Functional Vulnerability, WASH Barriers and Self-Reported Morbidity among Older Adults in Urban Ghana: A Cross-Sectional Study
This cross-sectional study of older adults in urban Ghana reveals that high rates of functional limitations, such as arthritis and mobility issues, coincide with dense household WASH barriers and frequent hygiene-related morbidity, underscoring the need for disability-inclusive, age-friendly sanitation programming while acknowledging the study's inability to establish causality due to its design and reliance on self-reported data.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
As the world's population ages, a quiet but critical question is emerging in the fields of public health and urban planning: how do we design cities that allow older people to live with dignity and independence? This question moves beyond simply counting how many people are getting older; it asks how their changing bodies interact with the physical world around them. For many, the daily act of using a toilet, washing hands, or cleaning oneself requires a level of balance, strength, and vision that can fade with age. When the environment is not built to accommodate these changes, ordinary tasks can become sources of pain, dependence, or illness. This intersection between the physical limitations of aging and the design of water and sanitation systems is the focus of a new study conducted in Ghana, which seeks to understand how the built environment affects the health of older adults.
Researchers from the University of Energy and Natural Resources and other institutions traveled to the Sunyani Municipality in Ghana to investigate this issue. They focused on 224 residents aged sixty and older, living in urban communities within the region. The study was designed to look at two things simultaneously: the physical challenges these older adults face in their daily lives and the condition of the sanitation facilities they use. The team did not just ask people about their health; they also visited 177 of these households to directly observe the toilets, handwashing stations, and water sources. This combination of personal stories and direct observation allowed them to see the gap between what older people need and what their homes actually provide.
The findings reveal a landscape where the needs of aging bodies are largely unmet by the current infrastructure. The study found that three-quarters of the participants reported suffering from arthritis, a condition that makes bending and gripping painful, while half reported feeling a persistent lack of energy. These are not minor inconveniences; they are significant barriers to maintaining hygiene. When asked what made it difficult to stay clean, the most common answers were not a lack of knowledge or a shortage of facilities, but rather physical limitations and financial constraints. In fact, money was cited as a barrier just as often as physical disability, suggesting that even when a toilet exists, the cost of soap, tissue, or disinfectant can prevent its proper use.
The physical state of the homes themselves tells a similar story of disconnect. In the households the researchers visited, they found that sanitation barriers rarely appeared in isolation. Instead, they clustered together, with most homes carrying multiple problems at once. On average, a single household had five distinct issues, such as a lack of soap at the handwashing station, a toilet that was not cleaned regularly, or a handwashing area that was too dirty or broken to use. Crucially, the vast majority of these homes lacked features that would make them easier for an older person to use, such as handrails or toilets raised off the ground to avoid deep squatting. When asked directly, nearly nine out of ten older residents said their facilities were not adapted to their needs, and the most frequent suggestion for improvement was simply the installation of age-friendly features.
The health consequences of this mismatch are visible in the daily lives of the participants. The most commonly reported health issue was not an infection, but joint pain specifically caused by using the sanitation facility. More than half of the older adults said they experienced pain in their joints from the act of using the toilet, a symptom that aligns directly with the high prevalence of arthritis and the lack of supportive design. Beyond pain, the study found that hygiene-related illnesses were widespread. Nearly a third of participants reported eye infections, and about a fifth reported stomach upsets or diarrhea. These symptoms were frequent enough that almost forty percent of the older adults visited a health facility more than once a month for hygiene-related reasons. The researchers noted that while the study design cannot prove that the toilets caused the pain or the infections, the strong link between the two suggests that the environment is playing a major role in the health of this population.
One of the most striking discoveries was that the researchers could not find a simple link between the total number of problems in a house and whether an older person seemed to struggle with access. This suggests that it is not just the quantity of barriers that matters, but the specific type. For instance, the absence of soap at a handwashing station or the presence of unmanaged waste were strongly linked to observed difficulties, whereas the lack of age-friendly toilet features did not show the same statistical connection in this specific analysis. This nuance indicates that solving the problem requires looking at the specific details of daily life rather than just counting how many facilities are broken.
The study concludes that for older adults in this setting, the problem of sanitation is not merely about whether a toilet exists, but whether that toilet can be used safely and comfortably by a body that is changing. The high burden of physical limitation, combined with dense clusters of household barriers and frequent reports of pain and illness, points to a need for a new approach to public health. The authors suggest that future efforts must move beyond standard infrastructure to include disability-inclusive design that addresses both the physical structure of facilities and the affordability of the supplies needed to keep them clean. While the study cannot prove cause and effect, it provides a clear picture of a population struggling with an environment that was not built for them, highlighting the urgent need for cities to adapt to the realities of aging.
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