Cold, dark and malnourished: a cross-sectional analysis of the relationship between energy poverty and household burden of malnutrition in sub-Saharan Africa.

OBJECTIVE: Energy poverty contributes to the general well-being of households; however, there is representational paucity on its role in household nutrition across sub-Saharan Africa (SSA). This study examined the influence of different domains of energy poverty and a Multidimensional Energy Poverty Index (MEPI) on household burden of malnutrition in SSA. SETTING: Secondary data from the most recent Demographic and Health Survey conducted in 18 SSA countries were analysed. DESIGN: A cross-sectional design was used to examine the relationship between household energy poverty and household burden of malnutrition. METHODS: Different dimensions of household energy poverty and an MEPI were computed from the sources of energy used for cooking, lighting, entertainment and accessing information by households. Household burden of malnutrition was coded as a binary categorical dependent variable using indicators of undernutrition, overnutrition and anaemia among women of reproductive age (15-49 years) and children under five years in the household. RESULTS: More than nine in ten households were energy poor in terms of cooking fuel and about three in four were energy poor in terms of lighting. Considering the various domains of energy poverty, lack of electricity for lighting, using biofuels, not owning a refrigerator/freezer, not owning a television/radio and not owning a mobile phone were associated with increased odds of a household experiencing undernutrition. Similarly, deprivation in these domains was associated with a lower likelihood of households experiencing overnutrition, the only exception being using biofuels. Overall, households that were most energy poor on the MEPI were more likely to be undernourished and double and triple burden malnutrition households but less likely to suffer from overnutrition. CONCLUSION: These results highlight the complex and multifaceted nature of the relationship between energy poverty and household burden of malnutrition and provides guidance for appropriate interventions to address energy poverty and malnutrition in SSA.

Intimate partner violence and malnutrition among women of reproductive age in Western Africa: A geostatistical analysis.

Intimate partner violence (IPV) is a public health issue, and the experience varies among population sub-groups in Africa. In the West African sub-region, IPV perpetrated against women remains high and is exacerbated by the pertaining cultural milieu. It affects women's health, wellbeing, and nutritional status. We examined the association between women's lifetime experiences of physical, sexual, and emotional IPV and undernutrition by quantifying the association at smaller geographical settings in West African countries. We used a bivariate probit geostatistical technique to explore the association between IPV and undernutrition, combining data from the latest Demographic and Health Survey conducted in ten Western African countries. Bayesian inference relies on Markov chain Monte Carlo simulation. The findings demonstrate spatial clustering in the likelihood of experiencing IPV and being underweight in the regions of Mali, Sierra Leone, Liberia and neighboring Cote d'Ivoire, Ghana, Togo, Benin, Cameroon, and Nigeria. The pattern of clustering was somewhat similar when physical violence was combined with underweight and emotional violence combined with underweight. The findings also indicate protective effects of education, wealth status, employment status, urban residence, and exposure to mass media. Further, the likelihood of experiencing IPV and the likelihood of being underweight or thin declined with age and age-gap between the woman and her partner. The findings provide insight into the location-specific variations that can aid targeted interventions, and underscore the importance of empowering women holistically, in the domains of education, socio-economic and socio-cultural empowerment, in addressing women's vulnerability to IPV and malnutrition (underweight and thinness). Furthermore, IPV prevention programmes will need to address gender inequality and cultural factors such as male dominance that may heighten women's risk of experiencing IPV.

Physical Activity Behaviour and Comparison of GPAQ and Travel Diary Transport-Related Physical Activity in Accra, Ghana.

There is a lack of data on physical activity (PA), active travel, and the comparison of measurement instruments in low-resource settings. The objective of this paper is to describe PA behaviour and the agreement of walking estimates from the Global Physical Activity Questionnaire (GPAQ) and the travel diary in a low-resource setting. We used a cross-sectional survey design to capture data from the residents of Accra (Ghana) between May 2020 and March 2021. Of the 863 participants aged 15+ years, 65% were females, and 86% reported PA. The median weekly PA was 18 (interquartile range: 5-75) metabolic equivalent of task hours, with 50% of females and 37% of males achieving low PA levels. In the GPAQ, 80% of participants reported weekly walking; the mean number of days walked was 3.8 (standard deviation (SD): 2.5); hence, 54% of participants reported walking on any day, and the mean daily walking duration was 51 (SD: 82) minutes. In the diary, 56% of participants reported walking for over 24 h, with a mean walking duration of 31 (SD: 65) minutes. The correlation of walking duration between instruments was weak (rho: 0.31; 95% Confidence Interval: 0.25-0.37); the mean bias was 20 min, with GPAQ estimates being 0.1 to 9 times higher than diary estimates. We concluded that low PA is prevalent in Accra, and while the travel diary and GPAQ estimate similar walking prevalence, their walking duration agreement is poor. We recommend accompanying PA questionnaires with objective measures for calibration.

Is Infant birth weight and mothers perceived birth size associated with the practice of exclusive breastfeeding in Ghana?

INTRODUCTION: Despite widespread advocacy for exclusive breastfeeding, and the associated benefits of exclusive breastfeeding for both infants and mothers, there is low prevalence in both developed and developing countries. Additionally, although several studies have been conducted on exclusive breastfeeding, very few of such studies have linked birth weight and birth size to exclusive breastfeeding. This study seeks to examine the influence of birth weight and birth size on exclusive breastfeeding. METHODOLOGY: This study adopted a sequential explanatory mixed method approach using both quantitative and qualitative methods. The quantitative approach used cross-sectional data from the 2014 Ghana Demographic and Health Survey (GDHS) and the qualitative data from interviews with exclusive breastfeeding mothers from two health facilities in La Nkwantanang Municipal Assembly in Accra, Ghana. Logistic regression analysis was used to examine whether infants birth weight and mothers perceived birth size are associated with the practice of exclusive breastfeeding while the qualitative data provided further insights into the findings from the quantitative analysis. RESULTS: Majority (85%) of the infants in the study were of normal birth weight while 52% of the infants were perceived by their mothers to be of small birth size. The prevalence of exclusive breastfeeding was found to be 54.8%. The birth weight of infants and mothers' perceived birth size were found to be significant predictors of exclusive breastfeeding. Infants of normal birth weight (OR = 7.532; 95% CI: 2.171-26.132) and high birth weight (OR = 6.654; 95% CI: 1.477-29.978) were more likely to be exclusively breastfed compared to low-birth-weight infants. Similarly, infants perceived to be of normal birth size were more likely (OR = 1.908; 95% CI: 1.058-3.441) to be exclusively breastfed compared to infants perceived to be of small birth size. The findings from the qualitative analysis show that birth weight rather than birth size influence mothers' decision to practice exclusive breastfeeding. CONCLUSION: The findings of the study underscore the relevance of infant birth weight and perceived birth size in the practice of exclusive breastfeeding and highlights the need to incorporate both actual measurement of birth weight, and perception of infant's birth size into policies targeted at exclusive breastfeeding. There is the need for deliberate targeted efforts at women who deliver infants of low birth weight and women who perceive their children to be of small birth size to practice exclusive breastfeeding.

Enablers and inhibitors of exclusive breastfeeding: perspectives from mothers and health workers in Accra, Ghana.

BACKGROUND: Despite the health and economic benefits of exclusive breastfeeding, there is evidence of a decline globally and in Ghana. Previous studies addressing this problem are mostly quantitative with only a few of such studies using qualitative or mixed methods to examine the predictors, benefits, ways of improving and managing exclusive breastfeeding, and the challenges associated with exclusive breastfeeding from the perspective of exclusive and nonexclusive breastfeeding mothers, and health workers. This study employs the health belief model to examine the experiences of mothers and health workers regarding exclusive breastfeeding to fill this gap in the literature. METHODS: A cross-sectional qualitative study involving in-depth interviews was conducted among health workers and mothers attending child welfare clinic at two polyclinics in Madina, Accra-Ghana in 2019. Purposive sampling was used to select health facilities and participants for the study. Twenty participants comprising ten exclusive breastfeeding mothers, six non-exclusive breastfeeding mothers and four health workers were interviewed for the study. The data were analyzed based on emerging themes from inductive and deductive coding. RESULTS: The decision to practice exclusive breastfeeding was based on mothers' work, advertisement on exclusive breastfeeding and education on breastfeeding provided by health workers. Insufficient flow of breast milk, pressure from family and friends, and insufficient breast milk for infants were among the reasons for discontinuing exclusive breastfeeding. The factors that help improve exclusive breastfeeding include eating healthy food and breastfeeding on demand, while counselling and monitoring, restricting advertisement on infant formula and granting maternity leave for breastfeeding mothers were identified as factors that can  facilitate the practice of exclusive breastfeeding. CONCLUSION: Different levels of experience affect and shape exclusive breastfeeding practice in Ghana. The decision to practice exclusive breastfeeding, as well as the challenges and strategies employed in managing exclusive breastfeeding, emanates from mothers' personal experiences and interactions with institutional factors. In view of this, there should be counselling on the management of challenges associated with exclusive breastfeeding and provision of accurate information on exclusive breastfeeding to enable mothers practice exclusive breastfeeding.

Profiling household double and triple burden of malnutrition in sub-Saharan Africa: prevalence and influencing household factors.

OBJECTIVE: Undernutrition and anaemia (the commonest micronutrient deficiency), continue to remain prevalent and persistent in sub-Saharan Africa (SSA) alongside a rising prevalence of overweight and obesity. However, there has been little research on the co-existence of all three conditions in the same household in recent years. The current study examines the co-existence and correlates of the different conditions of household burden of malnutrition in the same household across SSA. SETTING: The study involved twenty-three countries across SSA who conducted Demographic and Health Surveys between 2008 and 2017. PARTICIPANTS: The analytical sample includes 145 020 households with valid data on the nutritional status of women and children pairs (i.e. women of reproductive age; 15-49 years and children under 5 years). DESIGN: Logistic regression analyses were used to determine household correlates of household burden of malnutrition. RESULTS: Anaemia was the most common form of household burden of malnutrition, affecting about seven out of ten households. Double and triple burden of malnutrition, though less common, was also found to be present in 8 and 5 % of the households, respectively. The age of the household head, location of the household, access to improved toilet facilities and household wealth status were found to be associated with various conditions of household burden of malnutrition. CONCLUSIONS: The findings of the current study reveal that both double and triple burden of malnutrition is of public health concern in SSA, thus nutrition and health interventions in SSA must not be skewed towards addressing undernutrition only but also address overweight/obesity and anaemia.

The Need to Address Fragmentation and Silos in Mortality Information Systems: The Case of Ghana and Peru.

Objectives: We aimed to understand the information architecture and degree of integration of mortality surveillance systems in Ghana and Peru. Methods: We conducted a cross-sectional study using a combination of document review and unstructured interviews to describe and analyse the sub-systems collecting mortality data. Results: We identified 18 and 16 information subsystems with independent databases capturing death events in Peru and Ghana respectively. The mortality information architecture was highly fragmented with a multiplicity of unconnected data silos and with formal and informal data collection systems. Conclusion: Reliable and timely information about who dies where and from what underlying cause is essential to reporting progress on Sustainable Development Goals, ensuring policies are responding to population health dynamics, and understanding the impact of threats and events like the COVID-19 pandemic. Integrating systems hosted in different parts of government remains a challenge for countries and limits the ability of statistics systems to produce accurate and timely information. Our study exposes multiple opportunities to improve the design of mortality surveillance systems by integrating existing subsystems currently operating in silos.

Towards universal access to healthcare for older adults: an assessment of the old-age exemption policy under Ghana's National Health Insurance Scheme.

BACKGROUND: Despite calls for governments to provide universal health coverage for all, social health insurance programmes (SHI) that specifically target older adults continue to be largely absent in many African countries. Only a few African countries have implemented SHI programmes that include specific provisions for older adults. Ghana's National Health Insurance Scheme (NHIS) is one of the few programmes in Africa that exempts older adults from paying premiums for health insurance. This study examined socio-demographic factors associated with old-age premium exemption under Ghana's NHIS. METHODS: The study used data from the seventh round of the Ghana Living Standards Survey (GLSS 7) conducted in 2017. Descriptive statistics and binary logistic regression were used in analysing data from a sample of 1532 older adults aged 70 years and older. RESULTS: The results reveal that only about 43% of older adults who were enrolled on the NHIS at the time of the survey acquired their membership through the old-age exemption policy. Additionally, increasing age was associated with higher odds of reporting exemption from paying premiums for health insurance. Also, older adults who are living in rural areas were more likely to pay premiums rather than being exempt as compared to their counterparts living in urban areas. CONCLUSIONS: These findings indicate that the old-age exemption policy is not achieving the intended goal of providing financial risk protection for some older adults. Additionally, the policy is not reaching those who need it most, particularly those living in rural areas. Specific targeting is required for older adults living in rural areas who are less likely to benefit from the old-age exemption policy in spite of being eligible.

"Cementing" marriages through childbearing in subsequent unions: Insights into fertility differentials among first-time married and remarried women in Ghana.

Fertility in Ghana has declined steadily since 1980, however, a slight increase was observed between 2008 and 2014. While several factors may account for this pattern, research on the contribution of type of union is limited. This study examined differentials in the fertility of women in different types of union. Secondary data from 6,285 (weighted) ever-married women aged 15-49 years were analysed using compare means, t-test, analysis of variance, Poisson and binary logistic regression analyses. The findings indicate that, independent of other factors, fertility among remarried women is higher compared to first-time married women but this does not hold true when other factors are controlled for. Additionally, there was no significant difference in the fertility of remarried women who were in union and women who were in union in a first-time marriage. However, compared to remarried women who were currently in a union, fertility was significantly lower among remarried women who were not currently in union (ß = -0.121, p<0.01) and women who have been married only once but were not currently in union (ß = -0.212, p<0.001). Further analysis revealed that remarried women were significantly more likely to desire more children and less likely to use any method of contraception compared to first-time married women. There is the need for further research to better understand the fertility needs of remarried women.

Cash Transfers, Early Marriage, and Fertility in Malawi and Zambia.

There is increasing interest in the ability of cash transfers to facilitate safe transitions to adulthood in low-income settings; however, evidence from scaled-up government programming demonstrating this potential is scarce. Using two experimental evaluations of unconditional cash transfers targeted to ultra-poor and labor-constrained households over approximately three years in Malawi and Zambia, we examine whether cash transfers delayed early marriage and pregnancy among youth aged 14 to 21 years at baseline. Although we find strong impacts on poverty and schooling, two main pathways hypothesized in the literature, we find limited impacts on safe transition outcomes for both males and females. In addition, despite hypotheses that social norms may constrain potential impacts of cash transfer programs, we show suggestive evidence that pre-program variation in social norms across communities does not significantly affect program impact. We conclude with policy implications and suggestions for future research.

Registered or unregistered? Levels and differentials in registration and certification of births in Ghana.

BACKGROUND: The birth of a child is a vital event that needs to be registered but this is not always the case as an estimated 40 million births go unregistered annually. Birth registration safeguards the basic rights of children and gives them an identity, citizenship/nationality and legal protection against violence, abuse and human rights violations. It is therefore necessary that all births are registered and even more critical that the registration of a birth is followed by the issuance of a birth certificate. But sadly, birth registration in many African countries continues to remain below acceptable international standards and not all registered births are certified. This paper examined birth registration and certification in Ghana. Differentials in the characteristics of children and mothers of children whose births are registered and certified, children whose births are registered but not certified and children whose births are not registered were examined. METHODS: This paper analysed data from the 2014 Ghana Demographic and Health Survey drawing on variables from the household and children's data files. Descriptive analytical tools (frequencies, percentage and cross tabulations) and multinomial logistic regression analysis were used to examine differentials in birth registration status among an analytical sample of 3880 (weighted) children aged 0-4 years. RESULTS: The birth of about every 1 in 4 (28.89%) children in Ghana have never been registered. Birth registration and certification was lowest among children born to young mothers (15-19 years), children whose mothers have no formal education, mothers who reside in rural areas and mothers in the poorest wealth quintile. Additionally, home births and births that were not assisted by a medical professional were observed to have the lowest proportion of registered and certified births. Furthermore, the birth of children who are less than a year old was significantly more likely not to be registered or issued with a birth certificate. CONCLUSION: Efforts aimed at improving birth registration and certification in Ghana need to target groups of children and mothers with low levels of registration and certification particularly children who are born at home, children born to young mothers and children whose mothers are poor and or reside in rural areas.

Examining equity in health insurance coverage: an analysis of Ghana's National Health Insurance Scheme.

BACKGROUND: Following years of out-of-pocket payment for healthcare, some countries in Africa including Ghana, Kenya and Rwanda have instituted social health protection programs through health insurance to provide access to quality and affordable healthcare especially for the poor. This paper examines equity in coverage under Ghana's National Health Insurance Scheme (NHIS). METHODS: Secondary data from the 2008 Ghana Demographic and Health Survey based on an analytical sample of 4821 females (15-49 years) and 4568 males (15-59 years) were analysed using descriptive, bivariate and multivariate methods. Concentration curves and indices were used to examine equity in coverage on the NHIS. RESULTS: As at 2008, more than 60% of Ghanaians aged 15-59 years were not covered under the NHIS with slightly more females (38.9%) than males (29.7%) covered. Coverage was highest among the highly educated, professionals, those from households in the richest wealth quintile and urban residents. Lack of coverage was most concentrated among the poor. CONCLUSIONS: Universal coverage under the NHIS is far from being achieved with marked exclusion of the poor. There is the need for deliberate action to enrol the poor under the NHIS.

The Local Food Environment and Body Mass Index among the Urban Poor in Accra, Ghana.

Obesity in the sub-Saharan Africa region has been portrayed as a problem of affluence, partly because obesity has been found to be more common in urban areas and among the rich. Recent findings, however, reveal rising prevalence among the poor particularly the urban poor. A growing body of literature mostly in Western countries shows that obesity among the poor is partly the result of an obesogenic-built environment. Such studies are lacking in the African context. This study examines the characteristics of the local food environment in an urban poor setting in Accra, Ghana and further investigates the associated risk of obesity for residents. Data on the local food environment was collected using geographic positioning system (GPS) technology. The body mass indices (BMI) of females (15-49 years) and males (15-59 years) were calculated from measured weight and height. Data on the socio-demographic characteristics and lifestyle behaviors of respondents was also collected through a household survey. Spatial analysis tools were used to examine the characteristics of the local food environment while the influence of the food environment on BMI was examined using a two-level multilevel model. The measures of the food environment constituted the level 2 factors while individual socio-demographic characteristics and lifestyle behaviors constituted the level 1 factors. The local food environment in the study communities is suggestive of an obesogenic food environment characterized by an abundance of out-of-home cooked foods, convenience stores, and limited fruits and vegetables options. The results of the multilevel analysis reveal a 0.2 kg/m(2) increase in BMI for every additional convenience store and a 0.1 kg/m(2) reduction in BMI for every out-of-home cooked food place available in the study area after controlling for individual socio-demographic characteristics, lifestyle behaviors, and community characteristics. The findings of this study indicate that the local food environment in urban poor Accra is associated with increased risk of obesity through providing access to convenience stores. In order to reduce the risk of obesity in these urban poor communities, there is the need to regulate the availability of and access to convenience stores while also encouraging healthier offerings in convenience stores.

Recreation, transportation or labour saving? Examining the association between household asset ownership and body mass index among Ghanaian women.

BACKGROUND: In most of the developing world, ownership of modern household assets such as television sets, refrigerators, microwave ovens and washing machines is becoming common. Ownership of these household assets, however, promotes sedentary behaviour which has implications for obesity and non-communicable disease conditions such as hypertension, diabetes, stroke and other cardiovascular conditions. Additionally, increased household asset ownership is an indicator of socio-economic status and is also associated with obesity promoting dietary behaviours especially in urban areas. Very few studies have examined the relationship between household asset ownership and obesity in sub-Saharan Africa where asset ownership is becoming a norm. This paper examined the relationship between ownership of different types of household assets and Body Mass Index (BMI) among a nationally representative sample of Ghanaian women. METHODS: The study analysed secondary data from the 2008 Ghana Demographic and Health Survey (GDHS) involving a total of 4916 women aged 15-49 years. The analytical sample consist of 4010 (weighted sample) non-pregnant females who had valid data on all the variables used in the analyses. The BMI of the women was used as the dependent variable with three categories of normal weight, overweight and obese based on the standard World Health Organization (WHO) classifications. Multinomial logistic regression models were specified to examine the relationship between ownership of household assets and BMI. RESULTS: Obesity was more common among women whose household owned a television-15.60 %, DVD/VCD-18.58 %, computer-20.70 %, refrigerator-17.16 % and washing machine-27.43 %, but less common among women whose household owned a motorcycle/scooter-7.74 % and a bicycle-7.92 %. Household ownership of DVD was significantly associated with increased odds of obesity (OR = 1.59, P < 0.01) while ownership of a motor cycle/scooter (OR = 2.05, P <0.001), a refrigerator (OR = 1.33, P < 0.05), and a television set (OR = 1.27, P < 0.10) were associated with higher odds of overweight. Ownership of each additional household asset was also associated with 15 % and 25 % higher odds of overweight and obesity respectively. CONCLUSION: The findings indicate that at least one asset among the various domains of household assets examined is associated with either overweight or obesity among Ghanaian women. Also, increased household asset ownership is associated with increased odds of overweight and obesity. Interventions that aim at reducing sedentary and unhealthy dietary behaviours in the phase of increasing asset ownership maybe helpful in addressing the rising prevalence of obesity among Ghanaian women.

Where do Overweight Women in Ghana Live? Answers from Exploratory Spatial Data Analysis.

Contextual influence on health outcomes is increasingly becoming an important area of research. Analytical techniques such as spatial analysis help explain the variations and dynamics in health inequalities across different context and among different population groups. This paper explores spatial clustering in body mass index among Ghanaian women by analysing data from the 2008 Ghana Demographic and Health Survey using exploratory spatial data analysis techniques. Overweight was a more common occurrence in urban areas than in rural areas. Close to a quarter of the clusters in Ghana, mostly those in the southern sector contained women who were overweight. Women who lived in clusters where the women were overweight were more likely to live around other clusters where the women were also overweight. The results suggest that the urban environment could be a potential contributing factor to the high levels of obesity in urban areas of Ghana. There is the need for researchers to include a spatial dimension to obesity research in Ghana paying particular attention the urban environment.

Healthy lifestyle behaviour among Ghanaian adults in the phase of a health policy change.

BACKGROUND: Many countries have adopted health policies that are targeted at reducing the risk factors for chronic non-communicable diseases. These policies promote a healthy population by encouraging people to adopt healthy lifestyle behaviours. This paper examines healthy lifestyle behaviour among Ghanaian adults by comparing behaviours before and after the introduction of a national health policy. The paper also explores the socio-economic and demographic factors associated with healthy lifestyle behaviour. METHOD: Descriptive, bivariate and multivariate regression techniques were employed on two nationally representative surveys (2003 World Health Survey (Ghana) and 2008 Ghana Demographic and Health Survey) to arrive at the results. RESULTS: While the prevalence of some negative lifestyle behaviours like smoking has reduced others like alcohol consumption has increased. Relatively fewer people adhered to consuming the recommended amount of fruit and vegetable servings per day in 2008 compared to 2003. While more females (7.0%) exhibited healthier lifestyles, more males (9.0%) exhibited risky lifestyle behaviours after the introduction of the policy. CONCLUSION: The improvement in healthy lifestyle behaviours among female adult Ghanaians will help promote healthy living and potentially lead to a reduction in the prevalence of obesity among Ghanaian women. The increase in risky lifestyle behaviour among adult male Ghanaians even after the introduction of the health policy could lead to an increase in the risk of non-communicable diseases among men and the resultant burden of disease on them and their families will push more people into poverty.

Sociodemographic correlates of obesity among Ghanaian women.

OBJECTIVE: To examine the sociodemographic correlates of obesity among Ghanaian women. DESIGN: The 2003 and 2008 Ghana Demographic and Health Survey data sets were used to examine the sociodemographic characteristics and the BMI of women aged 15-49 years using descriptive statistics, bivariate and multivariate analyses. SETTING: Ghana is a West African country which is divided into ten administrative regions. The country is further divided into the northern and southern sectors. The northern sector includes the three northern regions (Northern, Upper East and Upper Westen regions) and the seven remaining regions form the southern sector. SUBJECTS: Women aged 15-49 years whose BMI values were available. RESULTS: The overall prevalence of obesity and overweight increased from 25·5 % in 2003 to 30·5 % in 2008. Obesity varied directly with age from 20 to 44 years. Women with higher education had the highest rate of obesity. Obesity was more common among women from wealthy households compared to women from poor households. CONCLUSIONS: Obesity and overweight were found to be more common among older women, urban women, married women, women with higher education and women from rich households. Adoption of healthy lifestyles and the implementation of policies that promote healthy living can help reduce the prevalence of overweight and obesity.