Providing Measurement, Evaluation, Accountability, and Leadership Support (MEALS) for Non-communicable Diseases Prevention in Ghana: Project Implementation Protocol

Making food-related health taxes palatable in sub-Saharan Africa: lessons from Ghana

Amidst high burden of infectious diseases, undernutrition and micronutrient deficiencies, non-communicable diseases (NCDs) are predicted to become the leading cause of death in Ghana by 2030. NCDs are driven, to a large extent, by unhealthy food environments. Concerned, the Ghana Ministry of Health (MOH) has since 2012 sought to garner the support of all to address this challenge. We aimed to support the MOH to address the challenge through public health policy measures, but would soon be reminded that longstanding challenges to policy development such as data poverty, and policy inertia needed to be addressed. To do this, the we generated the needed evidence, curated the evidence, and availed the evidence to Ghanaian policymakers, researchers and civil society actors. Thus, we addressed the problem of data poverty using context-relevant research, and policy inertia through advocacy and scholar activism. In this paper, we share how a public interest coalition used context-relevant research, evidence-informed advocacy and scholar activism to valorise and increase demand for healthy food policy (including food-related health taxes) in Ghana.

Addressing the marketing and availability of unhealthy food and beverages in and around selected schools in Ghana: a community readiness appraisal

OBJECTIVE

This study assessed stakeholder readiness to address unhealthy food and beverage marketing and availability in/around Public Basic Schools (for children 4-15 years) in Greater Accra Region, the highly urbanised administrative capital of Ghana.

DESIGN

The community readiness model was used to conduct in-depth mixed methods interviews with stakeholders. Using predefined anchored rating statements, quantitative readiness scores ranging from 1 to 9 were generated. Thematic qualitative analysis was undertaken to understand barriers and facilitators that could influence the implementation of interventions.

SETTING

Greater Accra Region, Ghana.

PARTICIPANTS

18 key informants from various school/education/citizen sectors, which together represented the 'school community' of Greater Accra Region.

RESULTS

The mean readiness scores indicated that the 'school community' was at the 'preplanning' stage of readiness (4.44±0.98) to address the marketing and availability of unhealthy food and beverages in and around schools. The mean readiness score for 'leadership' was the highest of all dimensions (5.36±1.60), corresponding to the 'preparation' stage. The lowest scores were found for 'community knowledge of efforts' (3.19±2.45) and 'resources for efforts' (3.64±0.87), both of which were at a 'vague awareness' stage.

CONCLUSIONS

The 'school community' recognised that the marketing and availability of unhealthy food and beverages was a problem. Additionally, current leadership was actively supportive of continuing/improving efforts that create healthier children's food environments. However, actions that aim to increase the 'school community's' knowledge of existing interventions and securing resources to sustain those interventions are needed before introducing readiness appropriate strategies.

Availability of healthy and unhealthy foods in modern retail outlets located in selected districts of Greater Accra Region, Ghana

Background

Intake of unhealthy foods is linked to the onset of obesity and diet-related non-communicable diseases (NCDs). Availability of unhealthy (nutritionally poor) foods can influence preference, purchasing and consumption of such foods. This study determined the healthiness of foods sold at modern retail outlets- supermarkets and mini-marts in the Greater Accra Region of Ghana.

Methods

All modern retail outlets located in six districts of Greater Accra were eligible. Those < 200 m² of floor area and with permanent structures were categorized as mini-marts; and those ≥200 m² as supermarkets. Shelf length of all available foods were measured. Healthiness of food was determined using two criteria - the NOVA classification and energy density of foods. Thus, ultra-processed foods or food items with >225 kcal/100 g were classified as unhealthy. The ratio of the area occupied by unhealthy to healthy foods was used to determine the healthiness of modern retail outlets.

Results

Of 67 retail outlets assessed, 86.6% were mini-marts. 85.0% of the total SHELF area was occupied by foods categorized as unhealthy (ranging from 9,262 m² in Ashiaman Municipality to 41,892 m² in Accra Metropolis). Refined grains/grain products were the most available, occupying 30.0% of the total food shelf space, followed by sugar-sweetened beverages (20.1% of total shelf space). The least available food group-unprocessed staples, was found in only one high income district, and occupied 0.1% of the total food shelf space. Retail outlets in two districts did not sell fresh fruits or fresh/unsalted canned vegetables. About two-thirds of food products available (n = 3,952) were ultra-processed. Overall, the ratio of ultra-processed-to-unprocessed foods ranged from 3 to 7 with an average (SD) of 5(2). Thus, for every healthy food, there were five ultra-processed ones in the studied retail outlets.

Conclusion

This study reveals widespread availability of ultra-processed foods in modern retail outlets within the selected districts. Toward a healthier food retail environment, public health and food regulators, in partnership with other stakeholders need to institute measures that improve availability of healthy foods within supermarkets and mini-marts.

"Some are healthy and others not": Characterization of vended food products by Accra-based food retailers

Background and objectives

Increasing the availability of healthy foods within food retail outlets can improve consumers' food environments. Such actions or inactions by food retailers may affect people's food purchasing and consumption behavior. This study explored Accra-based food retailers' perceptions and appreciation of "healthiness of food" as a concept. It also documented measures that food retailers adopt to encourage healthy food choices.

Methods

In-person semi-structured interviews were conducted with owners and managers of Accra-based supermarkets (n = 7) and corner stores (n = 13) in March 2021. The interviews were recorded, transcribed, coded, and analyzed thematically.

Results

The retailers' understanding of healthy food, or lack thereof, is exemplified by such expressions as "health, absence of disease, longevity, balanced diet, diversity, sanitation, and certification." A handful of retailers described what they sell as "products that meet consumer needs," "harmless," or "generally good." Very few retailers described the food they sell as "junk," high in sugar, fat, and salt, or energy-dense but nutrient poor foods, or as food that could pose some health risk to consumers. However, some retailers indicated that they advise their customers against the overconsumption of some foods.

Conclusion

Overall, Accra-based retailers have a fair understanding of what constitutes healthy food - exhibiting limited knowledge of the connection between very salty, very sugary, and very fatty foods and health outcomes. Retailers in Accra require interventions that improve their food, health, and nutrition literacy. Improving retailers' food and nutrition literacy may improve the availability of healthier options in food retail outlets in Accra.

The Africa Food Environment Research Network (FERN): from concept to practice

Background:

Africa is contending with unhealthy food environments that are, in part, driving increasing rates of overweight, obesity and diet-related non-communicable diseases, alongside persistent undernutrition. This current paradigm requires expanded efforts – both in the volume and nature of empirical research, as well as the tools and capacity of those who conduct it. High quality and context-relevant research supports the development and implementation of policies that create healthy food environments.

Aim and approach:

This paper sets out the concept of the Africa Food Environment Research Network (FERN) initiative recently established by the Measurement, Evaluation, Accountability, and Leadership Support for non-communicable diseases (NCDs) (MEALS4NCDs) prevention project. Central to the Africa FERN initiative are: 1) building research capacity for innovative food environment research in Africa; 2) improving South–South, South–North partnerships to stimulate robust food environment research and monitoring in Africa and 3) sustaining dialogue and focusing priorities around current and future needs for enhanced food environment research and monitoring in Africa.

Conclusion:

The FERN initiative presents an opportune platform for researchers in Africa and the global North to weave the threads of experience and expertise for research capacity building, collaboration and advocacy, to advance food environment research.

Advertising of unhealthy foods and beverages around primary and junior high schools in Ghana's most urbanized and populous region

Introduction

The advertising of energy-dense, nutrient-poor foods and beverages is a common feature in obesogenic food environments. Such advertising, within and around settings where children live, learn, and play, negatively affects their food acquisition and consumption. We examined the extent and nature of food and beverage advertising around primary and junior high schools in Ghana's most populous and urbanized region, Greater Accra.

Materials and methods

Outdoor advertisements for foods and beverages within a 250 m road network distance of 200 randomly sampled schools were geocoded. For each food and beverage advertisement, information was collected on the setting, type, size, and number of product types featured in the advertisement. Promotional techniques (promotional characters and premium offers) used in advertisements were documented. Advertised foods and beverages were classified using the INFORMAS and NOVA food classification systems.

Results

A total of 5,887 advertisements were identified around the schools surveyed, 42% of which were for foods and beverages. Advertisements were most prevalent at food outlets (78% of all food advertisements), but also along roads and on non-food structures. Overall, 70% of food advertisements featured non-core/unhealthy products, while 12 and 14% had core/healthy and miscellaneous (including soup cubes, seasonings, and tea) products. About 4% of food advertisements had only a product/brand name or logo displayed. One out of two of the foods and beverages advertised were ultra-processed foods, 30% processed, 3% processed culinary ingredients, and 17% unprocessed or minimally processed foods. Sugar-sweetened beverages were the most advertised food product type (32%). Promotional characters were found on 14% of all food advertisements (most-69% were cartoons or manufacturer's characters), while 8% of all food advertisements had premium offers (including price discounts and gift/collectables).

Conclusions

There is an abundance of unhealthy food advertisements around primary and junior high schools in the Greater Accra Region. Policy actions such as restricting the promotion of unhealthy foods in children's settings are needed to protect pupils from such advertising practices.

Perspective: Food Environment Research Priorities for Africa-Lessons from the Africa Food Environment Research Network

Over the last 2 decades, many African countries have undergone dietary and nutrition transitions fueled by globalization, rapid urbanization, and development. These changes have altered African food environments and, subsequently, dietary behaviors, including food acquisition and consumption. Dietary patterns associated with the nutrition transition have contributed to Africa's complex burden of malnutrition-obesity and other diet-related noncommunicable diseases (DR-NCDs)-along with persistent food insecurity and undernutrition. Available evidence links unhealthy or obesogenic food environments (including those that market and offer energy-dense, nutrient-poor foods and beverages) with suboptimal diets and associated adverse health outcomes. Elsewhere, governments have responded with policies to improve food environments. However, in Africa, the necessary research and policy action have received insufficient attention. Contextual evidence to motivate, enable, and create supportive food environments in Africa for better population health is urgently needed. In November 2020, the Measurement, Evaluation, Accountability, and Leadership Support for Noncommunicable Diseases Prevention Project (MEALS4NCDs) convened the first Africa Food Environment Research Network Meeting (FERN2020). This 3-d virtual meeting brought researchers from around the world to deliberate on future directions and research priorities related to improving food environments and nutrition across the African continent. The stakeholders shared experiences, best practices, challenges, and opportunities for improving the healthfulness of food environments and related policies in low- and middle-income countries. In this article, we summarize the proceedings and research priorities identified in the meeting to advance the food environment research agenda in Africa, and thus contribute to the promotion of healthier food environments to prevent DR-NCDs, and other forms of malnutrition.