ABSTRACT

Rapid urbanisation, largely due to rural-urban migration, has not only led to increased city slums but has also led to an increase in health related challenges for the rural-urban migrant slum dweller. Health seeking behaviour among these sub-populations can only be achieved when policies designed take contextual issues into consideration. Although, considerable amount of research on the health seeking behaviour of slum dwellers exist, studies on the contextual exploration of rural- urban migrant slum settlements are relatively few. This study aims to investigate health seeking behavior among rural-urban migrant slum dwellers at Madina. The Health Belief Model (HBM), which is health specific behavioural cognitive model (Taylor et al., 2006; Orji et al 2012), was adopted and modified to help understand the health seeking behavior among rural- urban migrant slum dwellers, and how interventions by health planners can be achieved in slum settings such as the case of Madina in the Greater Accra Region. The conceptual framework suggests that to avoid a mismatch between context environments and health programmme interventions, there is the need for planners i.e. government and other stakeholders engaged in health programme interventions, to carry out a contextual exploration of specific environment situation to be able to know the exact health seeking behaviour patterns of the specific slum communities in order to formulate need based policies that lead to expected lifestyle behaviours. The study adopted the mixed method research design approach. Questionnaire and interview guides were used to collect data from rural-urban migrant households through the simple random technique and purposive sampling respectively. A total of 241 questionnaires were retrieved from the respondents representing a response rate of 100%. Eight (8) key informants and health officials were interviewed. The findings of the study show that various diseases in the slum were attributed to poor housing units and work conditions. However, few cases or no cases of disease attack were reported at places of origin. The study also found that health seeking behaviour was observed at various places of origin as compared to the slum. Additionally, the study indicates that though there were a few challenges in health seeking behaviour before migration, these challenges were more pronounced in the slums. The financial constraints in accessing health care compelled them to resort to various coping strategies to overcome their health challenges in the slum. The study also highlighted the absence of a policy to promote health seeking behaviour. Hence, policy responses were raised to help address the challenges of health seeking behaviour, key among them is the need to embark on health education programmes both at places of origin and the slum.

CHAPTER ONE INTRODUCTION

            BACKGROUND OF THE STUDY

Globally, about 54 percent of the world‘s population are urban residents, a billion of whom are estimated to be living in slums conditions (UN-Habitat, 2016). According to the International Organization for Migration (2015), sub-Saharan Africa is home to 61.7 percent of slum dwellers. In Ghana, as of 2001, the slum population was estimated to be around 4.5 million. This number has increased to 1.83 percent per annum and evidenced in key cities of the country. This figure reached 4.9 million in 2010 and 5.3 million in 2014 (UN-Habitat, 2016).

Like slums in other parts of the world, Ghana‘s urban slums serve as home to many internal and international migrants and are characterised by overcrowding, insanitary conditions, unsafe buildings, deprived access to basic facilities such as health services, sanitation and clean water (Owusu et al., 2008). Though urbanisation is occurring at a rapid pace, Ghana‘s housing deficit currently stands at 1.7 million units and a minimum of 170,000 housing units will have to be built annually to salvage the situation (Daily Graphic online, 2014). This phenomenon is mainly as a result of rural-urban migration. The motive behind the large movement from the rural-urban areas is due to the better living conditions and the relative improvement of different facilities in the urban areas compared to the rural areas (Habtamu, 2015). Rural-urban migration involves the movement of people from the rural areas into the cities, often the metropolitan cities of a country. This change of residence is often connected with the migration of labor and a career change from primary to second or third sector – not necessarily, though, as it can refer to the migration of people who are not working in agriculture or farming as well (Todaro, 1976). Rural-

urban migration is, therefore, a critical component of urbanisation (Tacoli et al., 2015). One of the major challenges faced by countries that are undergoing rapid urbanisation is the spread of diseases. This is because there is inadequate basic infrastructure, social and economic inequities in urban cities, a situation which leads to severe health problems (Vlahov et al., 2006).

The World Health Organisation (2005, 2006), notes that many infectious diseases such as worm infections and diarrhea easily spread through contaminated water and  the  unavailability of water poses a major challenge to families in maintaining basic hygienic conditions in their home environment. The challenge, therefore, in many urban areas is how the health situation and the living conditions of such underprivileged populations can be improved (Dahlgren & Whitehead, 2006).

Efforts directed at slum improvements in the past were as a response to outbreak of contagious diseases that were believed to have originated in slums. There is abundance of literature linking housing deprivation with ill health later in life; even during the 1950s, morbidity rates in urban UK were higher than in the rural areas. Slums in Bangladesh, for instance, have child mortality rates much higher than in rural areas. Some small cities in Brazil, a middle-income country that contains areas indistinguishable from the HICs on all social measures, have mortality rates more typical of LDCs. Stunting rates for children in urban areas with low socio-economic scores are similar to rural averages in many less developed countries. Millions of people who live in slums suffer unhealthy living conditions, resulting in shorter life and chronic illness. The  poorer general health of slum dwellers and the lack of access to medical attention increase their likelihood of dying from epidemic diseases such as AIDS and tuberculosis, while poor sanitation exposes them to waterborne diseases (Dahlgren & Whitehead, 2006).

In most developing countries, disproportionately more health services are demanded and received by better-off people than the poor. The inability of most poor people to access health care (mainly due to the lack of financial resources) exacerbates their poor health condition, a situation caused by poor diet and poor living conditions. In some countries, people from the slums may not even be entitled to attend public health clinics, because they may not have a registered address (Dahlgren & Whitehead, 2006).

Interestingly, while, most of the slums in the cities may be located close to heath care facilities, residents are deprived of access to these facilities thereby leading to negative economic and health consequences (Agyei-Mensah and de-Graft Aikins, 2010). Attempts at addressing some  of these challenges in Ghana and the world, have led to the introduction of some targets and policies, prominent among them being target eleven (11) of the Millennium Development Goals which aims at improving the lives of at least 100 million slum dwellers world wide by 2020 (UN-HABITAT, 2006a). The Sustainable Development Goal (SDG) three (3), which seeks to improve health remains a global priority during 2016-2030, this is to focus on ensuring healthy lives and promoting well-being for all at all ages (WHO, 2016).

The MDG‘s and SDG‘s are both expected to bring improved health outcomes of rural – urban slum dwellers as well. This makes it necessary that healthcare policies are formulated in a way that brings about positive health outcomes for such underprivileged populations. Health seeking behaviour in their communities becomes an important step towards finding cure for any disease among any population (Prince and Hawkins, 2007). According to Ahmedet al., (2000), health seeking behaviour refers to any activity carried out by individuals who perceive themselves to have a health problem or ill for the purpose of finding appropriate remedies. It is more or less the

summation of the characteristics of the individual, the environmental conditions in which the person lives and the interaction that goes on between the individual and environment. It also takes into consideration issues of whether, when, and from where care is obtained for an illness (Chomi et al., 2014). There is therefore health differences in terms of rural settings and the urban slum settlements with regards to how such groups engage in health seeking behaviour.  Therefore, knowledge about health seeking behaviour among the rural- urban migrant slum dwellers is crucial not only to ensure the well-being of such population but also to provide need based health service delivery. Using a mixed method approach, this present study sought to investigate the health seeking behavior among rural –urban migrant slum dwellers in Madina in the Greater Accra Region of Ghana. The study adopted and modified the Health Belief Model (HBM), which is health specific behavioural cognitive model (Taylor et al. 2006; Orji et al 2012) to help explain health seeking behaviour among rural – urban migrant slum dwellers.

            STATEMENT OF THE PROBLEM

Some of the adverse effects of the increase in urbanisation are urban sprawl and the emergence of slums and other informal settlements which are common phenomenon in most cities of developing countries. This occurrence is largely attributed to rural – urban migration (Davis, 2004). Slums have developed and grown in many different parts of Ghana over the years. In the Greater Accra Region of Ghana alone, a report by the Population Division of the United Nations Department for Economic and Social Affairs (2009) indicates that nearly one-third of the population are slum dwellers. According to Afrane (2010), one of the migrant communities in Ghana popularly referred to as ‗Zongo,‘ and newly emerging squatter communities largely contribute to the rapid expansion of slums. Old Fadama, and Nima among others, are some of the examples of slums communities in Accra. Other rapidly growing slums such as Madina are also

found in low income suburbs of the region (GSS, 2010). A major problem often faced by these slum communities is the episode of diseases due to the poor living conditions which raises a major concern. This is because in most circumstances, slum dwellers find themselves in a vicious cycle of economic and psychological poverty. The extremely excruciating situation they find themselves in makes it difficult for them to afford many essentials of life; they experience grave deprivation pushing them into a state of despondency (Unger 2007; UN-Habitat 2003; Sheuya 2008).