A critical review and analysis of the context, current burden, and application of policy to improve cancer equity in Ghana

BACKGROUND

Cancer causes a major disease burden worldwide. This is increasingly being realised in low and middle-income countries, which account disproportionately for preventable cancer deaths. Despite the World Health Organization calling for governments to develop policies to address this and alleviate cancer inequality, numerous challenges in executing effective cancer policies remain, which require consideration of the country-specific context. As this has not yet been considered in Ghana, the aim of this review was to bring together and critique the social-environmental, health policy and system factors to identifying opportunities for future health policies to reduce cancer burden in the Ghanian context. A critical policy-focused review was conducted to bring together and critique the current health systems context relating to cancer in Ghana, considering the unmet policy need, health system and social factors contributing to the burden and policy advances related to cancer.

CONCLUSION

The findings highlight the changing burden of cancer in Ghana and the contextual factors within the socio-ecosystem that contribute to this. Policies around expanding access to and coverage of services, as well as the harmonization with medical pluralism have potential to improve outcomes and increase equity but their implementation and robust data to monitor their impact pose significant barriers.

Dietary patterns among adults in three low-income urban communities in Accra, Ghana

OBJECTIVE

Dietary patterns describe the dietary behaviour and habits of individuals. Unhealthy dietary patterns provide individuals with limited nutrients while increasing the risk of nutrition-related diseases. Unhealthy dietary patterns are high in urban areas, especially among low-income urban residents. This study examined dietary patterns in three low-income urban communities in Accra, Ghana, between 2011 and 2013.

METHODS

This study used Wave 2 and 3 data from the Urban Health and Poverty Survey (EDULINK 2011 and 2013). The sample size was 960 in 2011 and 782 in 2013. Dietary pattern was examined using factor analysis and the NOVA food classification system. Summary statistics were computed for sociodemographic characteristics and diet frequency and pattern. Differences in dietary behaviours between 2011 and 2013 were also estimated. Three logistic regression models were computed to determine the predictors of dietary patterns.

RESULTS

The frequency of consumption of animal-source foods (ASF) and fruits was higher in 2013 compared with 2011. The intake of processed culinary ingredients (NOVA Group 2), processed foods (NOVA Group 3) and ultra-processed foods (NOVA Group 4) was higher in 2013 versus 2011. In 2013, 29% consumed ultra-processed foods compared to 21% in 2011. Three dietary patterns (rice-based, snack-based, and staple and stew/soup) were identified. About two out of every five participants consumed the food items in the rice (43%) and staple and sauce patterns (40%). The proportion of participants who consumed the food items in the snack pattern was 35% in 2011 but 41% in 2013. Respondents aged 25-34 and those with higher education often consumed the snack-based and rice-based dietary patterns. In 2013, participants in Ussher Town had a higher probability of consuming food items in the snack pattern than those living in Agbogbloshie.

CONCLUSIONS

This study found that between 2011 and 2013, more participants consumed ASFs, fruits, and processed foods. A complex interplay of personal and socio-cultural factors influenced dietary intake. The findings of this study mirror global changes in diet and food systems, with important implications for the primary and secondary prevention of NCDs. Health promotion programs at the community level are needed to address the increasing levels of processed food consumption.

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.

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.

Individual‐level drivers of dietary behaviour in adolescents and women through the reproductive life course in urban Ghana: A Photovoice study

Evidence on the individual‐level drivers of dietary behaviours in deprived urban contexts in Africa is limited. Understanding how to best inform the development and delivery of interventions to promote healthy dietary behaviours is needed. As noncommunicable diseases account for over 40% of deaths in Ghana, the country has reached an advanced stage of nutrition transition. The aim of this study was to identify individual‐level factors (biological, demographic, cognitive, practices) influencing dietary behaviours among adolescent girls and women at different stages of the reproductive life course in urban Ghana with the goal of building evidence to improve targeted interventions. Qualitative Photovoice interviews (n = 64) were conducted in two urban neighbourhoods in Accra and Ho with adolescent girls (13–14 years) and women of reproductive age (15–49 years). Data analysis was both theory‐ and data‐driven to allow for emerging themes. Thirty‐seven factors, across four domains within the individual‐level, were identified as having an influence on dietary behaviours: biological (n = 5), demographic (n = 8), cognitions (n = 13) and practices (n = 11). Several factors emerged as facilitators or barriers to healthy eating, with income/wealth (demographic); nutrition knowledge/preferences/risk perception (cognitions); and cooking skills/eating at home/time constraints (practices) emerging most frequently. Pregnancy/lactating status (biological) influenced dietary behaviours mainly through medical advice, awareness and willingness to eat foods to support foetal/infant growth and development. Many of these factors were intertwined with the wider food environment, especially concerns about the cost of food and food safety, suggesting that interventions need to account for individual‐level as well as wider environmental drivers of dietary behaviours.

Time constraints, eating at home, eating out, cooking skills, food preferences and food safety concerns were identified as key factors influencing dietary behaviours at the individual level in urban Ghana.

Ability to eat nutritious, safe food was largely mediated by income and wealth.

Biological factors, such as pregnancy/lactating status influenced behaviours through medical advice, nutrition knowledge and willingness to promote foetal/infant development.

Many individual‐level factors were intertwined with the wider food environment.

Factors influencing dietary behaviour at different levels need to be considered together when developing interventions/policies for healthier diets.

Participating in a Nutrition-Sensitive Agriculture Intervention Is Not Associated with Less Maternal Time for Care in a Rural Ghanaian District

Background

Nutrition-sensitive agriculture (NSA) interventions may increase farm-related work for mothers, with consequences for child nutrition. The Nutrition Links (NL) intervention provided mothers with poultry, gardening inputs, technical support, and education to improve livelihoods and child nutrition outcomes in rural Ghana.

Objectives

Our objective was to compare time allocated to child care by a cross-section of mothers in the intervention group of the NL intervention with the control group (NCT01985243).

Methods

A cross-section of NL mother-child pairs was included in a time allocation substudy [intervention (NL-I) n = 74 and control (NL-C) n = 69]. In-home observations of the mother-child pair were conducted for 1 min, every 5 min, for 6 h. Observations were categorized into 4 nonoverlapping binary variables as follows: 1) maternal direct care, 2) maternal supervisory care, 3) allocare, and 4) no direct supervision. Allocare was defined as care by another person in the presence or absence of the mother. Any care was defined as the observation of maternal direct care, maternal supervisory care, or allocare. Generalized linear mixed models with binomial data distribution were used to compare the child care categories by group, adjusting for known covariates.

Results

Maternal direct care (OR = 1.07; 95% CI: 0.89, 1.28) and any care (OR = 1.56; 95% CI: 0.91, 2.67) did not differ by intervention group. However, there was a higher odds of allocare (OR = 1.36; 95% CI: 1.04, 1.79) in NL-I than in NL-C women.

Conclusions

Maternal participation in an NSA intervention was not associated with a decrease in time spent directly on child care but was associated with an increase in care from other household and community members.The clinicaltrials.gov number provided is for the main NL intervention and not this current substudy.

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.

Strengthening Maternal, Infant, and Young Child Nutrition Training and Counseling in Ghana: A Community-Based Approach

Background

Evidence-based maternal, infant, and young child nutrition (MIYCN) counseling provides caregivers essential nutrition education to optimize infant and young child feeding practices and subsequently improve child growth and development. Effective integration of responsive feeding (RF) into current MIYCN training requires working with priority communities.

Objectives

Study objectives were to 1) assess MIYCN knowledge and practices among Ghanaian caregivers, 2) identify factors influencing RF/responsive parenting (RP) among Ghanaian caregivers, 3) identify barriers and facilitators influencing MIYCN training and counseling among Ghanaian health care providers, and 4) document recommendations for integrating an RF curriculum into the existing MIYCN training.

Methods

This was a qualitative study, conducted within the Central Region of Ghana, based on 1) 6 focus groups with caregivers of young children (<36 mo; n = 44) and 2) in-depth interviews with health care providers (n = 14). Focus group transcripts were coded independently, consensus was reached, and a final codebook developed. The same coding process and thematic analysis were applied to the in-depth interviews.

Results

Caregivers identified 3 domains influencing the primary outcome of RF/RP knowledge and practices and the secondary outcome of MIYCN: 1) health care provider counseling; 2) support from family, friends, and community members; and 3) food safety knowledge and practice. Providers identified barriers to MIYCN provider training as well as caregiver counseling which included limited access to financial and counseling resources and limited qualified staff to deliver infant and young child feeding counseling. Identified facilitators included availability of funding and counseling staff with adequate resources. Health care providers strongly endorsed integrating an RF curriculum into MIYCN training and counseling along with providing RF training and distribution of RF materials/tools to facilities.

Conclusions

Health care providers directly influenced RF/RP practices through MIYCN counseling. Strengthening MIYCN counseling through the integration of an RF curriculum into MIYCN training is desired by the community.

Barriers and Facilitators to Optimal Infant and Young Child Feeding Practices in the Central Region of Ghana: Perceptions of Heath Care Providers

Objectives

This qualitative study sought to describe provider's perspectives on barriers and facilitators to optimal infant and young child feeding (IYCF) practices (primarily exclusive breastfeeding (EBF), meal frequency, and diet diversity) among caregivers in Central Region of Ghana.

Methods

Qualitative data were collected through audiotaped in-depth interviews with care providers from three districts within the Central Region of Ghana: Gomoa East, KEEA, and Assin South (N = 18). Interviews were conducted in English, were audio taped, and transcribed. Transcripts were read and coded independently by two authors, consensus was reached about emerging domains and themes, and a final codebook was developed. The socioecological model was used to map barriers and facilitators for EBF and complementary feeding (CF) practices.

Results

Preliminary findings showed that several barriers and facilitators were similar for EBF and CF within each level. Individual level barriers included returning to work, poor maternal hygiene and ill health, limited maternal IYCF knowledge. Additional EBF barriers included not recognizing early hunger signs, breast problems, perceived breastmilk insufficiency while additional CF barriers were related to food access, time for preparation, and food safety. Interpersonal barriers/facilitators included family/provider support, family cultural beliefs/practices, family influence on practices, provider IYCF knowledge/education delivery, role modeling. Community level barriers/facilitators were related to the built environment including access to health facility and sanitation as well as community-level characteristics such as illiteracy and traditional beliefs. Societal barriers/facilitators included industry advertising, and IYCF policies/guidelines. Poverty was identified as a cross-cutting barrier. Providers recommended intensifying IYCF counseling, home visits to address barriers and training IYCF counseling.

Conclusions

Providers were aware of challenges caregivers face when trying to practice optimal IYCF. Multi-level interventions are needed, including IYCF counseling to address identified barriers.

Funding Sources

This study was funded by UNICEF-Ghana.

Infant and Young Child Feeding Perceptions and Practices Among Caregivers Living in Three Districts in the Central Region of Ghana

Objectives

This qualitative study sought to understand caregiver practices related to exclusive breastfeeding (EBF), meal frequency, diet diversity, and responsive feeding in rural communities in Ghana.

Methods

Fifty-two audio-taped in-depth interviews were conducted in local dialects with caregivers (teen and adult mothers, fathers, and grandmothers) of children younger than 1-year-old living in three districts in Ghana's Central Region. Recordings were translated, transcribed into English, then read and coded independently by two authors. Consensus was reached on emerging domains and themes, and a final codebook was developed.

Results

Caregivers were knowledgeable about EBF and complementary feeding recommendations. However, preliminary findings showed that non-adherence to EBF was common. Water was fed to address perceived thirst and/or to soothe persistent crying. Perceived readiness for complementary foods was tied to the belief that, by 3–6 months, breastmilk could not satisfy hunger. From the sixth month, infants were fed at least three times, including night feeds, and perceived to be capable of eating any family foods if home prepared soft and not spicy. Caregivers understood that local proteins such as pounded dried fish could be added to soups and stews while egg yolk could be added to porridge. Responsive and non-responsive feeding practices emerged. Meals were fed using spoons, cups, and bowls, and caregivers constantly engaged and interacted with the child (cooing) to encourage eating. Caregivers were aware that introducing new foods may require several tries before acceptance and recommended patience and encouragement when offering new foods. Caregivers typically used time of day and incessant crying to recognize hunger, not knowing how to identify subtle hunger cues. Some misperceptions about early foods centered around illness, especially stomach aches and diarrhea, and how those might be a result of late night feeding or sugary foods/snacks.

Conclusions

Gaps were seen between caregiver knowledge of feeding recommendations and some infant and young child (IYCF) perceptions/practice. Caregivers in this population may benefit from targeted IYCF counseling to facilitate optimal caregiver practices.

Funding Sources

This study was funded by UNICEF-Ghana.

Use of reusable menstrual management materials and associated factors among women of reproductive age in Ghana: analysis of the 2017/18 Multiple Indicator Cluster Survey

Background

The use of unsafe materials to collect menstrual blood predisposes women and girls to infections. There is a paucity of literature on the utilization of reusable menstrual materials in sub-Saharan Africa. This study examined factors associated with the use of reusable menstrual management materials among women of reproductive age in Ghana. Findings from this study can inform menstrual health programmes and reproductive health policy to address menstrual hygiene and specific areas of emphasis.

Methods

We analysed secondary data from the 2017/18 Ghana Multiple Indicator Cluster Survey. Descriptive statistics were employed to compute frequencies and percentages, while Chi-square and complex sample Binomial Logistic Regression was conducted to identify factors associated with the use of reusable menstrual materials.

Results

Half (52%) of the respondents were below 30 years old; mean (± sd) = 30.7(9.0). Thirteen percent used reusable materials to collect menstrual blood during their last period. Women aged 45–49 years (AOR = 5.34; 95% CI 3.47–8.19) were 5 times more likely to manage menstruation with reusable materials compared with those aged 15–19 years (p < 0.05). Women classified in the middle wealth quintile (AOR = 0.66; 95% CI 0.50–0.88) were 34% less likely to use reusable materials to collect menstrual blood compared with women in the poorest wealth quintile (p < 0.05). Also, women who were exposed to television (AOR = 0.78; 95% CI 0.61–0.99) had less odds of using reusable materials compared with women who were not exposed to television (p < 0.05).

Conclusion

This study showed that the use of reusable menstrual materials was influenced by socio-demographic factors, economic factors and exposure to mass media. Therefore, policies and programmes aimed at promoting menstrual health should focus on less privileged women. The mass media presents an opportunity for communicating menstrual hygiene.

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.

Stories of Change in Nutrition in Ghana: a focus on stunting and anemia among children under-five years (2009 – 2018)

The current study aimed to understand why child stunting and anemia (CS&A) rates declined in Ghana between 2009 and 2018, and which priority policies and programs will further improve nutrition outcomes. Trends and potential drivers of stunting (height-for-age z-score < -2.0 SD) and anemia (hemoglobin < 11.0 g/dL), and decomposition analysis of DHS data (2003 to 2014) were conducted. The quantitative evidence was triangulated with Net-Map analysis of nutrition stakeholder relationships and influence, desk review of policies and programs 2009–2019, and in-depth interviews with 25 stakeholders who provided additional insights to explain CS&A trends. Declines in stunting (29.6%) and anemia (14.1%) in children were observed at the national level, but with important subgroup variations. Decomposition analyses identified changes in the household, maternal, and child characteristics (including wealth, use of antenatal services, maternal education, and immunization) as correlates of anemia reduction. Stunting reduction was linked with changes in bed-net utilization, household wealth, and pregnancy care service utilization. Additionally, multiple policies and programs initiated/implemented across multiple sectors were considered potentially relevant to CS&A reduction over time, including those focused on infant and young child feeding, water and sanitation, social protection, and health care access. Initiation/strengthening of these interventions was stimulated by awareness creation and subsequently increased prioritization of stunting. However, program delivery was limited by deficits in government funding, perceived low priority of child anemia, low implementation capacity and coverage, and weak coherence across sectors. Reduced CS&A resulted from improved access to services implemented across multiple sectors, albeit limited by implementation scale and capacity. Further reduction in CS&A requires enhanced multi-sectorally coordinated actions and capacity.

Multiple pathways towards achieving a living income for different types of smallholder tree-crop commodity farmers

Many sources indicate that smallholder tree-crop commodity farmers are poor, but there is a paucity of data on how many of them are poor and the depth of poverty. The living income concept establishes the net annual income required for a household in a place to afford a decent standard of living. Based on datasets on smallholder cocoa and tea farmers in Ghana, Ivory Coast and Kenya and literature, we conclude that a large proportion of such farmers do not have the potential to earn a living income based on their current situation. Because these farmers typically cultivate small farm sizes and have low capacity to invest and to diversify, there are no silver bullets to move them out of poverty. We present an assessment approach that results in insights into which interventions can be effective in improving the livelihoods of different types of farmers. While it is morally imperative that all households living in poverty are supported to earn a living income, the assessment approach and literature indicate that focussing on short- to medium-term interventions for households with a low likelihood of generating a living income could be: improving food security and health, finding off-farm and alternative employment, and social assistance programmes. In the long term, land governance policies could address land fragmentation and secure rights. Achieving living incomes based on smallholder commodity production requires more discussion and engagement with farmers and their household members and within their communities, coordination between all involved stakeholders, sharing lessons learnt and data.

Anthropometric characteristics of children living in food-insecure households in the USA

OBJECTIVE

This study provides information on food insecurity and child malnutrition in a technologically advanced nation.

DESIGN

Population-based study using multistage probability cluster sampling design to collect survey data. Multivariable regression models were used to determine associations between food security status and various malnutrition indices.

SETTING

We used a national sample from the US National Health and Nutrition Examination Survey 2011-2014.

PARTICIPANTS

The anthropometric and demographic data sets of 4121 children <7 years old were analysed for this study.

RESULTS

Food-insecure infants younger than 6 months had shorter upper arm length (-0·4 cm, P = 0·012) and smaller mid-upper arm circumference (-0·5 cm, P = 0·004); likewise those aged 6 months-1 year had shorter upper arm length (-0·4 cm, P = 0·008), body length (-1·7 cm, P = 0·007) and lower body weight (-0·5 kg, P = 0·008). Food-insecure children younger than 2 years were more likely to be underweight (OR: 4·34; 95 % CI 1·99, 9·46) compared with their food-secure counterparts. Contrariwise, food-insecure children older than 5 years were more likely to be obese (OR: 3·12; 95 % CI 1·23, 7·96).

CONCLUSIONS

Food insecurity associates with child growth deficits in the USA. Food-insecure infants and young children are generally smaller and shorter, whereas older children are heavier than their food-secure counterparts, implying a double burden of undernutrition-overnutrition associated with child food insecurity. Child food and nutrition programmes to improve food insecurity should focus on infants and children in the transition ages.

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

Background: This study describes the rationale, adaptation, and final protocol of a project developed to address the increase in obesity and nutrition-related non-communicable diseases (NR-NCDs) in Ghana. Code-named the Measurement, Evaluation, Accountability, and Leadership Support for NCDs (MEALS4NCDs) project, it aims to measure and support public sector actions that create healthy food marketing, retail, and provisioning environments for Ghanaian children using adapted methods from the International Network for Food and Obesity/NCDs Research Monitoring and Action Support (INFORMAS).

Methods: The protocol for this observational study draws substantially from the INFORMAS' Food Promotion and Food Provision Modules. However, to appraise the readiness of local communities to implement interventions with strong potential to improve food environments of Ghanaian children, the MEALS4NCDs protocol has innovatively integrated a local community participatory approach based on the community readiness model (CRM) into the INFORMAS approaches. The setting is Ghana, and the participants include health and nutrition policy-makers, nutrition and food service providers, consumers, school authorities, and pupils of Ghanaian basic schools.

Results: The study establishes a standardized approach to providing implementation science evidence for the prevention of non-communicable diseases (NCDs) in Ghana. It demonstrates feasibility and the innovative application of the INFORMAS expanded food promotion and food provision modules, together with the integration of the CRM in a lower-middle income setting.

Conclusion: The research will facilitate the understanding of the processes through which the INFORMAS approach is contextualized to a lower-middle income African context. The protocol could be adapted for similar country settings to monitor relevant aspects of food environments of children.

Urban physical food environments drive dietary behaviours in Ghana and Kenya: A photovoice study

We identified factors in the physical food environment that influence dietary behaviours among low-income dwellers in three African cities (Nairobi, Accra, Ho). We used Photovoice with 142 males/females (≥13 years). In the neighbourhood environment, poor hygiene, environmental sanitation, food contamination and adulteration were key concerns. Economic access was perceived as a major barrier to accessing nutritionally safe and healthy foods. Home gardening supplemented household nutritional needs, particularly in Nairobi. Policies to enhance food safety in neighbourhood environments are required. Home gardening, food pricing policies and social protection schemes could reduce financial barriers to safe and healthy diets.

The African urban food environment framework for creating healthy nutrition policy and interventions in urban Africa

This study developed, validated, and evaluated a framework of factors influencing dietary behaviours in urban African food environments, to inform research prioritisation and intervention development in Africa. A multi-component methodology, drawing on concept mapping, was employed to construct a framework of factors influencing dietary behaviours in urban Africa. The framework adapted a widely used socio-ecological model (developed in a high-income country context) and was developed using a mixed-methods research approach that comprised: i. Evidence synthesis consisting of a systematic review of 39 papers covering 14 African countries; ii. Qualitative interview data collected for adolescents and adults (n = 144) using photovoice in urban Ghana and Kenya; and iii. Consultation with interdisciplinary African experts (n = 71) from 27 countries, who contributed to at least one step of the framework (creation, validation/evaluation, finalisation). The final framework included 103 factors influencing dietary behaviours. Experts identified the factors influencing dietary behaviours across all the four levels of the food environment i.e. the individual, social, physical and macro levels. Nearly half (n = 48) were individual-level factors and just under a quarter (n = 26) were at the macro environmental level. Fewer factors associated with social (n = 15) and physical (14) environments were identified. At the macro level, the factors ranked as most important were food prices, cultural beliefs and seasonality. Factors ranked as important at the social level were household composition, family food habits and dietary practices. The type of food available in the neighbourhood and convenience were seen as important at the physical level, while individual food habits, food preferences and socioeconomic status were ranked highly at the individual level. About half of the factors (n = 54) overlap with those reported in an existing socio-ecological food environment framework developed in a high-income country context. A further 49 factors were identified that were not reported in the selected high-income country framework, underlining the importance of contextualisation. Our conceptual framework offers a useful tool for research to understand dietary transitions in urban African adolescents and adults, as well as identification of factors to intervene when promoting healthy nutritious diets to prevent multiple forms of malnutrition.

A Review of Leadership and Capacity Gaps in Nutrition-Sensitive Agricultural Policies and Strategies for Selected Countries in Sub-Saharan Africa and Asia

BACKGROUND

Agriculture policies and strategies designed, purposefully, to address malnutrition are considered nutrition-sensitive and are a critical component of global efforts to address malnutrition in all its forms. However, limited evidence exists on extent and how nutrition is being integrated into agriculture sector policies, strategies, and programs. A review was conducted to address 2 questions: How nutrition-sensitive are agriculture policies, plans, and investments in selected Sub-Saharan African (SSA) and Asian countries? and Which capacity and leadership gaps limit scale up of nutrition-sensitive agriculture policy and programs?

METHODS

The review of existing policies was conducted for 11 selected focus countries (9 in SSA and 2 from Asia) of the CGIAR (Consultative Group on International Agricultural Research) Collaborative Research Programme on Agriculture for Nutrition and Health led by the IFPRI (International Food Policy Research Institute). The Food and Agriculture Organization (FAO)'s 10-point key recommendations for designing nutrition-sensitive agricultural interventions was used as an analytical framework. Additionally, a rapid systematic review of published peer-reviewed and grey literature was carried out to identify capacity gaps based on the United Nations Development Program's capacity assessment framework.

RESULTS

We found that there is nutrition sensitivity of the policies and strategies but to varying degrees. There is limited capacity for optimum implementation of these policies, programs, and strategies. For most of the countries, there is capacity to articulate what needs to happen, but there are important capacity limitations to translate the given policy/program instruments into effective action.

CONCLUSIONS

The gaps identified constitute important evidence to inform capacity strengthening of nutrition-sensitive actions for desired nutrition and health outcomes in Africa and Asia.

Development and Testing of Responsive Feeding Counseling Cards to Strengthen the UNICEF Infant and Young Child Feeding Counseling Package

BACKGROUND

The UNICEF Community-based Infant and Young Child Feeding Counseling Package (C-IYCFCP) currently has limited responsive feeding (RF) content, thus limiting dissemination of RF messages within infant and young child feeding (IYCF) counseling.

OBJECTIVES

This project 1) developed counseling cards based on existing evidence-based RF guidelines and 2) tested their feasibility in Ghana.

METHODS

Five RF counseling cards were developed focusing on eating with family; introducing new foods; hunger/satiety cues; food texture; and calming a child. Four focus group discussions (FGDs) were conducted with adult mothers and fathers of children younger than 3 y of age to assess the cultural appropriateness of the cards and accompanying key messages. The feasibility of including cards as part of IYCF counseling was tested via 1) systematic observation of 8 group education sessions utilizing the cards with the same target audience and 2) in-depth interviews with health care providers involved in IYCF training and/or counseling.

RESULTS

FGD findings guided changes to all cards to ensure comprehension and cultural appropriateness. The group education sessions suggested that the counseling cards provided important RF messages that are specific, clear, and feasible to implement. Health care providers strongly endorsed the need for and utility of the RF counseling cards and felt they were feasible and important to integrate into the C-IYCFCP currently being used to deliver IYCF training and counseling in Ghana.

CONCLUSIONS

The counseling cards have a strong potential to add key RF dimensions to IYCF training and counseling in Ghana.

Factors associated with concurrent wasting and stunting among children 6-59 months in Karamoja, Uganda

Children with concurrent wasting and stunting (WaSt) and children with severe wasting have a similar risk of death. Existing evidence shows that wasting and stunting share similar causal pathways, but evidence on correlates of WaSt remains limited. Research on correlates of WaSt is needed to inform prevention strategies. We investigated the factors associated with WaSt in children 6–59 months in Karamoja Region, Uganda.

We examined data for 33,054 children aged 6–59 months using June 2015 to July 2018 Food Security and Nutrition Assessment in Karamoja. We defined WaSt as being concurrently wasted (weight‐for‐height z‐scores <−2.0) and stunted (height‐for‐age z‐score <−2.0). We conducted multivariate mixed‐effect logistic regression to assess factors associated with WaSt. Statistical significance was set at p < 0.05.

In multivariate analysis, being male (adjusted odds ratio [aOR] = 1.79; 95% confidence interval [CI] [1.60–2.00]), aged 12–23 months (aOR = 2.25; 95% CI [1.85–2.74]), 36–47 months (aOR = 0.65; 95% CI [0.50–0.84]) and 48–59 months (aOR = 0.71; 95% CI [0.54–0.93]) were associated with WaSt. In addition, acute respiratory infection (aOR = 1.30; 95% CI [1.15–1.48]), diarrhoea (aOR = 1.25; 95% CI [1.06–1.48]) and malaria/fever (aOR = 0.83; 95% CI [0.73–0.96]) episodes were associated with WaSt. WaSt was significantly associated with maternal underweight (body mass index <18.5 kg/m²), short stature (height <160 cm), low mid‐upper arm circumference (MUAC <23 cm) and having ≥4 live‐births. WaSt was prevalent in households without livestock (aOR = 1.30; 95% CI [1.13–1.59]).

Preventing the occurrence of WaSt through pragmatic and joint approaches are recommended. Future prospective studies on risk factors of WaSt to inform effective prevention strategies are recommended.

Analysis of stakeholder networks for breastfeeding policies and programs in Ghana

Background

Suboptimal breastfeeding practices are driven by multiple factors. Thus, a multi-sectoral approach is necessary to design and implement appropriate policies and programs that protect, promote, and support breastfeeding.

Methods

This study used Net-Map, an interactive social network interviewing and mapping technique, to: a) identify key institutional actors involved in breastfeeding policy/programs in Ghana, b) identify and describe links between actors (i.e., command, dissemination, funding, and technical assistance (TA)), and c) document actors influence to initiate or modify breastfeeding policy/programs. Ten experts were purposively selected from relevant institutions and were individually interviewed. Interview data was analysed using social networking mapping software, Gephi (version 0.9.2).

Results

Forty-six unique actors were identified across six actor categories (government, United Nations agencies, civil society, academia, media, others), with one-third being from government agencies. Dissemination and TA links accounted for two-thirds of the identified links between actors (85/261 links for dissemination; 85/261 for TA). Command links were mainly limited to government agencies, while other link types were observed across all actor groups. Ghana Health Service (GHS) had the greatest in-degree centrality for TA and funding links, primarily from United Nations Children’s Fund (UNICEF) and development partners. The World Health Organization, UNICEF, Ministry of Health, and GHS had the highest weighted average relative influence scores.

Conclusions

Although diverse actors are involved in breastfeeding policy and programming in Ghana, GHS plays a central role. United Nations and donor agencies are crucial supporters of GHS providing breastfeeding technical and financial assistance in Ghana.

Facilitators of Responsive Feeding/Parenting Knowledge and Practices Among Parents in the Central Region of Ghana

Objectives

Identify facilitators of the practice of Responsive Feeding/Parenting (RF/P) among parents of children under 3 years of age in the Central Region of Ghana.

Methods

Qualitative data was collected through six audiotaped focus group discussions with mothers (n = 27) and fathers (n = 18) living in the Central Region of Ghana who a) were 18 years of age or older; b) had a child under 3 years of age; c) were involved in feeding the child. Transcripts were read and coded independently by three authors, consensus was reached about emerging domains and themes, and a final codebook was developed.

Results

Three factors were identified as direct facilitators of the practice of RF/P: support, health care providers infant and young child feeding (IYCF) education delivery, and IYCF practice. Family, friends and the community gave parents informational, instrumental and emotional support including education/counseling on childcaring practices, doing chores for parents, giving parents the time off to respond to their children's needs. This support enabled parents to learn and adopt some RF/P behaviours. Health care providers delivered education on IYCF, food safety and, in some instances, provided some RF/P counselling/guidance. This then enabled parents to identify the nutritional and the psychosocial needs of their children and to recognize they should attend to these needs using RF/P knowledge and practice. Non-responsive feeding/parenting practices also emerged within IYCF practices demonstrating the need for more high-quality RF/P education.

Conclusions

Health care providers as well as family/friends facilitate parent's IYCF practices, which in turn influences their RF/P practices. Strengthening IYCF knowledge delivery through enhanced antenatal and postnatal counselling targeting parents as well as family/friends can promote RF/P knowledge and practices among Ghanaian parents.

Funding Sources

Hecht-Albert Leadership Award to Dr. Hromi-Fiedler through the Global Health Leadership Institute, Yale University.

Implementation of healthy food environment policies to prevent nutrition-related non-communicable diseases in Ghana: National experts' assessment of government action

Nutrition-related non-communicable diseases (NR-NCDs) are a global health problem, increasingly recognised as driven by unhealthy food environments. Yet little is known about government action to implement food environment-relevant policies, particularly in low-and lower-middle income countries. This study assessed government action, implementation gaps, and priorities to improve the food environment in Ghana. Using the Healthy Food-Environment Policy Index (Food-EPI), a panel comprising government and independent experts (n = 19) rated government action to improve the healthiness of food environment in Ghana against international best practices and according to steps within a policy cycle. Forty-three good practice indicators of food environment policy and infrastructure support were used, with ratings informed by systematically collected evidence of action validated by government officials. Following the rating exercise, the expert panel proposed and prioritized actions for government implementation. Three-quarters of all good practice indicators were rated at 'low'/'very little' implementation. Restricting the marketing of breast milk substitutes was the only indicator rated "very high". Of ten policy actions prioritized for implementation, restricting unhealthy food marketing in children's settings and in the media were ranked the highest priority. Providing sufficient funds for nationally-relevant research on nutrition and NCDs was the highest priority infrastructure-support action. Other priority infrastructure-support actions related to leadership, monitoring and evaluation. This study identified gaps in Ghana's implementation of internationally-recommended policies to promote healthy food environments. National stakeholders recommended actions, which will require legislation and leadership. The findings provide a baseline for measuring government progress towards implementing effective policies to prevent NR-NCDs.

Concurrently wasted and stunted children 6-59 months in Karamoja, Uganda: prevalence and case detection

We assessed prevalence of concurrently wasted and stunted (WaSt) and explored the overlaps between wasted, stunted, underweight and low mid‐upper arm circumference (MUAC) among children aged 6–59 months in Karamoja, Uganda. We also determined optimal weight‐for‐age (WAZ) and MUAC thresholds for detecting WaSt. We conducted secondary data analysis with 2015–2018 Food Security and Nutrition Assessment (FSNA) cross‐sectional survey datasets from Karamoja. Wasting, stunting and underweight were defined as <−2.0 z‐scores using WHO growth standards. Low MUAC was defined as <12.5 cm. We defined WaSt as concurrent wasting and stunting. Prevalence of WaSt was 4.96% (95% CI [4.64, 5.29]). WaSt was more prevalent in lean than harvest season (5.21% vs. 4.53%; p = .018). About half (53.92%) of WaSt children had low MUAC, and all were underweight. Younger children aged <36 months had more WaSt, particularly males. Males with WaSt had higher median MUAC than females (12.50 vs. 12.10 cm; p < .001). A WAZ <−2.60 threshold detected WaSt with excellent sensitivity (99.02%) and high specificity (90.71%). MUAC threshold <13.20 cm had good sensitivity (81.58%) and moderate specificity (76.15%) to detect WaSt. WaSt prevalence of 5% is a public health concern, given its high mortality risk. All children with WaSt were underweight and half had low MUAC. WAZ and MUAC could be useful tools for detecting WaSt. Prevalence monitoring and prospective studies on WAZ and MUAC cut‐offs for WaSt detection are recommended. Future consideration to integrate WAZ into therapeutic feeding programmes is recommended to detect and treat WaSt children.

Concurrently wasted and stunted 6-59 months children admitted to the outpatient therapeutic feeding programme in Karamoja, Uganda: Prevalence, characteristics, treatment outcomes and response

This study assessed the prevalence of concurrently wasted and stunted (WaSt) children, their characteristics, treatment outcomes and response; and factors associated with time to recovery among children aged 6–59 months admitted to Outpatient Therapeutic Care (OTC) in Karamoja, Uganda. We conducted a retrospective cohort study with data from January 2016 to October 2017 for children admitted to nine OTCs in Karamoja. We defined wasted, stunted and underweight as 2.0 Z-scores below the median per WHO growth standards and < 12.5 cm for low Mid-Upper Arm Circumference (MUAC). WaSt was defined as concurrently wasted and stunted. Out of 788 eligible children included in the analysis; 48.7% (95% CI; 45.2–52.2) had WaSt. WaSt was common among males; 56.3% (95% CI; 51.3–61.3). Median age was 18 months in WaSt versus 12 months in non-WaSt children (p < 0.001). All WaSt children were underweight; and more severely wasted than non-WaSt children. During recovery, WaSt children gained weight more rapidly than non-WaSt children (2.2g/kg/day vs. 1.7g/kg/day). WaSt children had lower recovery rate (58.0% vs. 65.4%; p = 0.037). The difference in median time of recovery between WaSt and non-WaSt children (63 days vs. 56 days; p = 0.465) was not significant. Factors associated with time to recovery were children aged 24–59 months (aHR = 1.30; 95% CI;1.07–1.57;), children with MUAC 10.5–11.4 cm (aHR = 2.03; 95% CI; 1.55–2.66), MUAC ≥ 11.5 cm at admission (aHR = 3.31; 95% CI; 2.17–5.02) and living in Moroto (aHR = 3.34; 95% CI; 2.60–4.30) and Nakapiripirit (aHR = 1.95; 95% CI; 1.51–2.53) districts. The magnitude of children with WaSt in OTC shows that existing therapeutic feeding protocols could be used to detect and treat WaSt children. Further research is needed to identify and address the factors associated with sub-optimal recovery in WaSt children for effective OTC programming in Karamoja.

Limiting spread of COVID-19 in Ghana: Compliance audit of selected transportation stations in the Greater Accra region of Ghana

Globally, little evidence exists on transmission patterns of COVID-19. Recommendations to prevent infection include appropriate and frequent handwashing plus physical and social distancing. We conducted an exploratory observational study to assess compliance with these recommendations in selected transportation stations in Ghana. A one-hour audit of 45 public transport stations in the Greater Accra region was carried out between 27th and 29th March 2020. Using an adapted World Health Organization (WHO) hand hygiene assessment scale, the availability and use of handwashing facilities, social distancing, and ongoing public education on COVID-19 prevention measures were assessed, weighted and scored to determine the level of compliance of stations. Compliance with recommendations was categorized as "inadequate" "basic", "intermediate" and "advanced", based on the overall score. Majority (80%) of stations in Accra have at least one Veronica Bucket with flowing water and soap, but the number of washing places at each station is not adequate. Only a small minority (18%) of stations were communicating the need to wash hands frequently and appropriately, and to practice social/physical distancing while at the station. In most stations (95%), hand washing practice was either not observed, or only infrequently. Almost all stations (93%) did not have alcohol-based hand sanitizers available for public use, while social distancing was rarely practiced (only 2%). In over 90% of the stations, face masks were either not worn or only worn by a few passengers. Compliance with COVID-19 prevention measures was inadequate in 13 stations, basic in 16 stations, intermediate in 7 stations, and advanced in 9 stations. Compliance with COVID-19 prevention measures in public transportation stations in the Greater Accra region remains a challenge. Awareness creation should aim to elevate COVID-19 risk perception of transportation operators and clients. Transport operators and stations need support and guidance to enforce hand washing and social distancing.

Design and testing of communication materials for a breastfeeding social media marketing campaign: Breastfeed4Ghana

Breastfeed4Ghana was a social media-based campaign implemented to address identified gaps in the protection, promotion, and support of breastfeeding in Ghana. This paper describes the process of campaign materials development and testing to ensure their cultural and content appropriateness. The 60 campaign materials, each consisting of an image and text message, underwent a process of creation, testing, revision, and finalization. Existing research evidence and infant and young child feeding communication tools that were culturally relevant for Ghana were used to develop the materials. All materials were tested and finalized through an iterative process that incorporated input from six focus group discussions (FGDs) with mothers, and content and technical experts. The materials were revised to ensure scientific accuracy, understandability, and cultural appropriateness of the messages, as well as alignment of the messages with the images. Finalized materials were reviewed and approved by the Ghana Food and Drugs Authority. Analysis for this paper involved summarizing and categorizing the types and sources of input as well as the research team's responses to the input received. The 60 campaign materials received a total of 132 inputs. Most inputs came from FGDs (78.4%); and most inputs were on the campaign material images. The evidence-informed process of materials creation, use of multiple input sources, and a broad-based iterative process allowed the creation of 60 evidence-based and culturally appropriate materials for a breastfeeding social media campaign in Ghana. This paper could serve as a guide for other social media campaign efforts looking to develop culturally appropriate materials.

Breastfeed4Ghana: Design and evaluation of an innovative social media campaign

Although targeting health behaviour change through social media campaigns has gained traction in recent years, few studies have focused on breastfeeding social media campaigns. Within the context of rising social media utilization and recent declines in exclusive breastfeeding practices in Ghana, we implemented Breastfeed4Ghana, a Facebook‐ and Twitter‐based breastfeeding social media campaign. This study determined feasibility of implementing Breastfeed4Ghana and evaluated its impact on breastfeeding knowledge in Ghana. Key performance indicators of the campaign were monitored on social media platforms, Facebook and Twitter. An online cross‐sectional survey conducted across three time points (n = 451) assessed breastfeeding knowledge, campaign exposure, and understanding and acceptability of Breastfeed4Ghana among Ghanaian adults. Modified Poisson models were used to assess the relationship between campaign exposure and breastfeeding knowledge, adjusting for survey time point, sex, and parenthood status. The campaign acquired 4,832 followers. Based on follower demographics collected from Facebook and Twitter analytics, the target population was successfully reached. Campaign exposure among survey participants was 42.3% and 48.7% at midline and endline, respectively. Campaign acceptability was high (>90%), and >44% of those exposed to the campaign also shared the campaign with others. However, 61.0% of those exposed did not know or could not remember the purpose of the campaign. Campaign exposure was not associated with higher breastfeeding knowledge (APR [95% confidence interval] = 0.96 [0.73, 1.26]). Breastfeed4Ghana was highly feasible. However, campaign understanding yielded mixed findings and may explain the limited impact on breastfeeding knowledge.

Global Study of Social Odor Awareness

Olfaction plays an important role in human social communication, including multiple domains in which people often rely on their sense of smell in the social context. The importance of the sense of smell and its role can however vary inter-individually and culturally. Despite the growing body of literature on differences in olfactory performance or hedonic preferences across the globe, the aspects of a given culture as well as culturally universal individual differences affecting odor awareness in human social life remain unknown. Here, we conducted a large-scale analysis of data collected from 10 794 participants from 52 study sites from 44 countries all over the world. The aim of our research was to explore the potential individual and country-level correlates of odor awareness in the social context. The results show that the individual characteristics were more strongly related than country-level factors to self-reported odor awareness in different social contexts. A model including individual-level predictors (gender, age, material situation, education, and preferred social distance) provided a relatively good fit to the data, but adding country-level predictors (Human Development Index, population density, and average temperature) did not improve model parameters. Although there were some cross-cultural differences in social odor awareness, the main differentiating role was played by the individual differences. This suggests that people living in different cultures and different climate conditions may still share some similar patterns of odor awareness if they share other individual-level characteristics.

Development and Testing of Responsive Feeding Counseling Cards in Ghana (OR03-07-19)

Objectives

The United Nations Children Fund (UNICEF) Community based Infant and Young Child Feeding (IYCF) counselling package currently lacks comprehensive responsive feeding curriculum, thus limiting dissemination of these messages within IYCF counselling. Thus, project objectives were to: a) develop counselling cards based on recent evidence-based responsive feeding guidelines and b) test their feasibility in Ghana.

Methods

Five counselling cards were developed addressing the responsive feeding topics of: enjoying eating with family; hunger/satiety cues; introducing new foods; food texture as a function of child development; soothing a child. The UNICEF image bank was used to develop counselling cards with images compatible with the UNICEF Community based IYCF counselling package. Two peri-urban focus groups (FG) were conducted with Ghanaian mothers (N = 7) and fathers (N = 6) of children < 3 years to assess the cultural appropriateness of the cards. Card revisions were made and re-tested in two rural FGs with the same target audience (N = 10 mothers; N = 4 fathers). Feasibility of including the cards as part of IYCF counselling was tested via: a) in-depth interviews with health care providers providing IYCF training and/or education (N = 14) and b) systematically observing eight educational sessions utilizing the cards with Ghanaian mothers (N = 20) and fathers (N = 18) of children < 3 years.

Results

FG findings led to changes to card images for each topic to ensure they were culturally and health literacy appropriate. Educational session findings strongly suggest the counselling cards provide important responsive feeding messages that are specific, clear, and feasible for mothers and fathers of children < 3 years to implement. Health care providers strongly endorsed the need for and utility of the responsive feeding counselling cards. Furthermore, they felt the cards and corresponding messages were feasible and important to integrate into the UNICEF Community based IYCF counselling package currently being used to deliver IYCF training and education in Ghana.

Conclusions

The counselling cards developed and tested have a strong potential to add the key responsive feeding dimension to IYCF training, education, and counselling in Ghana on a large scale.

Funding Sources

Yale Global Health Leadership Institute.

Global implications of the new WHO and UNICEF implementation guidance on the revised Baby-Friendly Hospital Initiative

Although breastfeeding confers both short- and long-term benefits for children and their mothers, breastfeeding practice remains suboptimal, globally. In addition to barriers including misperceptions and inappropriate marketing of breast milk substitutes, inadequate support for breastfeeding remains a challenge in many settings. To improve access to appropriate health system support, the World Health Organization (WHO) has reviewed the Baby-Friendly Hospital Initiative (BFHI), which ensures provision of optimal clinical care and support to mothers and their infants. This review has resulted in revision of the Ten Steps to Successful Breastfeeding, which form the core standards of (BFHI). These now consist of critical management procedures to support breastfeeding (Steps 1 and 2) and key clinical practices to support breastfeeding (Steps 3-10). In Step 1, there is now specific emphasis on compliance with the WHO Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions as well as on internal monitoring. There are also significant position shifts like the recommendation to "Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers," which is a departure from the earlier position of avoiding reference to these technologies. These revisions require countries and states to revise activities and tools for their local situation but without compromising the standards.

An agriculture-nutrition intervention improved children's diet and growth in a randomized trial in Ghana

Stunting in Ghana is associated with rural communities, poverty, and low education; integrated agricultural interventions can address the problem. This cluster randomized controlled trial tested the effect of a 12-month intervention (inputs and training for poultry farming and home gardening, and nutrition and health education) on child diet and nutritional status. Sixteen clusters were identified and randomly assigned to intervention or control; communities within clusters were randomly chosen, and all interested, eligible mother-child pairs were enrolled (intervention: 8 clusters, 19 communities, and 287 households; control: 8 clusters, 20 communities, and 213 households). Intention-to-treat analyses were used to estimate the effect of the intervention on endline minimum diet diversity (≥4 food groups), consumption of eggs, and length-for-age (LAZ)/height-for-age (HAZ), weight-for-age (WAZ), and weight-for-length (WLZ)/weight-for-height (WHZ) z-scores; standard errors were corrected for clustering. Children were 10.5 ± 5.2 months (range: 0-32) at baseline and 29.8 ± 5.4 months (range: 13-48) at endline. Compared with children in the control group, children in the intervention group met minimum diet diversity (adjusted odds ratio = 1.65, 95% CI [1.02, 2.69]) and a higher LAZ/HAZ (β = 0.22, 95% CI [0.09, 0.34]) and WAZ (β = 0.15, 95% CI [0.00, 0.30]). Sensitivity analyses with random-effects and mixed-effects models and as-treated analysis were consistent with the findings. There was no group difference in WLZ/WHZ. Integrated interventions that increase access to high-quality foods and nutrition education improve child nutrition.

Factors influencing the implementation of the Becoming Breastfeeding Friendly initiative in Ghana

Becoming Breastfeeding Friendly (BBF) is an initiative designed to help countries assess their readiness to scale-up breastfeeding programs and develop key recommendations to strengthen their breastfeeding environment. In 2016, Ghana was one of two countries to first pilot BBF. In applying BBF, a committee of 15 Ghanaian nutrition, health, and breastfeeding experts implemented the BBF toolbox over 8 months. Following implementation, semistructured interviews were conducted with 12 committee members (CMs) to (a) identify facilitators and barriers to implement BBF and (b) determine factors needed to strengthen the breastfeeding environment in Ghana. Using a grounded theory approach, five domains were identified. First, a dynamic committee of key stakeholders drove the implementation of BBF. Second, CMs faced some logistical and methodological challenges, including difficulty accessing data and the need for strong in-country technical support for adhering to the BBF process. Third, CMs felt well positioned to facilitate and lead the dissemination and implementation of recommendations. Fourth, accountability would be essential to properly translate recommendations. Fifth, to move recommendations to action, advocacy would be a required first step, and BBF was proposed to facilitate this step. BBF provided an in-depth analysis of Ghana's current breastfeeding environment to help Ghana strengthen its breastfeeding governance, policies, and programs while informing CMs' government and non-governmental organizations' breastfeeding efforts.

Lessons learned from Evidence-Informed Decision-Making in Nutrition & Health (EVIDENT) in Africa: a project evaluation

Background

Evidence-informed Decision-making in Nutrition and Health (EVIDENT) is an international partnership that seeks to identify information needs in nutrition and health in Africa and build local capacity in knowledge management to help translate the best available evidence into context-appropriate recommendations aligned to the priorities of decision-makers. This study evaluates the extent to which EVIDENT achieved its intended activities, documents the lessons learned and draws on these lessons learned to inform future activities of EVIDENT, as well as in evidence-informed decision-making (EIDM) in nutrition overall.

Methods

Purposive and snowball sampling were used to identify participants that were either directly or indirectly involved with EVIDENT. An analytical framework of five key elements was developed to guide data collection from EVIDENT’s documentation, in-depth interviews (n = 20), online surveys (n = 26) and a participatory discussion. Interviews were transcribed verbatim and coded in NVivo 11, using deductive thematic content analysis and a phenomenological approach. Online surveys were analysed using Stata 14. Data were triangulated to address both objectives under each element of the analytical framework.

Results

EVIDENT succeeded in establishing a collaborative partnership, within which it delivered four short courses in EIDM. This capacity complemented case study activities in four partner African countries where EIDM processes were implemented and assessed. Identified barriers to these processes included little experience in EIDM, difficulties in engaging stakeholders, challenging local environments (e.g. donor influence, bureaucracy, inaccessibility to scientific research, poor internet connectivity), and limited time and funding. However, EVIDENT activities were driven by a local need for EIDM, a sheer interest and commitment to the cause, and the opportunity for the Global North and South to work together and build relationships. Future activities of EVIDENT, and EIDM in nutrition overall, should focus on sustained capacity-building in EIDM processes, leadership and functional skills across the Global South, investment in stakeholder engagement, context-specific EIDM, enhanced communication and linking, and strengthening relationships with existing stakeholder organisations.

Conclusions

In its first 3 years, EVIDENT developed and strengthened partnership, capacity and visibility on EIDM in Africa. Innovative and long-term capacity-building, dedicated leadership, further stakeholder engagement and sustainable financing, are needed for future activities of EVIDENT and EIDM in nutrition.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0413-6) contains supplementary material, which is available to authorized users.

Four Dissemination Pathways for a Social Media-Based Breastfeeding Campaign: Evaluation of the Impact on Key Performance Indicators

Background

Social media utilization is on the rise globally, and the potential of social media for health behavior campaigns is widely recognized. However, as the landscape of social media evolves, so do techniques used to optimize campaign dissemination.

Objective

The primary aim of this study was to evaluate the impact of 4 material dissemination paths for a breastfeeding social media marketing campaign in Ghana on exposure and engagement with campaign material.

Methods

Campaign materials (n=60) were posted to a Facebook and Twitter campaign page over 12 weeks (ie, baseline). The top 40 performing materials were randomized to 1 of 4 redissemination arms (control simply posted on each platform, key influencers, random influencers, and paid advertisements). Key performance indicator data (ie, exposure and engagement) were extracted from both Facebook and Twitter 2 days after the material was posted. A difference-in-difference model was used to examine the impact of the dissemination paths on performance.

Results

At baseline, campaign materials received an average (SD) exposure of 1178 (670) on Facebook and 1071 (905) on Twitter (n=60). On Facebook, materials posted with paid advertisements had significantly higher exposure and engagement compared with the control arm (P<.001), and performance of materials shared by either type of influencer did not differ significantly from the control arm. No differences in Twitter performance were detected across arms.

Conclusions

Paid advertisements are an effective mechanism to increase exposure and engagement of campaign posts on Facebook, which was achieved at a low cost.

An assets-based approach to promoting girls' financial literacy, savings, and education

PURPOSE

This study examined whether micro-savings programs can improve young adolescent girls' financial knowledge, savings behaviors, and schooling outcomes in Ghana.

METHODS

We evaluated the short- and medium-term effects of a randomized control trial in which a sub-sample of over 1400 girls living in the Eastern Region of Ghana received financial literacy training and a micro-savings account.

RESULTS

Girls in the intervention arm of the study initially exhibited higher levels of financial knowledge, planning, and savings, but some of these effects disappeared within two years. Nonetheless, girls with micro-savings retained their greater knowledge of interest rates, had higher levels of savings, and were more likely to save for school. The effects on girls' educational enrollment was strongest in the second year.

CONCLUSIONS

Our results suggest that even relatively young girls can manage micro-savings accounts and that such programs, if sustained, can effectively build girls' financial and educational assets.

Food security and dietary diversity are associated with health related quality of life after 6 months of follow up among people living with HIV in Accra, Ghana

With the efficacy of antiretroviral therapy, people living with HIV (PLWH) are surviving longer and improving their health related quality of life (HRQol) has become an important long-term HIV treatment and management indicator. HRQol has been associated with various factors, including food insecurity (FI). The objective of this prospective study was to examine the association between FI and dietary diversity (HDDS) and HRQol among PLWH in Accra, Ghana. We recruited 152 PLWH from the HIV clinics of six district hospitals Accra, Ghana and utilized a prospective cohort study design with data collection at baseline, three and six months after recruitment for this study. Participants completed questionnaires measuring HRQol, FI and HDDS. Repeated measures ANOVA was used to analyze the associations between FI and HRQol as well as HDDS and HRQol separately and then together. Being food secure [0.035 (95% CI = 0.005, 0.065)] and having a high dietary diversity score [0.029 (95% CI = 0.004, 0.053)] were independently associated with an improvement in quality of life scores over time after adjusting for other covariates and each other. Interventions to improve dietary diversity and food security among PLWH have the potential to improve nutritional status as well as HRQol.

Pilot testing of the Becoming Breastfeeding Friendly toolbox in Ghana

Background

Ghana has achieved significant progress in breastfeeding practices in the past two decades. Further progress is, however, limited by insufficient government funding and declining donor support for breastfeeding programs. The current study pretested feasibility of the Becoming Breastfeeding Friendly (BBF) toolbox in Ghana, to assess the existing enabling environment and gaps for scaling-up effective actions.

Methods

Between June 2016 and April 2017, a 15-person expert country committee drawn from government and non-government agencies was established to implement the BBF toolbox. The committee used the BBF index (BBFI), comprising of 54 benchmarks and eight gears of the Breastfeeding Gear Model (advocacy; political will; legislation and policy; funding and resources; training and program delivery; promotion; research and evaluation; and coordination, goals and monitoring). Available evidence (document reviews, and key informant interviews) was used to arrive at consensus-scoring of benchmarks. Benchmark scores ranged between 0 (no progress) and 3 (major progress). Scores for each gear were averaged to estimate the Gear Total Score (GTS), ranging from 0 (least) to 3.0 (strong). GTS’s were aggregated as a weighted average to estimate the BBFI which ranged from 0 (weak) to 3.0 (outstanding). Gaps in policy and program implementation and recommendations were proposed for decision-making.

Results

The BBFI score was 2.0, indicating a moderate scaling-up environment for breastfeeding in Ghana. Four gears recorded strong gear strength: advocacy (2.3); political will (2.3); legislation and policy (2.3); and coordination, goals and monitoring (2.7). The remaining four gears had moderate gear strength: funding and resources (1.3); training and program delivery (1.9); promotion (2.0); and research and evaluation (1.3). Key policy and program gaps identified by the committee included sub-optimal coordination across partners, inadequate coverage and quality of services, insufficient government funding, sub-optimal enforcement of policies, and inadequate monitoring of existing initiatives. Prioritized recommendations from the process were: 1) strengthen advocacy and empower breastfeeding champions, 2) strengthen breastfeeding regulations, including maternity protection, 3) strengthen capacity for providing breastfeeding services, and 4) expand and sustain breastfeeding awareness initiatives.

Conclusions

The moderate environment for scaling-up breastfeeding in Ghana can be further strengthened by addressing identified gaps in policy and programs.

Electronic supplementary material

The online version of this article (10.1186/s13006-018-0172-y) contains supplementary material, which is available to authorized users.

Perception and practice of breastfeeding in public in an urban community in Accra, Ghana

Background

Reported stigmatization and confrontation (verbal and aggressive), of women when breastfeeding in public spaces constitutes a barrier to the recommendation to breastfeed infants on demand. While such stigma of breastfeeding in public has been reported more commonly in Western country media, there is no documented evidence of this stigma in developing country settings. The current study describes community perception and experience of breastfeeding in public in Accra, Ghana. A secondary objective is to explore factors associated with breastfeeding in public.

Methods

A mixed methods design comprising a survey (n = 300), five Focus Group Discussions (FGD) with lactating women (n = 50), and nine In-Depth Interviews (IDI) with adult males (n = 5) and female health workers (n = 4) were also conducted. All data were collected between May and June, 2016 in the Ayawaso-West Sub-Metropolis, Accra. Data on sociodemographic characteristics; obstetric and breastfeeding history; and also perception, experience, and practice of breastfeeding in public, were collected. FGDs and IDI data were triangulated with survey data and presented using descriptive and analytical statistics and content analysis.

Results

Majority of the survey respondents (92%) reported ever practicing breastfeeding in public. However, some reported feeling uncomfortable (52%), embarrassed (27%), or stigmatized (15%). Nevertheless, 72% of respondents felt they should be able to breastfeed anywhere. Almost all respondents (81%) reported covering their breasts when breastfeeding in public, and 70% felt private places should be used when they breastfed in public. Women in FGDs and IDI mentioned that they bottle feed their children in public places as a way to overcome the challenges of breastfeeding in public. Otherwise, they breastfeed in public because their children need to feed. Women were more likely to breastfeed in public if they reported support from a spouse (OR 3.99, 95% CI 1.50, 10.57) or other family members (OR 3.27, 95% CI 1.31, 8.18).

Conclusions

Although women reported discomfort associated with breastfeeding in public, the practice is common. Awareness creation is needed to empower women to comfortably breastfeed and to sustain societal support of breastfeeding in public.

Lipid profile and dyslipidemia among school-age children in urban Ghana

Background

Dyslipidemia during childhood has been associated with higher risk of atherosclerosis later in life. Information on the lipid profile of Ghanaian children is scarce. The aim of this study was to assess the lipid profiles of school children between the ages of 9–15 years, living in urban Ghana.

Methods

A total of 802 randomly selected school-age children participated in the Ghana School Survey implemented in Kumasi and Accra, Ghana. A structured questionnaire was used to collect information on child and maternal socio-demographic characteristics (including age, education, and occupation), 7-day food frequency, home and school activity, as well as measurement of weight and standing height. Weight, height, and age data were converted into BMI-for-age indices to determine weight status. Finger-prick fasting blood samples were taken from the school-age children. Total cholesterol (TC), triglyceride (TG), high density lipoprotein (HDL-C) and low-density lipoprotein (LDL-C) cholesterol levels were determined using the CardioChek® PA Test System. Reference lipid levels based on the US National Cholesterol Education Program 2001 guidelines were used to determine the proportion of children with dyslipidemia.

Results

The mean TC, LDL-C, HDL-C, and TG levels were 149.0 ± 57.0 mg/dl, 80.1 ± 38.6 mg/dl, 53.5 ± 19.4 mg/dl, and 71.4 ± 54.7 mg/dl, respectively. Mean TC/HDL-C ratio was 3.0 ± 1.0. The proportion of children with abnormal values were 12.1% for TC, 4.5% for TG, 28.4% for HDL-C, 9.2% for LDL-C, and 6.6% for TC/HDL-C ratio. The levels of dyslipidemia (HDL, LDL, and TC/HDL-C ratio) were higher among overweight/obese compared to normal-weight children. More frequent fruit consumption was also linked with lower LDL-C (p = 0.020) while watching television (TV) in the mornings was linked with both higher TC (p = 0.011) and TG (p = 0.006).

Conclusions

Majority of urban-dwelling Ghanaian school children had normal lipid profiles. However, the higher levels of dyslipidemia observed among overweight and obese children suggest the need for population level physical activity and dietary interventions among children to reduce risk of cardiovascular diseases in adult life.

Child development in rural Ghana: Associations between cognitive/language milestones and indicators of nutrition and stimulation of children under two years of age

OBJECTIVES

Two studies aimed to assess the provision of nutrition and psychosocial stimulation in the home and to examine associations between mental development and nutrition and stimulation using a validated measure of development milestones.

METHODS

The first study consisted of secondary analyses on health and nutrition data from 1081 mother-child pairs (the children aged 0-12 months) and their households in Ghana's Eastern Region. For the second study, the Ghana Milestones Measure, consisting of items assessing cognitive and language development, was used to assess child development in a subsample (N = 330) of Study 1 participants one year later (children 10-24 months of age). This measure was mother-reported and had been validated in a separate community in Ghana. Correlation and linear regression analyses were used to analyze the data.

RESULTS

Family assets and maternal education were identified as key factors of the family context. Both variables were positively associated with preventive health practices (r = 0.08 to 0.13, p &lt; 0.0001 to 0.01), and dietary diversity (r = 0.15, p = 0.0001 to 0.0006), and negatively associated with maternal depressive symptoms (r = -0.19 to -0.12, p &lt; 0.0001). Taller children had higher receptive (standardized beta = 0.16; p = 0.04) and expressive (0.21; 0.003) language, but not cognitive (0.15; 0.07) milestone scores, and psychosocial stimulation was positively associated with all three milestones (receptive = 0.13, p = 0.01; expressive = 0.21, p &lt; 0.0001; and cognitive = 0.24, p &lt; 0.0001).

CONCLUSION

Our study provides the first validated measure of children's language and cognitive development in Ghana, finding associations with nutrition and stimulation. The Ghana Milestones Measure can be used to assess and help promote children's mental development.

Implementation of a nutrition assessment, counseling and support program and its association with body mass index among people living with HIV in Accra, Ghana

In spite of the important role nutrition plays in the management of HIV, access to nutrition services is inadequate, especially in resource limited settings. In addition, nutrition programs for people living with HIV (PLWH) have not been sufficiently evaluated for efficacy and this study was conducted to address this gap. This study aimed to evaluate the implementation of the nutrition assessment, counseling and support (NACS) program in Accra, Ghana, and to assess whether the level of implementation of NACS was associated with the body mass index (BMI) of PLWH. A cross-sectional study was conducted in six HIV clinics (3 NACS designated and 3 non-NACS). Study participants were 152 adult PLWH at least 6 months on antiretroviral therapy and not pregnant or breastfeeding. Using a NACS implementation scale developed for this study ranging from 0 to 8 (a higher score indicating better NACS implementation), median NACS implementation score was not different between NACS-designated, and non-NACS HIV clinics (5 vs 4, p = 0.14). Almost half (47%) of the respondents were overweight or obese. A higher score on the NACS implementation scale was not significantly associated with overweight or obesity (BMI >24.9 kg/m²) after adjusting for other covariates. It was concluded that, there was poor implementation of NACS in the NACS designated HIV clinics surveyed with no nutrition counseling offered nor food support available to those who might need it.

Prevalence and predictors of overweight and obesity among school-aged children in urban Ghana

BACKGROUND

Childhood overnutrition is a serious public health problem, with consequences that extend into adulthood. The aim of this study was to determine the prevalence and determinants of overweight and obesity among school-age children in two urban settings in Ghana.

METHODS

This cross-sectional study involved 3089 children (9-15 years) recruited between December 2009 and February 2012 in Accra and Kumasi, Ghana. Socio-demographic, dietary, and physical activity data were collected using pretested questionnaires. BMI-for-age z-scores were used to categorize anthropometric data of the children as thin, normal, or overweight/obese. Determinants of overweight were examined using multiple logistic regressions.

RESULTS

Seventeen percent of children were overweight or obese. Children who reported lower participation (< 3 times/week) in sports activity were 44% more likely to be overweight or obese (AOR = 1.44; 95% CI: 1.07, 1.94). Maternal tertiary education (AOR = 1.91, 95% CI: 1.07, 3.42), higher household socioeconomic status (AOR = 1.56, 95% CI: 1.18, 2.06), and attending private school (AOR = 1.74, 95% CI: 1.31, 2.32) were also associated with elevated risk of overweight and obesity.

CONCLUSIONS

Physical inactivity is a modifiable independent determinant of overweight or obesity among Ghanaian school-aged children. Promoting and supporting a physically active lifestyle in this population is likely to reduce risk of childhood overnutrition.

Corrigendum: Marital Satisfaction, Sex, Age, Marriage Duration, Religion, Number of Children, Economic Status, Education, and Collectivistic Values: Data from 33 Countries

[This corrects the article on p. 1199 in vol. 8, PMID: 28785230.].

Preferred Interpersonal Distances: A Global Comparison

Human spatial behavior has been the focus of hundreds of previous research studies. However, the conclusions and generalizability of previous studies on interpersonal distance preferences were limited by some important methodological and sampling issues. The objective of the present study was to compare preferred interpersonal distances across the world and to overcome the problems observed in previous studies. We present an extensive analysis of interpersonal distances over a large data set ( N = 8,943 participants from 42 countries). We attempted to relate the preferred social, personal, and intimate distances observed in each country to a set of individual characteristics of the participants, and some attributes of their cultures. Our study indicates that individual characteristics (age and gender) influence interpersonal space preferences and that some variation in results can be explained by temperature in a given region. We also present objective values of preferred interpersonal distances in different regions, which might be used as a reference data point in future studies.

Construct Validity of the Neighborhood Environment Walkability Scale for Africa

PURPOSE

The development of valid measures of built environments relevant for physical activity is an important step toward controlling the global epidemic of physical inactivity-related noncommunicable diseases and deaths. This study assessed the construct validity of a self-report neighborhood environment walkability scale adapted for Africa (NEWS-Africa), by examining relationships with self-reported walking for transportation and recreation using pooled data from six sub-Saharan African countries.

METHODS

NEWS was systematically adapted to assess urban, periurban, and rural environments in sub-Saharan Africa. Adults (n = 469, 18-85 yr, 49.7% women) from Cameroon, Ghana, Mozambique, Nigeria, South Africa, and Uganda were purposively recruited from neighborhoods varying in walkability and socioeconomic status, with some from villages. Participants completed the 76-item (13 subscales) NEWS-Africa by structured interview and reported weekly minutes of walking for transport and recreation using items from the International Physical Activity Questionnaire.

RESULTS

The overall "walkability" index had a positive relationship with both walking for transportation (η = 0.020, P = 0.005) and recreation (η = 0.013, P = 0.028) in the pooled analyses. The mixed-use access and stranger danger scales were positively related with transport walking (η = 0.020, P = 0.006 and η = 0.021, P = 0.040, respectively). Proximity of recreational facilities (η = 0.016, P = 0.015), road/path connectivity (η = 0.025, P = 0.002), path infrastructure (η = 0.021, P = 0.005), and overall places for walking and cycling (η = 0.012, P = 0.029) scales were positively related to recreational walking. Country-specific results were mostly nonsignificant except for South Africa and Uganda.

CONCLUSIONS

Of 14 NEWS-Africa scales, 7 were significantly related to walking behavior in pooled analyses, providing partial support for the construct validity of NEWS-Africa. However, effect sizes appeared to be lower than those from other continents. Further study with larger and more diverse samples is needed to determine whether the instrument performs well in each country.