Small area variations and factors associated with blood pressure and body-mass index in adult women in Accra, Ghana: Bayesian spatial analysis of a representative population survey and census data.

BACKGROUND: Body-mass index (BMI) and blood pressure (BP) levels are rising in sub-Saharan African cities, particularly among women. However, there is very limited information on how much they vary within cities, which could inform targeted and equitable health policies. Our study aimed to analyse spatial variations in BMI and BP for adult women at the small area level in the city of Accra, Ghana. METHODS AND FINDINGS: We combined a representative survey of adult women's health in Accra, Ghana (2008 to 2009) with a 10% random sample of the national census (2010). We applied a hierarchical model with a spatial term to estimate the associations of BMI and systolic blood pressure (SBP) and diastolic blood pressure (DBP) with demographic, socioeconomic, behavioural, and environmental factors. We then used the model to estimate BMI and BP for all women in the census in Accra and calculated mean BMI, SBP, and DBP for each enumeration area (EA). BMI and/or BP were positively associated with age, ethnicity (Ga), being currently married, and religion (Muslim) as their 95% credible intervals (95% CrIs) did not include zero, while BP was also negatively associated with literacy and physical activity. BMI and BP had opposite associations with socioeconomic status (SES) and alcohol consumption. In 2010, 26% of women aged 18 and older had obesity (BMI ≥ 30 kg/m2), and 21% had uncontrolled hypertension (SBP ≥ 140 and/or DBP ≥ 90 mm Hg). The differences in mean BMI and BP between EAs at the 10th and 90th percentiles were 2.7 kg/m2 (BMI) and in BP 7.9 mm Hg (SBP) and 4.8 mm Hg (DBP). BMI was generally higher in the more affluent eastern parts of Accra, and BP was higher in the western part of the city. A limitation of our study was that the 2010 census dataset used for predicting small area variations is potentially outdated; the results should be updated when the next census data are available, to the contemporary population, and changes over time should be evaluated. CONCLUSIONS: We observed that variation of BMI and BP across neighbourhoods within Accra was almost as large as variation across countries among women globally. Localised measures are needed to address this unequal public health challenge in Accra.

Women living with multi-morbidity in the Greater Accra Region of Ghana: a qualitative study guided by the Cumulative Complexity Model.

Defined as the co-occurrence of more than two chronic conditions, multi-morbidity has been described as a significant health care problem: a trend linked to a rise in non-communicable disease and an ageing population. Evidence on the experiences of living with multi-morbidity in middle-income countries (MICs) is limited. In high-income countries (HICs), multi-morbidity has a complex impact on health outcomes, including functional status, disability and quality of life, complexity of health care and burden of treatment. Previous evidence also shows that multi-morbidity is consistently higher amongst women. This study aimed to explore the perceptions and experiences of women living with multi-morbidity in the Greater Accra Region, Ghana: to understand the complexity of their health needs due to multi-morbidity, and to document how the health system has responded. Guided by the Cumulative Complexity Model, and using stratified purposive sampling, 20 in-depth interviews were conducted between May and September 2015 across three polyclinics in the Greater Accra Region. The data were analysed using the six phases of Thematic Analysis. Overall four themes emerged: 1) the influences on patients' health experience; 2) seeking care and the responsiveness of the health care system; 3) how patients manage health care demands; and 4) outcomes due to health. Spirituality and the stigmatization caused by specific conditions, such as HIV, impacted their overall health experience. Women depended on the care and treatment provided through the health care system despite inconsistent coverage and a lack of choice thereof, although their experiences varied by chronic condition. Women depended on their family and community to offset the financial burden of treatment costs, which was exacerbated by having many conditions. The implications are that integrated health and social support, such as streamlining procedures and professional training on managing complexity, would benefit and reduce the burden of multi-morbidity experienced by women with multi-morbidity in Ghana.

Women's health status in urban Ghana: dimensions and differentials using short form 36.

BACKGROUND: Global discourse on population, health and development have placed women's health issues at the top of development agenda. Women's reproductive health has received some attention in Ghana since the mid-1990s. However, studies on women's general health status, dimensions and the differentials in a rapidly growing urban setting is poorly understood and under-researched. This study sought to examine the various pathways in which individual socio-demographic factors, economic characteristics and endowment influence self-assessed health status among women living in the city of Accra, Ghana. METHODS: The paper draws on a cross-sectional study carried out in 2008 and 2009 using a representative sample of urban women 20 years and older (n = 2814). Multivariate stepwise linear regression models were performed to investigate the influence of socio-demographic, economic and health indicators on health-related quality of life, measured by eight sub-scales of the Short Form-36 (SF-36). Interaction effects between some demographic and socio-economic variables were also performed. RESULTS: The analyses show diverse relationships between demographic, socio-economic and health indicators and health outcomes assessed using eight SF-36 sub-scales. Education, disease symptoms and age of the respondent were the most significant factors influencing good overall health status. Interestingly, age has no significant effect on mental health after controlling for all other explanatory variables. CONCLUSIONS: The findings show that health issues are multi-faceted requiring socio-cultural, health and economic policy interventions. Investing in women's education is important to improve health status. There is also the need for more effective collaboration across various sectors to improve the health and well-being of women in general. Ageing has increasing relationship with poor physical health status and the elderly should be given needed attention and support.

Childbearing and Economic Work: The Health Balance of Women in Accra, Ghana.

OBJECTIVES: This study aims to investigate (1) whether the health of working women with young children differs from that of working women without young children, and (2) which social factors mediate the relationship between economic and maternal role performance and health among mothers with young children. METHODS: The analyses uses panel data from 697 women present in both waves of the Women's Health Study for Accra (WHSA-I and WHSA-II); a community based study of women aged 18 years and older in the Accra Metropolitan Area of Ghana conducted in 2003 and 2008-2009. Change in physical and mental health between the survey waves is compared between women with a biological child alive at WHSA-II and born since WHSA-I and women without a living biological child at WHSA-II born in the interval. To account for attrition between the two survey waves selection models were used with unconditional change score models being used as the outcome model. RESULTS: We found in our sample of working women that those who had a child born between WHSA-I and WHSA-II who was still alive at WHSA-II did not experience a change in mental or physical health different from other women. Among working women with young children, educational status, relationship to the household head and household demography were associated with change in mental health at the 5 % level, whilst migration status and household demography was associated with change in physical health scores. CONCLUSION: The results suggest there are no health penalties of combining work and childbearing among women with young children in Accra, Ghana.

Contraceptive Use among Women in Accra, Ghana: 2003 and 2008.

Despite a relatively low fertility rate, maternal mortality in Ghana still remains high. According to the Ghana Demographic and Health Surveys, about 22% of Ghanaian women of reproductive age currently use contraception. We analyzed contraceptive use among a representative sample of women in Accra, Ghana, to better understand contraceptive use patterns. We used data from two cross-sectional surveys of a representative cohort of women in Accra. In 2003, 28.9% of sexually active women used a contraceptive method. In 2008, 31.5% of sexually active women used a contraceptive method. Additionally, we observed high rates of discontinuation-from 64.1% among those using longer-acting methods to 82.1% among those using traditional methods-between years. Further research on women's contraceptive decision-making is needed to explain these patterns and to ensure that family planning interventions meet the needs of women in Ghana.

Multimorbidity and the inequalities of global ageing: a cross-sectional study of 28 countries using the World Health Surveys.

BACKGROUND: Multimorbidity defined as the "the coexistence of two or more chronic diseases" in one individual, is increasing in prevalence globally. The aim of this study is to compare the prevalence of multimorbidity across low and middle-income countries (LMICs), and to investigate patterns by age and education, as a proxy for socio-economic status (SES). METHODS: Chronic disease data from 28 countries of the World Health Survey (2003) were extracted and inter-country socio-economic differences were examined by gross domestic product (GDP). Regression analyses were applied to examine associations of education with multimorbidity by region adjusted for age and sex distributions. RESULTS: The mean world standardized multimorbidity prevalence for LMICs was 7.8 % (95 % CI, 7.79 % - 7.83 %). In all countries, multimorbidity increased significantly with age. A positive but non-linear relationship was found between country GDP and multimorbidity prevalence. Trend analyses of multimorbidity by education suggest that there are intergenerational differences, with a more inverse education gradient for younger adults compared to older adults. Higher education was significantly associated with a decreased risk of multimorbidity in the all-region analyses. CONCLUSIONS: Multimorbidity is a global phenomenon, not just affecting older adults in HICs. Policy makers worldwide need to address these health inequalities, and support the complex service needs of a growing multimorbid population.

Maternal obesity trends in Egypt 1995-2005.

According to the World Health Organization (WHO), 46% of adult females in Egypt are obese. This research was aimed at documenting obesity trends and identifying the populations most at risk for obesity. Using data from the 1995 and 2005 Egyptian Demographic and Health Surveys a linear model was employed to seek associations between household wealth, urban/rural residence, governorate of residence, employment status, parity and age and increases in body mass index (BMI) among married Egyptian women between the ages of 15-49. Between 1995 and 2005, the mean BMI of women of reproductive age in Egypt increased from 26.31 to 28.52. Although there was an overall trend towards greater obesity between 1995 and 2005, older women residing in rural, poor households became obese at a faster rate than younger women residing in richer, urban households. Studies have shown that household wealth is a key determinant of food consumption patterns. Rising obesity rates among the poor in developed countries are linked to the relatively cheap price of high-calorie, nutrient-poor foods. One factor that may be contributing to the rapid increases in obesity among the rural poor in Egypt is the subsidisation of high-energy, low-nutritive value foods that form a larger part of the diet of poor, rural populations.

Anaemia among Egyptian Children between 2000 and 2005: trends and predictors.

Anaemia remains the most prevalent nutritional disorder among women and children in the Middle East and North Africa region. We examined anaemia trends using data from the Egyptian Demographic and Health Surveys. Between 2000 and 2005, the prevalence of anaemia (defined as haemoglobin concentrations <11 g dL(-1) ) increased from 37.04% to over 52% among Egyptian children between 12 months and 36 months of age. We examined the associations of these changes with food consumption, vitamin A administration, recent illness, immunization status, socio-demographic factors and a child's anaemic status. Children under the age of 24 months who had recently been sick and those who resided in Upper Egypt were significantly more likely to be anaemic. Despite significant improvements in water and sanitation facilities, maternal education and asset-based household wealth, there were marked declines in the consumption of nutritive foods and increases in the prevalence of childhood diarrhoea between 2000 and 2005. Placing these analyses in the broader context of Egyptian economic trends suggests that the nutritional basket consumed by Egyptian households between 2000 and 2005 may have shifted towards less nutritive foods with lower costs per calorie, probably in response to economic difficulties and increasing food prices. Shifts in dietary consumption, in conjunction with increases in diarrhoea, are likely contributing to the rapid increase in childhood anaemia in Egypt between 2000 and 2005. National-level fortification efforts may be one way to combat rising levels of anaemia among Egyptian women and children.

The health of the "older women" in Accra, Ghana: results of the Women's Health Study of Accra.

The health of women residing in the developing countries is not limited to reproductive health conditions or infectious diseases. While these illnesses remain serious threats to a healthy life, as the population ages, the prevalence of illnesses considered to be of significance only in industrialized nations also increasingly afflicts the residents of the developing worlds. The health and well-being of the older women was evaluated in the 2003 Women's Health Study of Accra. This community based survey and clinical and laboratory examination of 1,328 women identified a significantly high prevalence of malaria and chronic, non-communicable diseases in all age groups without regard to education level or income. Hypertension, diabetes and obesity are significantly prevalent in women age 50 years and older. The prevalence of conditions which adversely affect health and quality of life, including impaired visual acuity, poor dentition, pain and limitations with mobility is significant in the women age 50 years and older. While these data are specific to Ghana, they have the potential to be generalizable to women in other urban areas in transition. As the life expectancy is increasing in developing countries, an increased awareness and treatment of chronic health conditions in the older women is critical to ensure a healthy life as they enter their golden years.

Contraceptive use by women in Accra, Ghana: results from the 2003 Accra Women's Health Survey.

The study was to determine the predictors of use of modern contraception among women in Accra, Ghana. Data were collected by trained interviewers using questionnaires. Complete data for 2199 women were analysed using Stata 8.2. The study showed that educational status was the most significant predictor of contraceptive use. Women with no formal education had a 48% reduction in the odds of having ever used contraception and a 66% reduction in the odds of currently using contraception. Regular use of health facilities did not affect contraceptive use. Female education should continue to be a priority of the Ghanaian government. Education about family planning and the effects of having large families should be integrated into the school curriculum. Ghanaian health workers need to be active in promoting the use of modern contraceptive methods.

Sexually transmitted infections and health seeking behaviour among Ghanaian women in Accra.

The study was to measure the prevalence of sexually transmitted infection (STI) symptoms among women in Accra, Ghana, to identify characteristics that predispose to STI symptoms and to identify factors that influence health-seeking behaviour of women with STI symptoms. Data were collected by trained interviewers through questionnaire interviews of 3183 women. Data analysis was restricted to 1329 women with complete data. Only 19% of our study group had STI symptoms. Only 35% of the women with STI symptoms received care. Having high wealth index, being older and having no history of condom use were protective factors for experiencing STI symptoms. Seeking care was associated with increased by high wealth index and the presence of an offensive vaginal odour. Income level on its own did not affect health seeking behavior. Wealth index is the most significant determinant of a woman having STI symptoms and seeking care in Accra.

Livestock ownership and microbial contamination of drinking-water: Evidence from nationally representative household surveys in Ghana, Nepal and Bangladesh.

BACKGROUND: Current priorities for diarrhoeal disease prevention include use of sanitation and safe water. There have been few attempts to quantify the importance of animal faeces in drinking-water contamination, despite the presence of potentially water-borne zoonotic pathogens in animal faeces. OBJECTIVES: This study aimed to quantify the relationship between livestock ownership and point-of-consumption drinking-water contamination. METHODS: Data from nationally representative household surveys in Nepal, Bangladesh, and Ghana, each with associated water quality assessments, were used. Multinomial regression adjusting for confounders was applied to assess the relationship between livestock ownership and the level of drinking-water contamination with E. coli. RESULTS: Ownership of five or more large livestock (e.g. cattle) was significantly associated with drinking-water contamination in Ghana (RRR=7.9, 95% CI=1.6 to 38.9 for medium levels of contamination with 1-31cfu/100ml; RRR=5.2, 95% CI=1.1-24.5 for high levels of contamination with >31cfu/100ml) and Bangladesh (RRR=2.4, 95% CI=1.3-4.5 for medium levels of contamination; non-significant for high levels of contamination). Ownership of eight or more poultry (chickens, guinea fowl, ducks or turkeys) was associated with drinking-water contamination in Bangladesh (RRR=1.5, 95% CI=1.1-2.0 for medium levels of contamination, non-significant for high levels of contamination). CONCLUSIONS: These results suggest that livestock ownership is a significant risk factor for the contamination of drinking-water at the point of consumption. This indicates that addressing human sanitation without consideration of faecal contamination from livestock sources will not be sufficient to prevent drinking-water contamination.

Assessment of the ideal body image of women in Accra, Ghana.

The hypothesis tested in this study was that the 'traditional build' is the culturally valued body shape by Ghanaian women. Culturally sensitive figural stimuli were designed to assess the current body image (CBI) and the ideal body image (IBI) of Ghanaian women. The most frequently selected model for the CBI was one that represented a slightly overweight woman; the IBI selected was consistent with a representation of normal body mass index; and the least healthy image was that figure that represented morbidly obesity.

Interest in healthy living outweighs presumed cultural norms for obesity for Ghanaian women.

BACKGROUND: Cultural norms indicate that obesity reflects increased wealth and prosperity. Yet obesity is linked to serious medical illnesses. The purpose of this study was to determine if Ghanaian women would change their body image if it meant a healthier life. METHODS: A questionnaire was administered to 305 Ghanaian women waiting for clinic appointments at Korle Bu Teaching Hospital, Accra Ghana. This survey included questions on current health, selection of figural stimuli, decision making on health and social determinants and 5 questions on self-perception of health from SF-36. Anthropometric measures were taken and body mass index calculated. Women were also provided with health related information at the conclusion of the interview. RESULTS: The majority of all women surveyed would reduce their current body image if it meant that they would have an overall healthier life and reduce the risks of obesity-linked illnesses and complications. Currently obese women were significantly more likely than non-obese women to reduce their body image to reduce the risk of hypertension (OR 2.03 [1.64 - 2.51],<0.001); cardiovascular accident (OR 1.96 [1.61 - 2.38],<0.001); diabetes (OR 2.00 [1.63 - 2.44],<0.001); myocardial infarction (OR 2.27 [1.80 - 2.86],<0.001); if requested by a spouse(OR 2.64 [1.98 - 3.52],<0.001); and to improve overall health (OR 1.95 [1.60 - 2.37], <0.001). There was no association with current body image and responses to SF-36. The decision to select a new body image was not influenced by education, income, marital status or parity. Age 50 years old and less was significantly associated with the body image size reduction to reduce the risk of hypertension, diabetes, and a cardiovascular accident. CONCLUSION: The Ghanaian women interviewed in this study are interested in living a healthy life and are willing to reduce their body size to reduce the risk of obesity-linked illnesses. The target group for any interventional studies and measures to reduce obesity appears to be women age 50 and younger.

ETHNIC RESIDENTIAL PATTERNS AS PREDICTORS OF INTRA-URBAN CHILD MORTALITY INEQUALITY IN ACCRA, GHANA.

As cities of developing nations absorb an increasing fraction of the world's population increase, questions have arisen about the potential for emerging inequalities in health within places that are already suffering from inadequate infrastructure. In this paper we explore the pattern of child mortality inequalities (as a proxy for overall health levels) within a large sub-Saharan African city-Accra, Ghana-and then we examine the extent to which existing residential patterns by ethnicity may be predictive of any observed intra-urban inequalities in child mortality. We find that the spatial variability in child mortality in Accra is especially associated with the pattern of residential separation of the Ga from other ethnic groups, with the Ga having higher levels of mortality than other ethnic groups. Being of Ga ethnicity exposes a woman and her children to characteristics of the places in Accra where the Ga live, in which one-room dwellings and poor infrastructure predominate. At the individual level, we find that regardless of where a woman lives, if she is of Ga ethnicity and/or is non-Christian, and if she is not married, her risks of having lost a child are elevated.

Subsidized Sachet Water to Reduce Diarrheal Disease in Young Children: A Feasibility Study in Accra, Ghana.

Use of drinking water sold in plastic bags (sachet water) is growing rapidly in west Africa. The impact on water consumption and child health remains unclear, and a debate on the taxation and regulation of sachet water is ongoing. This study assessed the feasibility of providing subsidized sachet water to low-income urban households in Accra and measured the resultant changes in water consumption. A total of 86 children, 6-36 months of age in neighborhoods lacking indoor piped water, were randomized to three study arms. The control group received education about diarrhea. The second arm received vouchers for 15 L/week/child of free water sachets (value: $0.63/week) plus education. The third arm received vouchers for the same water sachet volume at half price plus education. Water consumption was measured at baseline and followed for 4 months thereafter. At baseline, 66 of 81 children (82%) drank only sachet water. When given one voucher/child/week, households redeemed an average 0.94 vouchers/week/child in the free-sachet-voucher arm and 0.82 vouchers/week/child in the half-price arm. No change in water consumption was observed in the half-price arm, although the study was not powered to detect such differences. In the free-sachet-voucher arm, estimated sachet water consumption increased by 0.27 L/child/day (P = 0.03). The increase in sachet water consumption by children in the free-sachet-voucher arm shows that provision of fully subsidized water sachets might improve the quality of drinking water consumed by children. Further research is needed to quantify this and any related child health impacts.

HIV prevalence and risk factors in women of Accra, Gghana: results from the women's health study of Accra.

The Women's Health Study of Accra is a cross-sectional study designed to measure the burden of communicable and noncommunicable diseases in adult women residing in Accra, Ghana. This study assessed the prevalence rate of HIV and risk factors associated with HIV infection in 1,328 women age 18 years and older. The weighted overall HIV prevalence rate for women residing in Accra is 3.1%. The highest prevalence rate of HIV infections was identified in women age 25 to 29 years at 8.3%, OR (95%CI) 3.8 (1.68-8.33), P = 001. In addition to young age, other significant risk factors included sexually transmitted infection (STI) symptoms (OR 1.81 [1.14-2.87], P = 0.012) and mean number of lifetime sexual partners (P < 0.001). All HIV-positive women were sexually active. Other findings significantly associated with HIV-positive status included chills, oral lesions, tuberculosis, bloody sputum production, and intestinal parasite infections. There was a significant association with HIV-positive status and locality of residence in the city. There was no association with reported use of condoms, blood transfusions, surgery, reproductive health history including pregnancy or number of sexual partners, symptoms suggestive of AIDS, or self-perception of health. There was also no association with education level, religion, ethnicity, marital status, or socioeconomic level. This community-based study confirms the need to target young, sexually active women for HIV educational and preventive initiatives. A strong Ghanaian public health initiative to increase awareness of the risks of HIV and the link to STIs is critical at this time to prevent the further increase in HIV prevalence and the resultant HIV-associated illnesses.

Income and health in Accra, Ghana: results from a time use and health study.

This paper uses newly collected household survey data from Accra, Ghana, to investigate whether incomes affect acute and chronic health outcomes in settings that can be considered representative for the large and rapidly growing urban centers of sub-Saharan Africa. The Time Use and Health Study in Accra collected information on incomes, current health status, and health care use from 5,484 persons in 1,250 households, each repeatedly sampled on a rolling basis for a period of 13 weeks. Data collection took place during September 2008-March 2010 to capture seasonal variations. The study found that incomes varied widely between households, and that a high fraction of persons lived below the poverty line. Despite this level of income poverty and an overall remarkably high burden of treatable disease, no systematic differences in self-reported and objectively measured health conditions were detected across socioeconomic groups.

When urban taps run dry: sachet water consumption and health effects in low income neighborhoods of Accra, Ghana.

Intraurban differentials in safe drinking water in developing cities have been exacerbated by rapid population growth that exceeds expansion of local water infrastructure. In Accra, Ghana, municipal water is rationed to meet demand, and the gap in water services is increasingly being filled by private water vendors selling packaged "sachet" water. Sachets extend drinking water coverage deeper into low-income areas and alleviate the need for safe water storage, potentially introducing a health benefit over stored tap water. We explore correlates of using sachets as the primary drinking water source for 2093 women in 37 census areas classified as slums by UN-Habitat, and links between sachet water and reported diarrhea episodes in a subset of 810 children under five. We find that neighborhood rationing exerts a strong effect on a household's likelihood of buying sachet water, and that sachet customers tend to be the poorest of the poor. Sachet use is also associated with higher levels of self-reported overall health in women, and lower likelihood of diarrhea in children. We conclude with implications for sachet regulation in Accra and other sub-Saharan cities facing drinking water shortages.

Connecting the Dots Between Health, Poverty and Place in Accra, Ghana.

West Africa has a rapidly growing population, an increasing fraction of which lives in urban informal settlements characterized by inadequate infrastructure and relatively high health risks. Little is known, however, about the spatial or health characteristics of cities in this region or about the spatial inequalities in health within them. In this article we show how we have been creating a data-rich field laboratory in Accra, Ghana, to connect the dots between health, poverty, and place in a large city in West Africa. Our overarching goal is to test the hypothesis that satellite imagery, in combination with census and limited survey data, such as that found in demographic and health surveys (DHSs), can provide clues to the spatial distribution of health inequalities in cities where fewer data exist than those we have collected for Accra. To this end, we have created the first digital boundary file of the city, obtained high spatial resolution satellite imagery for two dates, collected data from a longitudinal panel of 3,200 women spatially distributed throughout Accra, and obtained microlevel data from the census. We have also acquired water, sewerage, and elevation layers and then coupled all of these data with extensive field research on the neighborhood structure of Accra. We show that the proportional abundance of vegetation in a neighborhood serves as a key indicator of local levels of health and well-being and that local perceptions of health risk are not always consistent with objective measures.