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

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 A limitation of our study was that the 2010 census dataset used for predicting small area variations is potentially outdated; the results should be updated when the next census data are available, to the contemporary population, and changes over time should be evaluated.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

Breast cancer treatment and outcomes at Cape Coast Teaching Hospital, Ghana.

Objectives: This study sought to determine the presentation, treatment and outcomes of breast cancer among women in Cape Coast, Ghana. Design: Retrospective medical record review. Setting: Cape Coast Teaching Hospital, Cape Coast, Ghana. Participants: Female breast cancer patients. Interventions: None. Main outcome measures: Proportion of female breast cancer patients presenting with advanced disease. Results: Approximately 84% of women had a primary presentation of breast cancer, with metastatic disease present in 34% of patients. Surgical management mainly involved partial mastectomy (21.7%) and total mastectomy (78.6%), with the most common postoperative complications being surgical site infections (3.8%). Non-surgical management involved chemotherapy, radiation therapy and anti-estrogen therapy, with Stage 3 and 4 patients twofold more likely to receive neoadjuvant chemotherapy than earlier stages (OR= 2.0 95% CI (1.4, 3.0, p<0.001). Grade 1 cancers were diagnosed in 11.0%, Grade 2 in 43.8%, and Grade 3 in 45.2%. The mean cancer size was 6.5 centimetres (range 1.5 to 20.0). Lymphatic vascular invasion was present in 59/125 (47.2%), estrogen receptor status was positive in 32.6%, progesterone receptors were positive in 22.1%, and Her-2/neu was positive in 32.6%. Triple-negative breast cancer was identified in 41/89 (46.1%). Conclusions: Women with breast cancer typically present to the Cape Coast Teaching Hospital with advanced stage disease and experience poor outcomes. Funding: Funding for this study was provided by the Harvard Medical School Scholars in Medicine.

A disease burden analysis of garment factory workers in Bangladesh: proposal for annual health screening.

Background: To characterize the health status of selected garment and textile factory workers in Bangladesh using a workplace mobile health clinic. Methods: A retrospective review of de-identified worker health information was performed using 1906 medical records. Results: The mean age of the workers was 27.9±7.3 y, with 60.3% (1150/1906) female and 39.7% (756/1906) male workers. The most common medical conditions identified were anemia (19.0%; 362/1906), elevated BP (EBP) (11.9%; 226/1906) and elevated fasting blood glucose (FBG) (8.0%; 151/1906). Among the workers who had EBP, 86.3% (195/226) were previously undiagnosed, while out of the workers with elevated FBG, 72.8% (110/151) were newly diagnosed. Men were more likely than women to have EBP (OR 3.5, 95% CI [2.12-5.56], p<0.001), a family history of diabetes (OR 3.6, 95% CI [2.1-5.9], p<0.001) and no formal education (OR 4.9, 95% CI [3.6-6.7], p<0.001). Conclusions: Despite the relatively young mean age, significant percentages of workers were identified as having undiagnosed chronic health conditions, including EBP and elevated FBG, that require urgent medical attention and health education. The findings suggest that provision for annual health screening, either by mobile on-site clinics or by training the existing in-house paramedics, will help improve health of the factory workers.

Perception of risk for hypertension and overweight/obesity in Cape Coast, Ghana.

BACKGROUND: This study examined the association between perception of risk for hypertension and overweight/obesity. DESIGN: Cross-sectional questionnaire-based survey. SETTING: Out-patient department of the Central Regional Hospital in Cape Coast, Ghana. PARTICIPANTS: Adult men and women at least 18 years old. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Perception of risk for hypertension, overweight/obesity. RESULTS: About 39% of the participants (N=400) were found to be overweight/obese, with disproportionally higher rates among women (50%) than men (28%). Results of the binary logistic regression models revealed a strong positive association (OR = 2.21, 95% CI =1.23, 3.96) between perception of risk for hypertension and overweight/obesity. Increasing age, high television exposure, female gender and being in a relationship were also noted to be associated with overweight/obesity. CONCLUSIONS: These findings highlight the need for the design of programmes to help individuals appreciate the reality of weight-related health risks, as well as the need to embrace lifestyles that promote healthy weight outcomes. FUNDING: Harvard Medical School Travelling Fellowship, Scholars in Medicine Office, Harvard Medical School.

Teaching rural women in Nicaragua the principles of breast health.

Breast cancer has emerged as an important health condition worldwide, including developing countries. Screening is limited or non-existent in resource-poor areas. The purpose of this study was to assess knowledge, attitudes, and practices of self (SBE) and clinical (CBE) breast examinations among 198 rural Nicaraguan women. Ten (5.1%) had performed a SBE, and 16 (8.1%) had a CBE. CBE was significantly associated with a pre-instruction total score of 70% or greater (OR = 13.7, 95% CI = 1.26, 149.70, p = 0.03). Family history of breast cancer was significantly associated with performing a SBE (OR = 5.5, 95% CI = 1.10, 27.81, p = 0.037) and a CBE (OR = 7.1, 95% CI = 1.40, 35.94, p = 0.018). A CBE is a significant determinant of pre-existing breast health knowledge. Physicians or physician extenders should be encouraged to perform a CBE as a routine component of health care delivery and cancer screening for women.

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

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

Contraceptive use by women in Accra, Ghana: results from the 2003 Accra women's health survey

The study was to determine the predictors of use of modern contraception among women in Accra, Ghana. Data were collected by trained interviewers using questionnaires. Complete data for 2199 women were analysed using Stata 8.2. The study showed that educational status was the most significant predictor of contraceptive use. Women with no formal education had a 48% reduction in the odds of having ever used contraception and a 66% reduction in the odds of currently using contraception. Regular use of health facilities did not affect contraceptive use. Female education should continue to be a priority of the Ghanaian government. Education about family planning and the effects of having large families should be integrated into the school curriculum. Ghanaian health workers need to be active in promoting the use of modern contraceptive methods (Afr J Reprod Health 2009; 13[1]:123-133)

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

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

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

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

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

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

Recommendation recall and satisfaction after attending breast/ovarian cancer risk counseling.

This study examined women's recall of physician recommendations as well as patient satisfaction following participation in a breast/ovarian cancer risk and prevention program. Participants were 41 high risk women who attended a cancer risk program 4-6 months earlier. Two-thirds of women who received recommendations for tamoxifen treatment and genetic testing did not recall these recommendations upon follow-up. A number of women misunderstood recommendations and a quarter of the sample recalled recommendations that were not made during the consultation. Although these high risk women were generally satisfied with their counseling visit, those individuals who received particularly complex sets of recommendations reported feeling less understood and were less satisfied with the counseling. Findings underline the importance of examining recommendation recall, in addition to perceptions of cancer risk, when evaluating the clinical implications of cancer risk assessment.

Results of the Women's Health Study of Accra: assessment of blood pressure in urban women.

BACKGROUND: The Women's Health Study of Accra was conducted to determine the burden of illness in a representative sampling of adult urban women. METHODS: This community-based survey selected study participants by a 2-stage cluster probability sample stratified by socioeconomic status based on the 2000 Ghanaian census data. It included a comprehensive household survey and medical and laboratory examination for 1328 women. Hypertension was defined as systolic blood pressure measurement > or = 140 mmHg or a diastolic of > or = 90 mmHg. RESULTS: A positive review of systems for hypertension was reported in 309 (23.7%) with only 52.5% using anti-hypertensive medication and only 4.4% had a normal blood pressure. The blood pressure measurement was elevated in 712/1303 (54.6%). Significant risk factors for an elevated blood pressure included age > or = 50 years (OR=14.24 [10.74,18.8], p<0.001); BMI > or = 30.00 (OR=2.89 [2.26,3.70], p<0.001); parity of three or more children (OR=5.16 [2.90,9.19], p<0.001); menopause before age 50 years (OR=5.88 [1.11,31.17], p=0.037); elevated fasting blood glucose (OR=3.98 [2.38,6.64], p<0.001); elevated fasting cholesterol (OR=1.69 [1.24, 2.30], p=0.001); no formal education (OR=2.75 [1.70,4.43], p<0.001) and first degree family history of hypertension (p<0.001). There was no association with income level, diet or activity. Significant protective factors include young age, nulliparity, normal BMI, and a lower than normal fasting LDL-cholesterol. CONCLUSION: The prevalence of presumptive hypertension is greater than anticipated. Public health initiatives to increase awareness of hypertension and to initiate and maintain treatment regimens will serve to improve the health of the women and the urban community.

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

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

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

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

Decision-making about tamoxifen in women at high risk for breast cancer: clinical and psychological factors.

PURPOSE: To explore the health-related and psychological factors that influence decision making about tamoxifen (Nolvadex; AstraZeneca, Waltham, MA) chemoprevention in women at increased risk for developing breast cancer. METHODS: This study involves the assessment of 129 women eligible to take tamoxifen following cancer-risk counseling. Treatment decision and decision satisfaction were measured at 2 and 4 months following counseling. Health-related factors included physician recommendation, personal and family-related health history, and concern about side effects. Psychological factors included breast cancer-related anxiety, risk perception, and depression. RESULTS: At 2 months' follow-up, 44% of participants declined tamoxifen treatment. This number increased to 49% at 4 months. Personal and family health history were not related to the decision, but history of abnormal biopsy did predict tamoxifen use. Physician recommendation was highly correlated with treatment decision. Concern about side effects was related to the decision to decline treatment. Breast cancer-related anxiety and heightened risk perception were associated with the decision to take tamoxifen. However, anxiety and psychological distress were also negatively related to treatment satisfaction. CONCLUSION: Decision-making about tamoxifen is complex, and many eligible women decline treatment or remain undecided. Findings call for further educational follow-up with high-risk women after they undergo initial counseling. Factors related to misperceptions of risk and side effects, as well as psychological distress, may be particularly important targets for intervention.

BRCA1 shifts p53-mediated cellular outcomes towards irreversible growth arrest.

The tumor suppressor protein BRCA1 has been shown to enhance p53 transcription, whereas activated p53 represses BRCA1 transcription. To further understand the functional interaction of these proteins, we investigated the role of BRCA1 in p53-induced phenotypes. We found that BRCA1 when subjected to forced expression acts synergistically with wild-type p53, resulting in irreversible growth arrest, as shown by VhD mouse fibroblast cells expressing a temperature-sensitive mutant of p53. Furthermore, reintroduction of both BRCA1 and p53 into BRCA1(-/-)/p53(-/-) mouse embryonic fibroblasts markedly increased the senescence phenotype compared to that induced by p53 alone. In particular, we found that BRCA1 expression attenuated p53-mediated cell death in response to gamma-irradiation. Moreover, microarray screening of 11 000 murine genes demonstrated that a set of genes upregulated by p53 is enhanced by coexpression of BRCA1 and p53, suggesting that BRCA1 and p53 exert a promoter selectivity leading to a specific phenotype. Taken together, our results provide evidence that BRCA1 is involved in p53-mediated growth suppression rather than apoptosis.