesses whether a respondent experienced a post-flood health risk. It also provides information on the specific types of post-flood health risk experienced. 2. Post-flood health risk determinants: This variable is sub-divided into two categories: dependent and independent variables. Table 3.1 provides information on their definition and measurement. 27 Table 3.1 Study Variables Variable Definition Measurement Dependent Variable Prob_health_risk Probability that a respondent will experience health risk *Experience post-flood health risk (coded 1). *Did not experience any post-flood health risk (coded 0). Independent Variables gender Gender of respondents *Male (coded 1). *Female (coded 0). age Age of respondent *18-35 years (coded 1). *36-55 years (coded 2). *56 years (coded 3). educ Respondent’s level of education *No formal education (coded 1). *Primary education (coded 2). *Junior high education (coded 3). *Senior high education (coded 4). *Tertiary education (coded 5). 28 marstatus Respondent’s marital status *Never married (coded 0). *Married but living alone (coded 1). *Married but living with spouse (coded 2). *Divorced or separated (coded 3). *Widowed (coded 4). work Respondent’s current employment status. *Yes (coded 1). *No (coded 0). flood_duration Duration of flood reported by a respondent. *Less than a week (coded 1). *More than a week but less than a month (coded 2). *More than a month (coded 3). pre_health_issue Respondent with pre-flood health issue. *Yes (coded 1). *No (coded 0). Table 3.0.1 Study Variables Source: Field Data, 2024. 3. Availability of health facilities: This variable indicates respondents’ report on the availability of a functional health facility in the community they reside, the type of health facility and the distance to the health facility. 29 4. Access to healthcare services post-flood: This variable comprises the following; respondents report on whether they received medical treatment for health issues they experienced; record of any delays in receiving medical treatment; reasons for the delay; availability of mental health support services; utilization of the mental health support services where they were provided; and the effectiveness of the mental health support services provided to affected communities. 5. Resilient-building practices and post-flood preparedness: This variable assesses whether respondents put in place measures to prepare for the flood. It also indicates the respondents’ actions when the flood occurred. Also, the variable outlines the resources the respondents’ employed in order to cope with the devastating impacts of the flood. In addition, it provides information on the respondents’ engagements in resilient- building activities after the flood and their assessment of the level of community collaboration after the flood. The variable also measures post-flood preparedness measures implemented by respondents in their various communities. 3.5 Sampling For this study a multi-stage approach was employed where the researcher used a Purposive sampling technique to select the communities and a systematic random sampling was used to select participants for the study. The sample was calculated using the Cochran’s formula (Cochran, 1977). n = 𝑍2 𝑥 𝑃 (1−𝑝) 𝑒² 30 Where; n = required sample size z = reliability co-efficient (95% CI, z ≈ 1.96) p = proportion of study population = 50% ≈ 0.5 e = margin of error = 5% = 0.05 therefore, n = (1.96)2𝑥 (0.5)( 1−0.5) 0.05² = 384.16 ≈ 384 A 10% non-response rate was estimated on the calculated sample (i.e. ≈ 38) and then added to the required sample size to make a total working sample of 422 residents. Proportional allocation technique was further used to estimate the number of residents to be considered in each selected community. Using the formula below: nh = 𝑁ℎ 𝑁 𝑥 𝑛 Where, nh = sample size for a particular community. Nh = Total population of a community. N = Total population for all the selected communities. n = Total working sample size. 31 Therefore, Table 3.2 Populations in the selected communities and required sample sizes. Name of Community Total Residents population Required sample size Bakpa Awadiwoekome 1060 1060 9934 𝑥 422 = 45 Kebegodo 800 800 9934 𝑥 422 = 34 Pediatorkope 8,074 8074 9934 𝑥 422 = 343 TOTAL 9934 422 Table 3.2 Populations in the Selected Communities and Required Sample Sizes. 3.6 Pre- Testing The questionnaire was administered to 40 residents of Bakpa Awadiwoekome for pretesting. This community which is part of the study sites was selected for pre-testing because Adidome which was initially selected for pre-testing was inaccessible due to a broken bridge leading to the town. The pre-testing helped to evaluate respondents’ comprehension of the questionnaire, identified and addressed potential problems with the questionnaire, making it more reliable and valid. Results from the pretesting was included in the analysis. 3.7 Data Handling Data was collected using a structured questionnaire. Participants were informed of the purpose of the study by so doing, their consent was sought, and the questionnaire was administered to 32 them to answer appropriately. Research assistants were trained to assist in collecting the data. Guidance was provided where necessary. The research instrument was given to the Research Supervisor for acceptance and to cross- check to see whether it is sufficiently comprehensive in seeking the proper range of responses and whether the questions have good content and face validity. 3.8 Data Analysis Descriptive statistics (frequency and percentage) and charts (bar chart and pie charts) were used to summarize the following; demographic characteristics of the respondents; the post- flood health risks experienced by the respondents; challenges in accessing health facilities and healthcare services; and the resilient-building activities and post-flood preparedness measures employed by the respondents. The study also employed the Pearson Chi-squared test to investigate whether the sociodemographic features of the respondents differ across the two districts. In addition, the test was used to determine whether the study variables (particularly relating to challenges in accessing health facility and healthcare services post- flood, resilient-building activities post-flood, and post-flood preparedness measures) vary across the two districts. The study also conducted a logistic regression analysis to determine the factors influencing the likelihood that a respondent will experience post-flood health risk. For both the Pearson Chi-squared test and the logistic regression analysis, the level of statistical significance was set at 5%. The STATA software (Version17) was used to perform all the statistical analysis. 33 3.9 Ethical Considerations A letter of approval was received from the Institutional Review Board of the Ensign Global College. Written permission was sought from both the traditional and civil leaders of the selected communities. Respondents were duly informed about the purpose of the study and both verbal and written consents were sought from respondents before answering the questionnaire. Any information regarding the identity of the respondents was not required in order to ensure anonymity and confidentiality. During the administration of questionnaires, participants who decided not to partake in the exercise again were given the liberty to do so. 3.10 Limitations of Study The reliance on self-reported data from residents may introduce some biases such as recall bias, as participants might forget details and overestimate or underestimate their health risks and accessibility issues. Accessibility to the selected community of Bakpa Zorotodzi was hindered by ongoing flood conditions which destroyed access to the community. Bakpa Zorotodzi was then replaced with Kebegodo, a community with similar characteristics and population size which was also affected by the flood in similar magnitude. 3.11 Assumptions No assumptions were made in this study. 34 4 CHAPTER 4 RESULTS 4.1 Introduction This chapter presents the findings of the study. The results provide insights into the health issues experienced by the flood victims, the determinants of post-flood health risk among the respondents, difficulties in accessing healthcare services during the floods, and the measures taken to build resilience against future floods. 4.2 Sociodemographic Characteristics of Respondents Table 4.1 depicts the sociodemographic characteristics of the respondents. In all, 381 respondents participated in the study: comprising 190 respondents (49.9%) from the Central Tongu district in the Volta Region and 191 respondents (50.1%) from the Ada East district in the Greater Accra Region. Respondents between the ages of 36-55 years constituted about 35.7% of the total sample. The smallest age group which represented 30.2% of the sample were at least 61 years old. The age distribution in the Central Tongu district indicate that 45.8% of the respondents were at least 56 years old with the smallest age group being those within 18- 35 years. In the Ada East districts, the largest (18-35 years) and the smallest (at least 56 years) age group constituted about 47.6% and 14.7% of the sample respectively. The total sample comprise more males (70.1%) than females (29.9%). The gender distribution for the sample selected from the two districts show a similar picture: more males from both districts (76.3% and 63.9% in the Central Tongu and Ada East districts respectively) than females (23.7% and 36.1% in the Central Tongu and Ada East districts respectively) participated in the study. 35 Table 4. 1 Sociodemographic Features of Respondents Total Central Tongu District Ada East District Sociodemographic Feature Frequency(n) Percentage (%) Frequency(n) Percentage (%) Frequency(n) Percentage (%) Age 18-35 years 130 34.12 39 20.53 91 47.64 36-55 years 136 35.70 64 33.68 72 37.70 56 years and above 115 30.18 87 45.79 28 14.66 Gender Male 267 70.08 145 76.32 122 63.87 Female 114 29.92 45 23.68 69 36.13 Educational attainment No formal education 125 32.81 87 45.79 38 19.9 Primary 113 29.66 66 34.74 47 24.61 Junior High 95 24.93 26 13.68 69 36.13 Senior High 42 11.02 11 5.79 31 16.23 Tertiary 6 1.57 - - 6 3.14 Current working status Yes 292 76.64 142 74.74 150 78.53 No 89 23.26 48 25.26 41 21.47 Occupation Not applicable 1 0.34 1 0.7 - - Farmer 126 43.15 111 78.17 15 10 Fisher 46 15.75 8 5.63 38 25.33 Religious leader 14 4.79 1 0.7 2 1.33 Student 3 1.03 - - 1 0.67 Teacher 1 0.34 2 1.41 4 2.67 Trader 6 2.05 19 13.38 76 50.67 Others (Artisans, carpenters, etc) 95 32.53 - - 14 9.33 36 Marital status Currently married but living alone 14 3.67 10 5.26 4 2.09 Currently married and living together 182 47.77 78 41.05 104 54.45 Divorced/Separated 43 11.29 28 14.74 15 7.85 Never married 67 17.59 22 11.58 45 23.56 Widowed 75 19.69 52 27.37 23 12.04 Religious affiliation Christian 321 84.25 164 86.32 157 82.2 Traditionalist 19 4.99 6 3.16 13 6.81 Muslim 40 10.5 20 10.53 20 10.47 Other 1 0.26 - - 1 0.52 Ethnicity Akan 2 0.52 190 100 2 1.05 Ewe 199 52.23 - - 9 4.71 Ga-Adangbe 180 47.24 - - 180 94.24 Table 4.1 Sociodemographic Features of Respondents Source: Field Data, 2024. 37 In the case of the total sample, respondents with no formal education represented about 32.8%. Those who have had tertiary level education were the least group (1.6%). Similarly, most of the respondents selected from the Central Tongu district (45.8%) had no formal education. In the Ada East district, most of the respondents (36.1%) had Junior High school qualification. When asked about their current working status, the majority of the respondents (76.6%) indicated that they were currently employed. Similarly, majority of the respondents sampled in both the Central Tongu (74.7%) and the Ada East (78.5%) districts indicated they were currently employed. Specifically, most of the respondents were farmers (43.2%). The most represented occupation-type in the sample selected from the Central Tongu and the Ada East districts were farming (78.2%) and fishing (25.3%) respectively. About 47.8% of the respondents were currently married and living together with their spouses, the smallest group according to marital status were those who were married but living alone (3.7%). Likewise, in both districts, the most represented group in terms of marital status were those who were married and living with their spouse (41.1% in the Central Tongu district and 54.5% in the Ada East district) and the least group were respondents who were married but living alone (5.3% and 4% in the Central Tongu and Ada East districts respectively). Regarding religion, the majority of the respondents (84.3%) identified as Christians whereas 10.5% and 5% were Muslims and traditionalists respectively. In both the Central Tongu and Ada East districts, the majority of the respondents (86.3% and 82.2% respectively) were Christians. A little more than half of the respondents (52.2%) were Ewes, followed by those who belong to the Ga-Adangbe ethnic group (47.2%). All respondents sampled from the Central Tongu district belong to the Ewe ethnic group. In the Ada East district, the majority of the respondents were Ga- Adangbe (94.2%). 38 4.3 Variation in Sociodemographic Features across Districts Table 4.2 indicates the chi-squared test results which tells whether the socio-demographic features of the respondents vary across the districts. The results indicate that age, gender, educational attainment, occupation, marital status, and ethnicity of respondents vary across the two districts at the 5% significance level. The religious affiliation of the respondents varies across the two districts at just the 10% significance level. Table 4.2: Pearson Chi-squared Test of Variation in Socio-demographic Features across Districts Variable Pearson chi2 Prob value Age 51.538 0.000 Gender 7.031 0.008 Educational attainment 57.387 0.000 Current working status 0.767 0.381 Occupation 143.797 0.000 Marital status 29.322 0.000 Religious affiliation 9.014 0.061 Ethnicity 346.628 0.000 Table 4.2 Pearson Chi-square Test of Variation in Socio-demographic Features across Districts Source: Field Data, 2024. 4.4 Post-Flood Health Risks Assessment Table 4.2 shows the various post-flood health risk experiences of the respondents. About 33.3% respondents reported experiencing health issues due to the flood caused by the dam spillage, while the remaining 66.7% did not report any health issues. Among those who experienced post-flood health issues, skin infections were the most common, reported by 44.1% of the respondents. The next commonly reported post-flood health issues among the respondents were Vector-borne diseases (30.7%), followed by gastrointestinal issues (15.8%), water borne (13.4%) and respiratory 39 diseases (13.4%), musculoskeletal diseases (12.6%), mental issues (10.2%), cardiovascular diseases (8.7%) and physical injuries (7.9%). Table 4.3: Distribution of Post-Flood Health Risks Total Central Tongue District Ada East District Post-Flood Health Risk Assessment Frequency (n) Percentage (%) Frequency (n) Percentage (%) Frequency (n) Percentage (%) Experience Health Issue from Dam Spillage Yes 127 33.33 66 34.74 61 31.94 No 254 66.67 124 65.26 130 68.06 Type of Post-Flood Health Issue Experienced Respiratory issues 17 13.39 11 16.67 6 9.84 Gastrointestinal issues 20 15.75 9 13.64 11 18.03 Skin infections 56 44.09 28 42.42 28 45.9 Vector-borne diseases 39 30.71 12 18.18 27 44.26 Water-borne diseases 17 13.39 5 7.58 12 19.67 Mental health issues 13 10.24 11 16.67 2 3.28 Cardiovascular diseases 11 8.66 8 12.12 3 4.92 Musculoskeletal diseases 16 12.6 9 13.64 7 11.48 Physical injury 30 7.87 17 25.75 13 21.31 Other health issues 1 0.79 - - 1 1.64 Table 4.3 Distribution of Post-Flood Health Risks Source: Field Data, 2024. In the Central Tongu district, 34.7% of the respondents reported experiencing one post-flood health issue or another. The most widely reported health issue among the respondents in the district were skin infections (42.4%), followed by physical injury (25.8%), vector-borne diseases (18.2%), mental issues (16.7%) and respiratory diseases (16.7%), gastrointestinal difficulties (13.6%) and musculoskeletal diseases (13.6%), cardiovascular diseases (12.1%) and water-borne diseases (7.6%). In the Ada East district, 31.9% of the respondents reported experiencing post-flood health issues. The most common health issues among the respondents in that district was skin infection (45.9%). This is followed by vector-borne diseases (44.3%), physical injury (21.3%), water-borne 40 diseases (19.7%), gastrointestinal problems (18%), musculoskeletal diseases (11.5%), respiratory issues (9.8%), cardiovascular diseases (4.9%) and mental health issues (3.3%). 4.5 Determinants of Post-Flood Health Risks Results according to the unadjusted odds ratio indicate that age, educational level, and employment status are significant factors influencing the likelihood that a respondent will experience post-flood health risk. Specifically, respondents between the ages of 36-35 years have higher odds (UOR=1.9) of experiencing post-flood health risk compared to those within the age group of 18- 35 years. Also, respondents who have primary level education are more likely (UOR=1.8) to experience post-flood health risk compared to those who do not have any formal education. In addition, the findings show lower of odds (UOR= 0.5) of experiencing post-flood health risk among respondents who are employed. Table 4.4 Logistic Regression Analysis of the Determinants of Health Risks among Flood Victims Variable UOR 95% CI Prob Value AOR 95% CI Prob Value Gender Female Reference category Reference category Male 1.319 0.834, 2.087 0.236 1.647 0.952, 2.848 0.074 Age 18-35 years Reference category Reference category 36-55 years 1.869 1.122, 3.114 0.016 2.344 1.253, 4.386 0.008 Above 56 years 0.969 0.555, 1.693 0.912 1.148 0.558, 2.364 0.708 Educational Level No formal education Reference category Reference category Primary education 1.761 1.028, 3.016 0.039 1.554 0.852, 2.835 0.151 Junior High education 1.256 0.706, 2.232 0.438 1.196 0.594, 2.409 0.616 Secondary education 0.877 0.398, 1.932 0.745 0.642 0.249, 1.652 0.358 41 Tertiary education 0.494 0.056, 4.381 0.527 0.358 0.037, 3.473 0.376 Marital Status Never married Reference category Reference category Currently married but living alone 1.534 0.474, 4.967 0.475 1.449 0.399, 5.258 0.573 Currently married and living with spouse 1.057 0.583, 1.916 0.856 0.964 0.479, 1.940 0.919 Divorced/Separated 0.987 0.436, 2.234 0.976 1.004 0.366, 2.752 0.994 Widowed 0.905 0.446, 1.836 0.782 0.908 0.360, 2.287 0.837 Employment Status No Reference category Reference category Yes 0.489 0.300, 0.795 0.004 0.398 0.234, 0.677 0.001 Flood Duration Less than a week Reference category Reference category More than a week but less than a month 3.056 0.359, 26.016 0.307 2.52 0.286, 22.239 0.405 More than a month 2.62 0.298, 23.044 0.385 Pre-flood Health Issue No Reference category Yes 3.043 0.359, 25.764 0.307 1.722 1.025, 2.890 0.04 Table 4.4 Logistic Regression Analysis of the Determinants of Health Risks among Flood Victims Note: UOR is unadjusted odds ratio, OR is adjusted odds ratio and CI is confidence interval. Results according to the adjusted odds ratio indicate that gender, age, employment status and existence of pre-flood health issues are factors that determine susceptibility to post-flood health risk among the respondents. The finding points to higher odds of experiencing post-flood health issues among men (OR=1.6) relative to females, but this is only significant at the 10% level. With regards to age, the results show that at the 5% significance level, middle-aged adults (36-55 years) have higher odds (OR=2.3) of developing post-flood health problems as compared to young adults 42 (18-35 years). Also, the results suggest that individuals who are economically engaged have lower odds (AOR=0.4) of experiencing post-flood health issues at the 5% significance level, compared to their counterparts who are unemployed. In addition, according to the results, individuals who have pre-flood health issues have higher odds (OR=1.7) developing post-flood health issues at the 5% significance level. The results suggest marital status, educational level and flood duration, do not influence susceptibility to post-flood health issues among the respondents. 4.6 Challenges in Accessing Healthcare Facilities and Services Post-flooding 4.6.1 Availability of Healthcare Facility during Floods More than half of the respondents (64%) reported the unavailability of functional health facilities in their community and the remaining approximately 36% indicated such facilities are available in the community. Figure 4.1 Respondents who reported having a functional health facility in their community (total sample) Figure 4.1: Respondents who reported having a functional health facility in their community (total sample). As displayed in Panel A, in the Central Tongu district, less than half of the respondents (49.5%) indicated they have a functional healthcare facility in their community. The majority of the 64.04% 35.96% Yes No 43 respondents in the Ada East district (78.5%) reported that they have access to a healthcare facility in their community (Panel B). Figure 4.2 Respondents who reported having a functional health facility in their community, by district. Figure 4.2: Respondents who reported having a functional health facility in their community, by district. Regarding the type of health facilities in the community, both CHPS Compounds and Health Centres were the most common, each reported by 45.5% of the respondents. The presence of private clinics and district hospitals were reported by 8.3% and 0.8% of the respondents respectively. The most common healthcare facility in the Central Tongu district (Ada East district) is the CHPS compound (a Health centre). The least reported healthcare facility among the respondents in the Central Tongu district is a health centre and that in the Ada East district is a district hospital. With regards to proximity to the nearest healthcare facility, 33.9% of the respondents reported the distance to the nearest facility is between 1km to 5km. The respondents who indicated that the distance to the nearest facility is less than 1km comprise about 33.6% of the total sample. About 18.9% indicated the nearest healthcare facility is between 6km to 10km and 13.7% reported the distance to the closest facility is more than 10km. Table 4. 5 Distribution and Accessibility of Healthcare Facilities Total Central Tongu District Ada East District Variable Frequency (n) Percentage (%) Frequency (n) Percentage (%) Frequency (n) Percentage (%) What Type of Health Facility CHPS compound 110 45.45 83 90.22 27 18 49.47%50.53% Panel A: Central Tongu District Yes No 78.53% 21.47% Panel B: Ada East District Yes No 44 Health centre 110 45.45 4 4.35 106 70.67 District hospital 2 0.83 5 5.43 2 1.33 Private clinic 20 8.26 15 10 Distance to Nearest Healthcare Facility Less than 1 km 128 33.6 78 41.05 50 26.18 1km to 5 km 129 33.86 57 30 72 37.7 6km to 10km 72 18.9 33 17.37 39 20.42 More than 10km 52 13.65 22 11.58 30 15.71 Table 4.5 Distribution and Accessibility of Healthcare Facilities Source: Field Data, 2024. 4.6.2 Variation in Respondents’ Views on the Availability of Functional Health Facility across the Districts Table 4.6 shows the chi-squared test for all the indicators of availability of health facility are significant at the 5% significant level. The results point to significant variation in the availability of functional health facility, type of and distance to health facility, as reported by respondent across the two districts. Table 4.6: Pearson Chi-squared Test of Variation in Availability of Functional Health Facility across the Districts. Variable Pearson chi2 Prob value Availability of functional health facility 34.93 0.000 What type of health facility 123.271 0.000 Distance to nearest healthcare facility 9.597 0.000 Table 4.6 Pearson Chi-squared Test of Variation in Availability of Functional Health Facility across the Districts. Source: Field Data, 2024. 45 4.6.3 Access to Healthcare Services Post-flood When asked about receiving medical treatment for health issues experienced post-flood, 53.3% respondents affirmed receiving treatment whereas 46.7% indicated otherwise. In the Central Tongu district, more than half of the respondents (61.5%) reported that they received medical treatment. On the other hand, in the Ada East district, less than half of the respondents (47.1%) had received medical treatment. For the total number of respondents who sought medical treatment for their health issues, 28.1% experienced delays while 71.92% did not face any delays. The reasons for delays included staff not being available (43.9%), lack of transportation (42.1%), shortage of medical supplies (40.4%), overcrowding at healthcare facilities (26.32%), and closed health facilities (14%). A little more than half of the respondents (58.62%) from the Central Tongu district reported shortage of medical supplies as the reason for the delay in receiving medical treatment. The respondents also cited the following as reasons why they did not receive treatment on time: lack of transportation (48.3%), overcrowding at health facilities (37.9%), and unavailability of staff (31%). In the Ada East the reasons for the delay in receiving medical treatment which were reported by the respondents were unavailability of staff (59.3%), lack of transportation (37%), shortage of medical supplies (22.2%) and closed healthcare facility (22.2%). Table 4.7: Access to Healthcare Services Post-flood Total Central Tongu District Ada East District Variable Frequency (n) Percentage (%) Frequency (n) Percentage (%) Frequency (n) Percentage (%) Medical treatment for the health issues experienced Yes 203 53.28 104 61.54 90 47.12 No 178 46.72 65 38.46 101 52.88 Delays in receiving medical treatment Yes 57 28.08 29 27.88 27 30 No 146 71.92 75 72.12 63 70 Reasons for the delay Lack of transportation 24 42.11 14 48.28 10 37.03 Overcrowding at healthcare facilities 15 26.32 11 37.93 4 14.81 Shortage of medical supplies 23 40.35 17 58.62 6 22.22 Closed health facility 8 14.04 2 6.9 6 22.22 46 Staff not available 25 43.86 9 31.03 16 59.26 Others 1 1.75 - - 1 3.7 Mental health support services provided in the community post-flooding Yes 75 19.69 62 32.63 13 6.81 No 306 80.31 128 67.37 178 93.19 Utilization of the mental health support services Yes 47 62.67 39 62.9 8 61.54 No 28 37.33 23 37.1 5 38.46 Effectiveness of mental health support services provided post flooding Very effective 20 44.44 16 43.24 4 50 Somewhat effective 22 48.89 18 48.65 4 50 Not very effective 3 6.67 3 8.11 - - Table 4.7 Access to Healthcare Services Post-Flood Source: Field Data, 2024. Overall, the provision of mental health support services post-flooding was reported by 19.69% of the respondents while 80.31% indicated the absence of such services. Among those with access to mental health support, 62.67% utilized the services and 37.33% did not. About 48.89% of the respondents indicated these services were somewhat effective whereas 44.44% reported they were very effective. In the district analysis, majority of the respondents in both the Central Tongu district (69.23%) and the Ada East district (87.96%) indicated that they were not provided any mental health support services after the floods. For the respondents in the Central Tongu district who indicated that mental health support services were provided, 62.90% utilized the services. With regards to the assessment of the services, 48.65% of the respondents who utilized the mental health support services in the Central Tongu district rated the services as somewhat effective whereas 43.24% were of the view that the services were very effective. Similarly, in the Ada East district, 61.54% of the respondents reported they utilized the mental health support services that were provided. Exactly half of the respondents (50%) who utilized the support services considered them very effective. The other half (50%) who benefited from the support services rated them as somewhat effective. 47 4.6.4 Variation in Respondents’ Views on Access to Healthcare Services Post-flood across the Districts Table 4.8 indicates that, at the 5% significance level, there is significant variation in responses on access to medical treatment for health issues experienced during the flooding across the districts. Also, the chi-squared test for responses on the provision of mental health support services post- flooding is significant at the 5% level, indicating there is variation in the responses across the two districts. The test for utilization and effectiveness of mental health support services is however not significant at the 5% level. Table 4.8: Pearson Chi-squared Test of Variation in Responses across Districts on Access to Healthcare Services. Variable Pearson chi2 Prob value Medical treatment for the health issues experienced 5.839 0.016 Delays in receiving medical treatment 0.296 0.587 Mental health support services provided in the community post-flooding 40.181 0.000 Utilization of the mental health support services 0.009 0.926 Effectiveness of mental health support services provided post flooding 0.719 0.698 Table 4.8 Pearson Chi-squared Test of Variation in Responses across Districts on Access to Healthcare Services. Source: Field Data, 2024. 4.7 Resilience Building Practices and Post-Flood Preparedness 4.7.1 Resilience Building Practices Table 4.9 shows the most of the respondents (51.40%) did undertake personal actions to prepare for the floods. In the Central Tongu, more than half of the respondents (52.80%) indicated they did prepare for the flood. With regards to actions taken during the flood, 43.83% of the respondents indicated they ran away from their homes, 40.74% sought help from God and 21.6% initiated no action during the flood. In the Ada East district, 51.85% of the respondents reported they did not 48 prepare for the flood. In terms of actions taken during the flood, 49.74% of the respondents ran away from home and 26.18% sought God’s intervention. About 32.86% reported they took no action. The results indicate respondents made use of various resources to cope with the flood. Social support networks were utilized by 49.08% of the respondents. Respondents (19.16%) also indicated financial resources were very useful during the flood. Respondents who indicated access to information and community cohesion as their coping mechanism during the flood constituted about 8.14% and 5.51% respectively. In the Central Tongu district the most widely used resources as coping mechanism among the respondents were social support network (60.53%), access to information (12.11%) and financial resources (11.05%). In the Ada East district, respondents made use of social support network (37.7%) and financial resources (27.23%). About 27.23% of the respondents in the district did not use any resource as a coping mechanism during the flood. Table 4.9 Resilient Building Practices during and after the Floods Total Central Tongu District Ada East District Variable Frequency (n) Percentage (%) Frequency (n) Percentage (%) Frequency (n) Percentage (%) Took specific measures before the flood Yes 92 51.40 66 52.80 26 48.15 No 87 48.60 59 47.20 28 51.85 Action taken when the flood occurred Run away from our homes 166 47.03 71 43.83 95 49.74 Run away with farm produce 1 0.28 1 0.62 - - Abandoned the farm and wait for the next season 2 0.57 1 0.62 1 0.52 Create drains to contain and direct the flood 16 4.53 3 1.85 13 6.81 Seek God's intervention 116 32.86 66 40.74 50 26.18 Nothing 97 27.48 35 21.6 62 32.46 Others 3 0.85 3 1.57 - - Resources used to cope with the f