Implementing a national non-communicable disease policy in sub-Saharan Africa: Experiences of key stakeholders in Ghana.

Introduction: Comprehensive national non-communicable disease (NCD) policy development and implementation are crucial for preventing and controlling the increasing NCD burden, particularly in the Africa region where the largest increase in NCD related mortality is expected by 2030. Yet, even where national NCD policies exist, effective implementation remains hindered for reasons not clearly elucidated. This study explored the experiences of key health stakeholders at national and sub-national levels with implementing a national NCD policy in Ghana. Methods: This was an explanatory, cross-sectional and grounded theory study using in-depth interview guides to collect primary data from 39 purposively sampled health policymakers and implementing officials at the national and sub-national levels in Ghana. A thematic approach was used in data analysis. Results: Several interwoven factors including poor policy awareness, poor coordination and intersectoral engagements and inadequate funding for NCD programs and activities are key challenges thwarting the effective implementation of the national NCD policy in Ghana. At the sub-national levels, inadequate clarity and structure for translating policy into action and inadequate integration further affect operationalizing of the national NCD policy. Conclusion: The findings call for policymakers to adopt a series of adaptive measures including sustainable NCD financing mechanisms, effective intersectoral coordination, policy sensitisation and capacity building for implementing health professionals, which should be coupled with governmental and global resource investment in effective implementation of national NCD policies to make sustained population level gains in NCD control in Ghana and in other resource constrained settings.

Illness representations and coping practices for self-managing hypertension among sub-Saharan Africans: A comparative study among Ghanaian migrants and non-migrant Ghanaians.

OBJECTIVE: Hypertension (HTN) control is a major obstacle among sub-Saharan African populations partly due to poor self-management. We explored and compared how persons' social and physical context shapes their illness representations regarding HTN and the coping strategies they develop and adapt to mitigate challenges in self-managing HTN. METHODS: A cross sectional multisite qualitative study using semi-structured interviews among 55 Ghanaians with HTN living in The Netherlands and urban and rural Ghana. A thematic approach was used in data analysis. RESULTS: Family HTN history, personal experiences with HTN and outcomes of using biomedical and traditional treatments shaped participants' illness representations and coping strategies. Migrants and urban non-migrants modified medication schedules and integrated taking medication into daily routine activities to cope with experienced side effects of taking antihypertensive medication while rural non-migrants used traditional remedies and medicines to mitigate experienced medication side effects and/or in search for a cure for HTN. CONCLUSION: Contextual factors within participants' social and physical environments shape their illness representations and coping strategies for HTN though interactive phrases. PRACTICE IMPLICATIONS: Health professionals should harness the relationships within peoples' social and physical environments, encourage implementation of family-wide behavioural changes and involve family and communities in HTN treatment to enhance patients' self-management of HTN.

Is social support associated with hypertension control among Ghanaian migrants in Europe and non-migrants in Ghana? The RODAM study.

Hypertension (HTN) control is crucial in preventing HTN-related complications such as stroke and coronary heart disease. Yet, HTN control remains suboptimal particularly among sub-Saharan African (SSA) populations partly due to poor self-management. Self-management of HTN is influenced by social support, but the evidence on the role of social support on HTN control particularly among SSA populations is limited. This study assessed the association between multiple proxies for social support and HTN control among Ghanaians resident in Ghana and Europe. The Research on Obesity and Diabetes among African Migrants (RODAM) study participants with HTN and who self-reported HTN (n = 1327) were included in this analysis. Logistic regression was used to assess the association between proxies of social support and HTN control (SBP < 140 mmHg and DBP < 90 mmHg) with adjustments for age and socioeconomic status (SES). Among Ghanaian males in both Europe and Ghana, cohabiting with more than two persons was associated with increased odds of having HTN controlled. Male hypertensive patients cohabiting with ≥ 5 persons had the highest odds of having HTN controlled after adjustment for age and SES (OR 0.30; 95% CI 0.16-0.57; 0.60; 0.34-1.04, respectively). This association was not observed among females. Relationship status, frequency of religious activity attendance and satisfaction with social support did not show any significant association with HTN control. Our study shows that cohabitation is significantly associated with HTN control but in males only. The other proxies for social support appeared not to be associated with HTN control. Involving persons living with Ghanaian men with HTN in the treatment process may help to improve adherence to HTN treatment. Further research is needed to explore in-depth, how these social support proxies could contribute to improved HTN control among SSA populations.

Lay community perceptions and treatment options for hypertension in rural northern Ghana: a qualitative analysis.

OBJECTIVE: Adherence to hypertension treatment is a major public health challenge for low and middle-income countries particularly in sub-Saharan Africa. One potential reason could be the discordance between lay and medical explanatory models of hypertension and its treatment. Understanding community perceptions and practices may contribute to improving hypertension control as they present insights into psychosocial and cultural factors that shape individual behaviour. We explore community perceptions regarding hypertension and its treatment in rural northern Ghana and how they differ from medical understanding. DESIGN: This was a qualitative study using semi-structured interviews and focus group discussions to collect data, which were analysed using a thematic approach. SETTING: A multisite study conducted in four rural communities in two regions of northern Ghana. PARTICIPANTS: We conducted 16 semi-structured interviews and eight focus group discussions with community leaders and members, respectively. RESULTS: Three major themes were identified: community perceptions, treatment options and community support for people with hypertension. Community perceptions about hypertension include hypertension perceived as excess blood in the body and associated with spiritual or witchcraft attacks. Traditional medicine is perceived to cure hypertension completely with concurrent use of biomedical and traditional medicines encouraged in rural communities. Community members did not consider themselves at risk of developing hypertension and reported having inadequate information on how to provide social support for hypertensive community members, which they attributed to low literacy and poverty. CONCLUSION: There is a substantial mismatch between communities' perceptions and medical understanding of hypertension and its treatment. These perceptions partly result from structural factors and social norms shaped by collective processes and traditions that shape lay beliefs and influence individual health behaviour. Socioeconomic factors also thwart access to information and contribute to inadequate social support for persons with hypertension. These findings highlight the need for a public health approach to hypertension control targeting families and communities.

Fertility regulation as identity maintenance: Understanding the social aspects of birth control.

We take a dialogical approach to exploring fertility regulation practices and show how they can maintain or express social identity. We identify three themes in educated Ghanaian women's accounts of how they navigate conflicting social demands on their identity when trying to regulate fertility: secrecy and silence - hiding contraception use and avoiding talking about it; tolerating uncertainty - such as using unreliable but more socially acceptable contraception; and wanting to be fertile and protecting menses. Family planning programmes that fail to tackle such social-psychological obstacles to regulating fertility will risk reproducing social spaces where women struggle to claim their reproductive rights.

Tracing Africa's progress towards implementing the Non-Communicable Diseases Global action plan 2013-2020: a synthesis of WHO country profile reports.

BACKGROUND: Half of the estimated annual 28 million non-communicable diseases (NCDs) deaths in low- and middle-income countries (LMICs) are attributed to weak health systems. Current health policy responses to NCDs are fragmented and vertical particularly in the African region. The World Health Organization (WHO) led NCDs Global action plan 2013-2020 has been recommended for reducing the NCD burden but it is unclear whether Africa is on track in its implementation. This paper synthesizes Africa's progress towards WHO policy recommendations for reducing the NCD burden. METHODS: Data from the WHO 2011, 2014 and 2015 NCD reports were used for this analysis. We synthesized results by targets descriptions in the three reports and included indicators for which we could trace progress in at least two of the three reports. RESULTS: More than half of the African countries did not achieve the set targets for 2015 and slow progress had been made towards the 2016 targets as of December 2013. Some gains were made in implementing national public awareness programmes on diet and/or physical activity, however limited progress was made on guidelines for management of NCD and drug therapy and counselling. While all regions in Africa show waning trends in fully achieving the NCD indicators in general, the Southern African region appears to have made the least progress while the Northern African region appears to be the most progressive. CONCLUSION: Our findings suggest that Africa is off track in achieving the NCDs indicators by the set deadlines. To make sustained public health gains, more effort and commitment is urgently needed from governments, partners and societies to implement these recommendations in a broader strategy. While donors need to suit NCD advocacy with funding, African institutions such as The African Union (AU) and other sub-regional bodies such as West African Health Organization (WAHO) and various country offices could potentially play stronger roles in advocating for more NCD policy efforts in Africa.

Improving the Measurement of Fertility Regulation Practices: Findings from Qualitative Research in Ghana.

CONTEXT: According to Demographic and Health Survey (DHS) data, highly educated urban women in some West African countries simultaneously have low rates of both contraceptive use and fertility-suggesting that the DHS may not be capturing a complete picture of women's contraceptive practices. METHODS: Individual in-depth interviews and focus group discussions were conducted with a total of 48 women aged 18-49 in Accra, Ghana, who had at least a secondary education to explore their reproductive lives and relationships, and their views on and use of fertility regulation strategies. Data were analyzed using iterative thematic techniques. RESULTS: Women commonly reported using combinations of contraceptive methods, including "counting days" (using a calendar and the date of one's last menstrual period to estimate "unsafe" days-those on which the risk of conception is high), as well as withdrawal, condoms and frequent use of emergency contraceptive pills. Women described practicing "periodic contraception": for example, counting days to determine unsafe days and practicing contraception ad hoc on such days. Method use combinations varied from cycle to cycle-forming a "mosaic" of method use combinations over time. CONCLUSIONS: The fertility control strategies commonly reported by the study respondents-periodic contraception, and frequent use of traditional methods and emergency contraceptive pills-are likely not adequately captured in general surveys such as the DHS. Such surveys are also not well suited to measuring combinations of methods and mosaics of method combinations. New ways of capturing women's fertility regulation practices should be considered, including additional survey items, new question modules and specialist studies.