The contextual awareness, response and evaluation (CARE) diabetes project: study design for a quantitative survey of diabetes prevalence and non-communicable disease risk in Ga Mashie, Accra, Ghana.

Diabetes is estimated to affect between 3.3% and 8.3% of adults in Ghana, and prevalence is expected to rise. The lack of cost-effective diabetes prevention programmes designed specifically for the Ghanaian population warrants urgent attention. The Contextual Awareness, Response and Evaluation (CARE): Diabetes Project in Ghana is a mixed methods study that aims to understand diabetes in the Ga Mashie area of Accra, identify opportunities for community-based intervention and inform future diabetes prevention and control strategies. This paper presents the study design for the quantitative survey within the CARE project. This survey will take place in the densely populated Ga Mashie area of Accra, Ghana. A household survey will be conducted using simple random sampling to select households from 80 enumeration areas identified in the 2021 Ghana Population and Housing Census. Trained enumerators will interview and collect data from permanent residents aged ≥ 25 years. Pregnant women and those who have given birth in the last six months will be excluded. Data analysis will use a combination of descriptive and inferential statistics, and all analyses will account for the cluster sampling design. Analyses will describe the prevalence of diabetes, other morbidities, and associated risk factors and identify the relationship between diabetes and physical, social, and behavioural parameters. This survey will generate evidence on drivers and consequences of diabetes and facilitate efforts to prevent and control diabetes and other NCDs in urban Ghana, with relevance for other low-income communities.

Coverage of preventive measures and surveillance for neglected tropical diseases in hard-to-reach communities in Ghana.

BACKGROUND: Neglected tropical diseases (NTDs) are a major public health burden which mainly affects poor populations living in tropical environments and hard-to-reach areas. The study sought to examine coverage of preventive efforts, and case surveillance for NTDs in hard-to-reach communities in Ghana. METHODS: The study investigated treatment efforts for lymphatic filariasis (LF), and onchocerciasis and schistosomiasis/soil transmitted helminths (SCH/STH) at household level, in difficult-to-access communities in Ghana. A total of 621 households were sampled from 6 communities in the Western, Oti and Greater Accra regions. RESULTS: Over 95% of the households surveyed were covered under mass drug administration (MDA) campaigns for lymphatic filariasis (LF) and onchocerciasis. More than 80% of households had received at least two visits by community drug distributors under the MDA campaigns in the last two years preceding the study. In addition, over 90% of households in the LF and onchocerciasis endemic communities had at least one member using anthelminthic medications under the MDA campaigns in the 12 months preceding the study. However, households where no member had taken anthelminthic medications in 12 months preceding the study were over 6 times likely to have someone in the household with LF. CONCLUSIONS: This study determined that SCH/STH, LF and onchocerciasis are of serious public health concern in some communities in Ghana. There is an urgent need for holistic practical disease control plan involving both financial and community support to ensure total control of NTDs in difficult-to-access communities is achieved.

Perceptions of the roles, impact, challenges and needs of community drug distributors in the control and elimination of neglected tropical diseases in difficult-to-access communities in Ghana.

INTRODUCTION: The success of mass drug administration (MDA) campaigns to control and eliminate neglected tropical diseases (NTDs) in Ghana depends, to a large extent, on the essential role community drug distributors (CDDs) play. This study aimed to investigate community's perceptions of CDDs' roles, impact of CDDs' work, challenges faced by CDDs, and views on resources required to enhance CDDs' work to sustain MDA campaigns. METHODS: A cross-sectional qualitative study employing the use of focus group discussions (FGDs) with community members and CDDs in selected NTD endemic communities together with individual interviews with district health officers (DHOs) was conducted. We interviewed 104 people aged 18 and over, purposively selected, through eight individual interviews, and 16 focus group discussions. RESULTS: Participants in the community FGDs noted that health education and the distribution of drugs were the main roles of CDDs. Participants also perceived that the work of CDDs had prevented the onset of NTDs, treated symptoms of NTDs, and generally reduced the incidence of infections. In the interviews with CDDs and DHOs, lack of cooperation/non-compliance by community members, demands by community members, lack of working resources and low financial motivation were mentioned as the main challenges to the work of CDDs. Moreover, the provision of logistics and financial motivation for CDDs were identified as factors that will enhance their work. CONCLUSIONS: Incorporating more attractive schemes will incentivise CDDs to improve output. Addressing the challenges highlighted is an important step for the work of CDDS to be effective in controlling NTDs in difficult-to-access communities in Ghana.

Perceptions of the roles, impact, challenges and needs of community drug distributors in the control and elimination of neglected tropical diseases in difficult-to-access communities in Ghana.

The success of mass drug administration (MDA) campaigns to control and eliminate neglected tropical diseases (NTDs) in Ghana depends, to a large extent, on the essential role community drug distributors (CDDs) play. This study aimed to investigate community's perceptions of CDDs' roles, impact of CDDs' work, challenges faced by CDDs and views on resources required to enhance CDDs' work to sustain MDA campaigns. Methods : A cross-sectional qualitative study employing the use of focus group discussions (FGDs) with community members and CDDs in selected NTD endemic communities together with individual interviews with district health officers (DHOs)was conducted. We interviewed 104 people aged 18 and over, purposively selected, through eight individual interviews, and 16 focus group discussions. Results : Participants in the community FGDs noted that health education and distribution of drugs were the main roles of CDDs. Participants also perceived that the work of CDDs had prevented the onset of NTDs, treated symptoms of NTDs and generally reduced the incidence of infections. In the interviews with CDDs and DHOs, lack of cooperation/non-compliance by community members, demands by community members, lack of working resources and low financial motivation were mentioned as the main challenges to the work of CDDs. Moreover, provision of logistics and financial motivation for CDDs were identified as factors that will enhance their work. Conclusions : Incorporating more attractive schemes shall incentivise CDDs to improve output. Addressing the challenges highlighted is an important step for the work of CDDS to be effective in controlling NTDs in difficult-to-access communities in Ghana.

Psychosocial stressors among Ghanaians in rural and urban Ghana and Ghanaian migrants in Europe.

Psychosocial stressors have significant health and socio-economic impacts on individuals. We examined the prevalence and correlates of psychosocial stressors among non-migrant and migrant Ghanaians as there is limited research in these populations. The study was cross-sectional and quantitative in design. A majority of the study participants had experienced stress, discrimination and negative life events. Increased age, female sex, strong social support and high sense of mastery were associated with lower odds of experiencing psychosocial stressors in both populations. Interventions should be multi-level in design, focusing on the correlates which significantly influence the experience of psychosocial stressors.

Lay knowledge of cardiovascular disease and risk factors in three communities in Accra, Ghana: a cross-sectional survey.

OBJECTIVES: Cardiovascular disease is a major cause of morbidity and mortality in Ghana, and urban poor communities are disproportionately affected. Research has shown that knowledge of cardiovascular disease (CVD) is the first step to risk reduction. This study examines knowledge of CVD and risk factors and determinants of CVD knowledge in three urban poor communities in Accra, Ghana. METHODS: Using the Cardiovascular Disease Risk Factors Knowledge Level Scale, which has been validated in Ghana, we conducted a cross-sectional survey with 775 respondents aged 15-59 years. CVD knowledge was computed as a continuous variable based on correct answers to 27 questions, and each correct response was assigned one point. Linear regression was used to determine the factors associated with CVD knowledge. RESULTS: The mean age of the participants was 30.3±10.8 years and the mean knowledge score was 19.3±4.8. About one-fifth of participants were living with chronic diseases. Overall, 71.1% had good CVD knowledge, and 28.9% had moderate or poor CVD knowledge. CVD knowledge was low in the symptoms and risk factor domains. A larger proportion received CVD knowledge from radio and television. The determinants of CVD knowledge included ethnicity, alcohol consumption, self-reported health and sources of CVD knowledge. CVD knowledge was highest among a minority Akan ethnic group, those who were current alcohol consumers and those who rated their health as very good/excellent, compared with their respective counterparts. CVD knowledge was significantly lower among those who received information from health workers and multiple sources. CONCLUSION: This study underscores the need for health education programmes to promote practical knowledge on CVD symptoms, risks and treatment. We outline health systems and community-level barriers to good CVD knowledge and discuss the implications for developing context-specific and culturally congruent CVD primary prevention interventions.

Perceptions and beliefs about anaemia: A qualitative study in three agroecological regions of Ghana.

Little evidence exists concerning perceptions of anaemia in Ghanaian communities, which limits understanding of how to potentially improve health in settings with high anaemia prevalence. We explored lay perceptions of anaemia to understand local knowledge and beliefs and to provide an opportunity to inform interventions. A cross-sectional, qualitative study was conducted in selected communities in three regions of Ghana with high prevalence of anaemia. Forty-eight focus group discussions (FGDs) were conducted with adolescent girls, adult women of reproductive age and adult men (16 FGDs for each demographic group). Participants across the three demographic groups generally described anaemia as inadequate blood in the body and reported that poor diet, heat, alcohol intake, physiological factors and diseases such as malaria were the main causes of anaemia. Consequences of anaemia mentioned in the FGDs included dizziness, weight loss, loss of appetite and weakness. Prevention of anaemia was perceived to result from improved diet, avoidance of exposure to heat and improved sanitation to avoid diseases. The findings suggest that despite areas of convergence between lay and biomedical knowledge on the causes, consequences and prevention of anaemia, the burden of anaemia remains high in the study regions. This highlights a disconnect between local knowledge of anaemia and the health and nutrition behaviours needed to reduce its incidence. Effective interventions can be developed with and for communities that build upon existing knowledge while filling remaining knowledge gaps or misconceptions.

Hypertension awareness, treatment and control in Ghana: a cross-sectional study.

Objective: This study assessed the rates of hypertension awareness, treatment and control as well as the socio-economic and demographic correlates in Ghana. Methods: This was a cross-sectional study. We used wave 1 of the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) conducted between 2007and 2008. The sample was 5526 respondents aged 18 years and above. Descriptive statistics were used to describe the characteristics of the respondents and binary logistic regression was used to determine the correlates of hypertension awareness, treatment and control. Results: The hypertension prevalence was 58.9%. About 19.0% of the individuals living with hypertension were aware of their hypertension; 67.6% of those who were aware of their hypertension were treating the condition, and; 11.6% of those who were on treatment had their hypertension controlled. Age, place of residence, level of education, employment status, ethnicity, and religion were associated with hypertension awareness and treatment. None of the factors was associated with hypertension control. Conclusion: Our study suggests high hypertension prevalence in Ghana, with low rates of awareness, treatment and control. Socio-economic and demographic factors are essential correlates of hypertension awareness and treatment in Ghana. The findings indicate the need to develop pragmatic intervention approaches such as rigorous education programs and use of the task-shifting system, in addressing hypertension and issues related to it.

Psychosocial factors and hypertension prevalence among Ghanaians in Ghana and Ghanaian migrants in Europe: The RODAM study.

Despite progress made to prevent and control hypertension, its prevalence has persisted in many countries. This study examined the associations between psychosocial factors and hypertension among Ghanaian non-migrants and migrants. Data were drawn from the Research on Obesity and Diabetes among African Migrants (RODAM) project. Findings show that among migrant women, those who experienced periods of stress at home/work had higher odds of hypertension. Among non-migrants, women with depression symptoms were more likely to be hypertensive. Furthermore, there was a positive association between negative life events and hypertension among non-migrant men. The findings highlight the importance of psychosocial factors in addressing hypertension prevalence in Ghanaian populations.

Knowledge and perceptions of type 2 diabetes among Ghanaian migrants in three European countries and Ghanaians in rural and urban Ghana: The RODAM qualitative study.

African migrants in Europe and continental Africans are disproportionately affected by type 2 diabetes (T2D). Both groups develop T2D at a younger age, and have higher morbidity and mortality from T2D and complications, compared to European populations. To reduce risk, and avoidable disability and premature deaths, culturally congruent and context specific interventions are required. This study aimed to: (a) assess perceptions and knowledge of T2D among Ghanaian migrants in Europe and their compatriots in Ghana and (b) identify specific perceptions and knowledge gaps that might predispose migrants to higher risk of diabetes. Data was gathered through 26 focus groups with 180 individuals, aged 21 to 70, from Amsterdam, Berlin and London and rural and urban Ashanti Region, Ghana. Thematic analysis of the data was informed by Social Representations Theory, which focuses on the sources, content and functions of social knowledge. Three key insights emerged from analysis. First, there was general awareness, across migrant and non-migrant groups, of T2D as a serious chronic condition with life threatening complications, and some knowledge of biomedical strategies to prevent diabetes (e.g healthy eating) and diabetes complications (e.g medication adherence). However, knowledge of T2D prevention and reduction of diabetes complications was not comprehensive. Secondly, knowledge of biomedical diabetes theories and interventions co-existed with theories about psychosocial and supernatural causes of diabetes and the efficacy of herbal and faith-based treatment of diabetes. Finally, migrants' knowledge was informed by both Ghanaian and European systems of T2D knowledge suggesting enculturation dynamics. We discuss the development of culturally congruent and context-specific T2D interventions for the research communities.

Community and individual sense of trust and psychological distress among the urban poor in Accra, Ghana.

BACKGROUND: Mental health disorders present significant health challenges in populations in sub Saharan Africa especially in deprived urban poor contexts. Some studies have suggested that in collectivistic societies such as most African societies people can draw on social capital to attenuate the effect of community stressors on their mental health. Global studies suggest the effect of social capital on mental disorders such as psychological distress is mixed, and emerging studies on the psychosocial characteristics of collectivistic societies suggest that mistrust and suspicion sometimes deprive people of the benefit of social capital. In this study, we argue that trust which is often measured as a component of social capital has a more direct effect on reducing community stressors in such deprived communities. METHODS: Data from the Urban Health and Poverty Survey (EDULINK Wave III) survey were used. The survey was conducted in 2013 in three urban poor communities in Accra: Agbogbloshie, James Town and Ussher Town. Psychological distress was measured with a symptomatic wellbeing scale. Participants' perceptions of their neighbours' willingness to trust, protect and assist others was used to measure community sense of trust. Participants' willingness to ask for and receive help from neighbours was used to measure personal sense of trust. Demographic factors were controlled for. The data were analyzed using descriptive and multivariate regressions. RESULTS: The mean level of psychological distress among the residents was 25.5 (SD 5.5). Personal sense of trust was 8.2 (SD 2.0), and that of community sense of trust was 7.5 (SD 2.8). While community level trust was not significant, personal sense of trust significantly reduced psychological distress (B = -.2016728, t = -2.59, p < 0.010). The other factors associated with psychological distress in this model were perceived economic standing, education and locality of residence. CONCLUSION: This study presents evidence that more trusting individuals are significantly less likely to be psychologically distressed within deprived urban communities in Accra. Positive intra and inter individual level variables such as personal level trust and perceived relative economic standing significantly attenuated the effect of psychological distress in communities with high level neighbourhood disorder in Accra.

Leveraging smallholder livestock production to reduce anemia: A qualitative study of three agroecological zones in Ghana.

Livestock production and Animal-Source Foods (ASFs) like meat, milk, and eggs are excellent sources of essential micronutrients, including iron and zinc. There is evidence that encouraging increased access to and consumption of these ASFs may either positively or negatively impact anemia, or have no nutritional effects. Drawing upon first-hand experiences in Ghana, this study sought to: (1) identify the main motivations for raising livestock in Ghana; (2) describe the major barriers to consuming ASFs, especially among women of reproductive age (WRA); and (3) explore the feasibility of different livestock-centered interventions to reduce anemia. Key informant interviews and focus group discussions were held with relevant stakeholders at different geographical scales - the national, regional, district, and community levels. The results suggest that livestock enable savings, allow resource-poor households to accumulate assets, and help finance planned and unplanned expenditures (e.g., school fees and illness). Due to these multiple and often pressing uses, direct consumption of home-reared ASFs is not a major priority, especially for poor households. Even when ASFs are consumed, intra-household allocation does not favor women and adolescent girls, demographic groups with particularly high micronutrient requirements. The study participants discussed possible interventions to address these challenges, including (1) increasing livestock ownership through in-kind credit; (2) encouraging nutrition-related behavior change; (3) improving livestock housing; and (4) hatchery management. The paper discusses these interventions based upon potential acceptance, feasibility, cost effectiveness, and sustainability in the Ghanaian context.

Livestock ownership is associated with higher odds of anaemia among preschool-aged children, but not women of reproductive age in Ghana.

Livestock ownership may influence anaemia through complex and possibly contradictory mechanisms. In this study, we aimed to determine the association of household livestock ownership with anaemia among women aged 15-49 years and children aged 6-59 months in Ghana and to examine the contribution of animal source foods (ASFs) to consumption patterns as a potential mechanism mediating this association. We analysed data on 4,441 women and 2,735 children from the 2014 Ghana Demographic and Health Survey and 16,772 households from the Ghana Living Standards Survey Round 6. Haemoglobin measurements were used to define anaemia (non-pregnant women: <120 g/L; children: <110 g/L). Child- and household-level ASF consumption data were collected from 24-hour food group intake and food consumption and expenditure surveys, respectively. In multiple logistic regression models, household livestock ownership was associated with anaemia among children (OR, 95% CI: 1.5 [1.1, 2.0]), but not women (1.0 [0.83, 1.2]). Household ownership of chickens was associated with higher odds of anaemia among children (1.6 [1.2, 2.2]), but ownership of other animal species was not associated with anaemia among women or children. In path analyses, we observed no evidence of mediation of the association of household livestock ownership with child anaemia by ASF consumption. Ownership of livestock likely has limited importance for consumption of ASFs among young children in Ghana and may in fact place children at an increased risk of anaemia. Further research is needed to elucidate if and how pathogen exposure associated with livestock rearing may underlie this increased risk of anaemia.

Factors associated with treatment-seeking for malaria in urban poor communities in Accra, Ghana.

BACKGROUND: In Ghana, about 3.5 million cases of malaria are recorded each year. Urban poor residents particularly have a higher risk of malaria mainly due to poor housing, low socio-economic status and poor sanitation. Alternative treatment for malaria (mainly African traditional/herbal and/or self-medication) is further compounding efforts to control the incidence of malaria in urban poor communities. This study assesses factors associated with seeking alternative treatment as the first response to malaria, relative to orthodox treatment in three urban poor communities in Accra, Ghana. METHODS: This cross-sectional study was conducted in three urban poor localities in Accra, Ghana among individuals in their reproductive ages (15-59 years for men and 15-49 years for women). The analytic sample for the study was 707. A multinomial regression model was used to assess individual, interpersonal and structural level factors associated with treatment-seeking for malaria. RESULTS: Overall, 31% of the respondents sought orthodox treatment, 8% sought traditional/herbal treatment and 61% self-medicated as the first response to malaria. At the bivariate level, more males than females used traditional/herbal treatment and self-medicated for malaria. The results of the regression analysis showed that current health insurance status, perceived relative economic standing, level of social support, and locality of residence were associated with seeking alternative treatment for malaria relative to orthodox treatment. CONCLUSIONS: The findings show that many urban poor residents in Accra self-medicate as the first response to malaria. Additionally, individuals who were not enrolled in a health insurance scheme, those who perceived they had a low economic standing, those with a high level of social support, and locality of residence were significantly associated with the use of alternative treatment for malaria. Multi-level strategies should be employed to address the use of alternative forms of treatment for malaria within the context of urban poverty.

Explanatory models of diabetes in urban poor communities in Accra, Ghana.

OBJECTIVES: The objective of the study was to examine explanatory models of diabetes and diabetes complications among urban poor Ghanaians living with diabetes and implications for developing secondary prevention strategies. DESIGN: Twenty adults with type 2 diabetes were recruited from three poor communities in Accra. Qualitative data were obtained using interviews that run between 40 and 90 minutes. The interviews were audio-taped, transcribed and analysed thematically, informed by the 'explanatory model of disease' concept. RESULTS: Respondents associated diabetes and its complications with diet, family history, lifestyle factors (smoking, excessive alcohol consumption and physical inactivity), psychological stress and supernatural factors (witchcraft and sorcery). These associations were informed by biomedical and cultural models of diabetes and disease. Subjective experience, through a process of 'body-listening,' constituted a third model on which respondents drew to theorise diabetes complications. Poverty was an important mediator of poor self-care practices, including treatment non-adherence. CONCLUSIONS: The biomedical model of diabetes was a major source of legitimate information for self-care practices. However, this was understood and applied through a complex framework of cultural theories of chronic disease, the biopsychological impact of everyday illness experience and the disempowering effects of poverty. An integrated biopsychosocial approach is proposed for diabetes intervention in this research community.

Prevalence, awareness, treatment and control of hypertension in urban poor communities in Accra, Ghana.

BACKGROUND: Hypertension is a major public health problem in many sub-Saharan African countries including Ghana, but data on urban poor communities are limited. The aim of this study was therefore to assess the prevalence, awareness, management and control of hypertension among a young adult population in their reproductive ages living in urban poor communities in Accra. METHODS: Cross-sectional, population-based survey of 714 young adults in their reproductive ages (women aged 15-49 years, men aged 15-59 years) living in three urban poor suburbs of Accra, Ghana. RESULTS: The overall prevalence of hypertension in all three communities was 28.3% (women 25.6% and men 31.0%). Among respondents who had hypertension, 7.4% were aware of their condition; 4% were on antihypertensive medication while only 3.5% of hypertensive individuals had adequate blood pressure (BP) control (BP <140/90  mmHg). The level of awareness and treatment was lower in men than in women (3.1 and 1.3% for men and 11.9 and 6.5% for women, respectively). Among individuals with hypertension, the rate of control was higher among women than among men (5.0 and 2.1%, respectively). CONCLUSION: Although about a quarter of the young adult population in these low-income communities of Accra have hypertension, the levels of awareness, treatment and control are abysmally low. We recommend community-specific primary and secondary prevention interventions that draw on existing resources, specifically implementing cardiovascular disease (CVD) interventions in faith-based organizations and task-shifting CVD care through the national Community-based Health Planning and Services (CHPS) programme.