Trends, Rural–Urban Inequalities and Forecasts of Open Defecation in Ghana Using Joinpoint Regression and ARIMA Analysis, 2000–2030
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Background
Open defecation remains a major public health challenge in Ghana and across sub-Saharan Africa, with persistent rural–urban inequalities undermining progress toward Sustainable Development Goal 6.2 (SDG 6.2). Despite two decades of national sanitation programming, structural and equity barriers continue to constrain progress. A repeated cross-sectional analyses combining WHO-standardised inequality measures, temporal trend modelling, and projections remain absent from the literature for Ghana.
Methods
National, rural, and urban open defecation prevalence (2000–2024) was analysed using WHO Health Equity Assessment Toolkit (HEAT) data. Four inequality measures: Difference, Ratio, Population Attributable Risk (PAR), and Population Attributable Fraction (PAF), quantified rural–urban disparities. Joinpoint regression identified statistically significant trend inflection points across MDG and SDG eras. ARIMA models projected prevalence to 2030 under status quo, accelerated, and decelerated scenarios; hold-out validation confirmed high forecast accuracy across all series (MAPE <1%).
Results
National prevalence declined from 20.31% to 17.79% (AAPC: −0.55%, p<0.001), with a joinpoint at 2016 (95% CI: 2015–2017) after which decline slowed during the SDG era. Rural prevalence rose marginally (AAPC: +0.07%) with no significant joinpoints across the 25-year period; urban prevalence also increased (AAPC: +0.76%). Rural prevalence exceeded urban more than threefold by 2024 (R=3.38); PAF improved from −62.62% to −48.85%, indicating a substantial national burden attributable to rural disadvantage. Under the status quo scenario, national and rural prevalence are projected at 17.24% and 30.88% by 2030, far exceeding the SDG 6.2 threshold.
Conclusion
Despite modest national progress, substantial rural–urban inequalities remain entrenched, and Ghana is unlikely to achieve SDG 6.2 under current trajectories. Accelerated, equity-focused interventions targeting structurally disadvantaged rural populations are urgently required to reduce sanitation inequalities and improve health outcomes.
