Health and wellbeing survey of informal settlements in Freetown, Sierra Leone, May 2023

In May 2023 a health and wellbeing survey of informal settlement residents in Cockle Bay, Moyiba and Dwazark, in Freetown, Sierra Leone was undertaken by ARISE partners. This blog acts as a summary, highlighting some of the main findings. We also have the full survey report available for download.

Background

This survey builds on the findings from the exploratory qualitative study that aimed to find out health and wellbeing issues and priorities on these communities (i.e., Cockle Bay, Moyiba, and Dwazark) based on their own voice. It is important to note that community members were included in the research process from start to end as this enhanced equitable partnership and created opportunities for research uptake thorough knowledge exchange, application, and dissemination. Therefore, this survey report aims to provide descriptive analysis about individual and household characteristics, access, and barriers to services (water, sanitation, and healthcare), environmental health risks/vulnerabilities (disasters, safety and security, livelihoods), and well-being priorities across the three informal settlements (i.e., Cockle Bay, Moyiba, and Dwazark) in Freetown, Sierra Leone. This survey was conducted to achieve the following specific objectives:

1. To examine the current state of service delivery in informal settlements and the barriers faced by different households and individuals to access ss healthcare, water, and sanitation services.
2. To identify the extent of health and environmental risks experienced through housing, livelihood, social safety, and security challenges, and how they differ across settlements social groups, and coping strategies.
3. To examine the different well-being goals, priorities, and strategies and analyse the economic, social, governance, and environmental barriers and the attainment of these priorities across individuals and social groups.

Overall summary

This report provides a descriptive analysis about individual and household characteristics, access, and barriers to services (water, sanitation, and healthcare), environmental health risks/vulnerabilities (disasters, safety and security, livelihoods), and wellbeing priorities across three informal settlements (i.e. Cockle Bay, Moyiba, and Dwazark) in Freetown, Seirra Leone.

The report provides a comprehensive overview of the trends of urbanization globally and its ramifications, particularly the rapid proliferation of informal settlements in Freetown, Sierra Leon. It further outlines the objectives of the survey and provides a detailed explanation of the methodology employed, including the rationale behind the selection of the study sites, the sampling approach, the process of questionnaire development, the recruitment and training of data collectors and community mobilisers, challenges encountered during data collection, and measures taken to ensure data quality and ethical compliance. Overall, the chapter serves to establish the framework and methodology used in the survey, setting the stage for the subsequent analysis and findings presented in the report.

The respondents and household characteristics of the 4871 households interviewed. It delves into the sociodemographic and household characteristics of respondents living in slums, offering a comprehensive understanding of their precarity. The analysis reveals a predominantly female population most of whom are married and have lived in the community for over 10 years, with significant proportions falling within the working-age bracket (26-46 years) and demonstrating varying levels of educational attainment. While households are predominantly male-headed, female members play crucial roles in household management. Large household sizes and high rates of tenancy underscore the challenges of housing within these settlements. Economic activities, primarily centered around daily income generation through small-scale businesses, sustain livelihoods, albeit with notable disparities in income levels.

The report explores the intricate dynamics of water and sanitation services across the three study areas (Cockle Bay, Dwarzark, and Moyiba). It examines several aspects, including water sources, accessibility, sanitation facilities, waste management, and associated challenges. The chapter presents a comprehensive analysis of drinking water sources, such as sachet water and community wells, as well as domestic water usage patterns and distances to water points. From the analysis, most of the respondents relied on sachet water and community wells as sources of drinking water. Overall, the sanitation system is relatively poor across the three communities. Flush toilets are mostly common in Cockle Bay and are connected to the sea for sludge discharge with pit latrines widely used in Moyiba and Dwarzark.

The healthcare landscape of the study sites, revealing significant variations in healthcare access and utilisation patterns. From the analysis, the predominant healthcare services available within the communities are public formal facilities which include hospitals and Peripheral Health Units (PHUs). However, Cockle Bay notably lacks such facilities, relying heavily on drug peddlers and private nurses. Conversely, Dwarzark and Moyiba exhibit a higher prevalence of public health facilities, particularly Peripheral Health Units (PHUs). Most respondents seek healthcare services within the community, primarily in public PHUs and pharmacies, but a considerable proportion in Cockle Bay seek healthcare outside their community. In terms of illnesses, malaria, common cold/flu, and typhoid are prevalent and mostly treated within the communities, with drug peddlers and private formal healthcare providers such as clinics and pharmacies being widely utilised. Moreover, significant challenges exist in accessing healthcare services across the three communities. These barriers such as distance, cost, and quality of care, are particularly pronounced for healthcare services within and outside the communities, with responses to reported barriers varying among the communities. Overall, while healthcare costs are lower within the communities, they are significantly higher outside, underscoring disparities in healthcare access and expenditure. Similarly, quality of care is better in healthcare services outside the communities than within, and this is the reason respondents with sustainable and higher income-generating activities sought healthcare providers outside the community.

Common natural disasters such as flooding, fire, building collapsing, and falling boulders affected respondents. Respondents reported theft/robbery, physical violence, road accidents, evictions, and sexual and gender-based violence (SGBV) to be common across communities mostly affecting the most vulnerable and marginalized groups.

Respondents’ perception of their health and wellbeing challenges and barriers are different across three communities. The factors that determine physical wellbeing in Cockle Bay and Moyiba are good health and a clean and safe environment while Dwazack is slightly different. On the other hand, Cockle Bay and Dwazack seem to have similar social and mental wellbeing priorities like financial stability, safety/security, and support network.

Overall implications

The findings of the report underscore the multifaceted challenges faced by residents of informal settlements in Freetown, SL, encompassing issues related to water, sanitation, healthcare, environmental risks, and overall wellbeing. The prevalence of inadequate water and sanitation infrastructure, coupled with disparities in healthcare access and utilisation, highlights systemic deficiencies in essential service provision within these communities. Moreover, the vulnerability of residents to natural disasters and various forms of violence underscores the urgent need for targeted interventions to enhance safety and security. The disparities in perceptions of health and wellbeing priorities across communities further emphasize the importance of context-specific approaches to addressing the diverse needs of residents. Overall, the report calls for comprehensive, multi-sectoral strategies aimed at improving living conditions, enhancing service delivery, and promoting holistic wellbeing in informal settlements, with a particular focus on addressing the underlying social, economic, and environmental determinants of health and vulnerability.

Summary of main findings

Characteristics of households and respondents

Two thirds of respondents were female with more than half of the respondents married. Most respondents have dwelled in these communities for more than 10 years, which means that they tend to dwell longer once they move there. The highest proportion of respondents was aged 26-49 years since they are more likely to settle as they search for employment opportunities in the city. More than two thirds of respondents were educated with the majority earning their income daily.

Most households consist of more than six individuals, which may be attributed to most households having extended families. A quarter of the households reported to be experiencing food insecurity, an indication that most families are susceptible to poor nutrition.  More than half of respondents are tenants with concrete and pan body dominant house structures because they mostly can’t own or build permanent structures. Most households generate income by engaging in business because they cannot be employed in offices, so their best means of survival is petty trading.

In conclusion, this survey helps us understand the characteristics of the households and individuals in this population. Even though households are mainly male-headed, women were more available for the interviews as compared to men, because they maybe away working during the daily upkeep of the homes. If there is any form of disability, the household heads are mostly unable to walk, which may either affect members of the house or responsibilities could be passed on and maybe shared amongst other individuals. Wherein these individuals earn on a daily from economic activity that involves selling (and buying) goods and services in small scale, ranging from agricultural produce to imported consumer goods. These findings reveal the vulnerabilities of this population in terms of their income and how this may affect their ability to absorb financial shocks which may in turn impact their health and wellbeing.

Community feedback on findings: Their thoughts of the data is that it reflects the socio-economic contexts across all the three communities. In cockle bay, there is currently an advocacy on land tenure security which is in an advanced stage. There is also an increase in the cost of living, in the construction of mudhouses and in the enrollment rate in higher education level. In Dwazark, they stated that there has been low income in the past one (1) year due to the loss of livelihoods, jobs, businesses, etc. The educational level within the community has decreased within the past one (1) year and a lot of young people, especially boys have dropped out of school because of drug addiction (Kush). While girl child education keeps increasing because most girls do not take these drugs. The community is becoming densely populated, resulting in additional two new zones i.e., Egypt and Portugal. Mental illness has increased drastically over the past year because of the rapid rate of Kush intake. Some participants in Moyiba pointed out that the income level of most people has been declining since last year. An increase in rentage is also observed, resulting in some people building their residential houses regardless of the nature of the house to escape the skyrocketing rental cost.

Access and barriers to services (water, sanitation, and healthcare)

Water and sanitation services

Sachet water and community wells are the main sources for drinking water across the settlements. Even though most households across the communities predominantly used sachet water, households in Cockle Bay used more sachet water than Dwarzark and Moyiba. There were differences in terms of domestic use water sources with Cockle Bay and Dwarzark highly dependent on community wells, while Moyiba relied mostly on surface water and rainwater. Fetching water in Cockle Bay was mainly done by adult women since the distances to water points are shorter and less hilly compared to Dwarzark and Moyiba where boys and girls predominantly fetched water. The average cost of drinking and domestic water across the settlements was relatively affordable at Le167. Payment for water services was primarily made by the head of the household.

The overall sanitation system is relatively poor across the three settlements. The use of flush toilets was common in Cockle Bay where most toilets in the community are connected to the sea for sludge discharge. The use of dry pit latrines in the hilltop communities (Dwarzark and Moyiba) is higher compared to Cockle Bay which can be attributed to the hilly terrain and water shortages which makes use of flush toilets economically infeasible. Sharing toilets with other households is common in these communities with toilet access not considered a challenge. The majority of respondents across three settlements did not report any issues about toilet inaccessibility to any relevant persons/authorities. However, few households reported their toilet inaccessibility to house owners, and they got positive responses.

The three communities are characterised by poor waste management, with uncontrolled dumping of waste into the sea (Cockle Bay), around the houses and drainages (Moyiba and Dwarzark). The average cost to access toilets and waste disposal at the household level was largely affordable.

Community feedback on findings: In Cockle Bay, for water there is access to spring water in the community. An increase in public water tap installation as five taps are being installed but will require minimal cost to access for buying from GUMA and maintenance. Poor road network within the community affects accessibility to water points and is not disable-friendly. There are more pour flush toilet facilities than a normal flush (Press flush). For sanitation, there are changes in waste management collection due to the Transforming Lives project that provided two tricycles to manage solid waste. Also, a reduction and improvement on hanging toilet.

In Dwazark, the water demand had increased while the supply kept decreasing because of the increase in population.  Increase in water cost for sachet water and jerry cans. All of these challenges keep increasing due to the increase in population while the water points remain the same. As community actions, there is continuous advocacy to the government and NGOs adds more water points within the community and most households are now digging water wells in their compounds. For sanitation, the waste service providers that were in the community have closed their operations. In the lower part of the community, people use MASADA to dispose of their waste.  While in the upper part, people dig holes in their compounds to dispose of their waste, burn them, or pay boys to throw the dirt.

In Moyiba, there are changes observed in terms of water, like an increase in the cost. For example, a jerry-can of water was three new leones (Le3) increased in cost to five new leones (Le 5), especially in the Nack Force and Soja Town zones located at the top part of the hill in the community. For sanitation, MASADA (a private waste collection company) was active in collecting waste, but the poor road network made them to cease waste collections in the community. The “Clean Salone” boys in the community are now more active in collecting waste but due to a lack of disposal sites, they usually dispose of waste around the community.

Healthcare services

The findings show that healthcare facilities vary between the coastal community (Cockle Bay) and hillside communities (Moyiba and Cockle Bay). Cockle Bay) lacks formal public healthcare services with private formal (pharmacies) and drug peddlers (i.e. informal medicine sellers) being the main healthcare providers. Dwarzark and Moyiba have more public health facilities which are dominated by the Peripheral Health Units (PHUs). However, drug peddlers, private formal, and nurses are also contributing to providing healthcare services in these two settlements. The majority of respondents sought formal public healthcare services outside their communities followed by the formal private.

Malaria infection and common cold/flu were the main illnesses which residents across these settlements sought medical care for. The total cost for healthcare utilisation within the communities is cheaper (Le203) compared to outside the communities (Le583) across three communities. On average, Cockle Bay dwellers spent less healthcare costs both within and outside community compared to Dwazark and Moyiba.

Distance to the health centers, cost of accessing the healthcare services, and quality of care were reported as the main barriers for healthcare utilisation. The majority of respondents in Cockle Bay (51%) had a positive experience after reporting barriers they encountered while accessing healthcare to relevant authorities. However, the majority of Dwarzark and Moyiba respondents did not report barriers they faced when accessing healthcare services to anyone.

Community feedback on findings: There is no public/private healthcare facility in Cockle Bay which does not reflect the result presented. Cockle Bay only has drug stores and drug peddlers and a high cost to access healthcare outside of the community.

In Dwarzark, the survey data reflects the reality of the healthcare challenges in the community, but no hospital exists as a formal healthcare facility; only PHU’s. Most pharmacies have closed because they are not registered with the pharmacy board. As a result, most people are now using drug peddlers as an alternative medical facility. The population of the community has increased more than the available healthcare facilities. Community stakeholders are advocating for more healthcare facilities within the community. There has been an increase in malaria, typhoid, and diarrhea infections.

In Moyiba, they intimated the lack of space in their PHU and health facilities including medicines, leading to prioritization of those covered by the free healthcare scheme (under-five children, pregnant women, and lactating mothers). Residents of Nack Force, and Soja Town are more vulnerable to health challenges due to the non-existence of health center in those parts of the community and the poor terrain. The PHU, which is overwhelmed and provides less care for people outside the free healthcare scheme. There is now a community land set aside for any intervention in the community relating to the construction of a bigger health centre/hospital. There is a surge in the population coupled with more demand for healthcare. They also noted an increase in healthcare cost due to long distance in seeking care outside, causing more people to seek alternative care to drug peddlers and native healthcare providers. as Malaria, typhoid, and cold cases continue to increase.

Environmental health risks (disasters, safety and security and livelihood)

The examination of the surveyed data across Cockle Bay, Dwarzark, and Moyiba highlighted a range of disaster and livelihood shocks faced by these communities. The thorough analysis delineated the prevalence and impact of disasters, showcasing the overwhelming affirmative responses across the communities regarding disaster occurrences, particularly in instances of flooding, fire, building collapses, and falling boulders. This underscored the necessity for tailored disaster response strategies, considering the nuanced differences in disaster occurrences at the community level, even at the zone level.

Information from households with firsthand experience of disaster impacts showed significant effects on property destruction and reduced livelihoods alongside the lack of assistance and support from local authorities. The findings illuminated a substantial portion of households reporting being unprepared for disasters, particularly in Dwarzark and Moyiba. The figures indicate the absence of public policies targeting the most frequent environmental disasters in these communities.

The varied approaches taken for disaster preparedness, such as physical flood barriers and improved disaster awareness, mainly organized by the communities, signified the need for more robust community-specific strategies.

There is an urgent need to increase safety in the three study communities, for everyone and for vulnerable groups including women, girls and the aged. Survey results indicate that theft/robbery are predominant across study communities and in turn vulnerable and marginalized groups are often targeted. There is the need to address all the identified safety concerns (theft/robbery; physical violence; road accidents; evictions; and SGBV) across the three communities; however, some concerns are particularly prevalent in specific communities, for example evictions in Cockle Bay.

The examination of livelihood shocks within these communities elucidated economic shocks as the most prevalent concern, influencing household livelihoods consistently across Cockle Bay, Dwarzark, and Moyiba. This dominance was accompanied by natural, political/social, and health shocks, revealing nuanced distributions across communities. The coping mechanisms adopted by households, including reductions in non-essential expenditures, altering food consumption, and borrowing from various sources, shed light on the adaptive approaches taken in the face of these shocks.

Additionally, the assessment of external support and future needs emphasized a significant lack of support for households impacted by disasters, highlighting the need for more robust support structures. While relatives remained a crucial support network, variations in reliance on friends, NGOs, and community members, as well as differences in the types of support received and future needs, provided invaluable insights for tailoring support strategies to the specific needs and dynamics of each community.

Lastly, the data on food insecurity unveiled varying degrees of challenges within each community, reflecting differences in the prevalence of food security challenges. This diverse and comprehensive narrative across disasters, household impacts, coping strategies, support structures, and food security underscored the necessity for targeted interventions and support tailored to the unique needs and challenges faced by each community within Cockle Bay, Dwarzark, and Moyiba. Efforts must focus on improving preparedness, enhancing support networks, and addressing the pressing food security concerns prevalent within these areas to ensure a more resilient and supported community fabric.

Community feedback on findings: In Cockle Bay they raised concern about the alarming flooding incidence from the findings as they experience less flash flooding. Residential homes close to the main drainages are frequently affected by flash flooding. They’re faced with more water logging and outbursts in houses without concrete floors when the water table rises. There is a reduction of Gender-based violence due to sensitization and awareness raising.

There is no specific evacuation centre so people often use religious places, schools, and community centres as rescue sites. There is less fire incidences due to the installation of high-tension cables from 25mm to 70mm within the different zones as each zone connects to different transformers. There is an increase in drug abuse (KUSH) that leads to alarming theft incidences.

In Dwazark the data reflect the reality in the community and nothing has changed since the data was collected till now. However,  there is a mismatch in some of the information for example, according to the data, respondents mentioned that buildings/ houses normally collapse in Italy and Brazil which are some of the zones within the community. While in reality, there is no disaster like that in those zones.

In Moyiba, the data speaks the truth about the community as flooding occurs due to lack of proper drainages. The fire incidents are now less but can only happen now when there is a malfunction in the community electricity. Collapsing buildings occur often both in the dry and rainy seasons and it is a threat to us in the community. The disease outbreak remains the same in the community and during the rainy season, diseases like diarrhea, common cold, skin rash, and malaria affect most people. Since the survey, there are still safety concerns in the community because the community safety volunteers (CSV’s) are not everywhere in the community and there are no police posts.

Well-being priorities and challenges

The general perception of well-being in slums may include material possessions such as cars and household assets, access to financial services and formal safety nets and social networks. All these aspects of well-being are essential for vulnerable populations living in slums. However, the lack of homogeneity in the perception of physical, social and mental well-being across informal settlements is rarely considered when implementing policies targeting these communities.

We found similarities and differences in the surveyed communities. For example, the factors that determine the physical well-being in Cockle Bay and Moyiba seem to agree are good health and a clean and safe environment, whilst Cockle Bay and Dwazack seem to have similar social and mental well-being priorities (e.g. financial stability, safety/security and support network)

The pattern in challenges and barriers to well-being differ across the communities, except for financial challenges, which was the option selected by most (>90%) of the respondents in all communities. Our findings indicated that Moyiba may face incidents of violent activities, as violence and conflict were common issues in all well-being categories (physical, mental and social) and challenges. Similarly, this study shows that safety, peace and security are essential well-being goals in Moyiba as their responses for physical well-being (safe environment, 87%), social well-being (peace, 93% and security and safety, 89%), mental well-being (peaceful coexistence, 90%), and well-being challenges (lack of safety and security, 80%) had reached high percentages.

Another interesting finding is about religion and how it may play a role in the communities. Across all communities, ‘God’ ranked top when households needed to report their daily struggles and challenges. Despite the positive aspect of the religion in the provision of emotional relief and spreading messages of generosity, this find may indicate a lack of trust from formal institutions (e.g., local authorities, NGOs) or even a lack of assistance from those who are expected to have an active position in these communities. In addition, households seem to trust the most on their spouses, other relatives, friends and neighbors as they reported more positive and timely responses, which reinforces the negligence of formal institutions.

From this survey, we could observe the perception of physical, social and mental well-being in Freetown’s informal settlements alongside barriers/challenges faced by these vulnerable communities. The findings indicated that the perception of health and well-being, challenges and barriers can differ across slum communities. These findings are crucial for evidence-based policy-making to improve local policy development. Also, these findings can contribute to prioritizing interventions focusing on well-being according to the different needs and challenges faced by slum dwellers in Freetown.

Community feedback on findings: In Cocklebay, the data on well-being is a reflection of what is happening in the community during the survey. The inflation is affecting the living conditions of those living in the community. Over the past year, the entire country has been plagued with high inflation, inflicting suffering, mental health problems, and increasing the blood pressure of many people in the community.

In Dwazack, there is poor health conditions because of excessive drug abuse, especially amongst the youth. This intake of “Kush” drugs affects the mental and physical well-being of the people taking it. Indirectly, it is also affecting their parents and neighborhoods through crimes like theft etc. For clean drinking water, the water body within the community is now contaminated because of excessive use, high demand, and low supply. The water has fewer intervals to replenish itself. For clean and safe environment, there are more garbage disposals around the community e.g. the street, drainages, etc. and theft is also in the increase. For improved sanitation, in terms of toilet access has improved within this one year due to additional public toilets in the community. Many households are digging pit latrines to move away from local toilets to improved toilets facilities. For proper housing, in the past year, most people have improved their structure from corrugated sheet houses to concrete, and mud brick houses.

In Moyiba, they said since the data collection period till now, the health system in the community has remained the same. There are no medicines in the health center. There are no pure and safe drinking water facilities. The environment is not safe, because of poor housing conditions and poor toilet facilities. They also said there is only one public toilet and there are no public trash cans within the community. They have poor drainage systems which causes flooding  and a poor road network which is our biggest challenge. They also pointed out inadequate job opportunities and most people are working without salary. They have challenges with domestic violence within the community. Finally they said women are faced with more challenges in taking care of their family because the burden is strongly on them.

For more information please download the full report: