Ama de-Graft Aikins

Epidemiological Transition and the Double Burden of Disease in Accra, Ghana

It has long been recognized that as societies modernize, they experience significant changes in their patterns of health and disease. Despite rapid modernization across the globe, there are relatively few detailed case studies of changes in health and disease within specific countries especially for sub-Saharan African countries. This paper presents evidence to illustrate the nature and speed of the epidemiological transition in Accra, Ghana’s capital city. As the most urbanized and modernized Ghanaian city, and as the national center of multidisciplinary research since becoming state capital in 1877, Accra constitutes an important case study for understanding the epidemiological transition in African cities. We review multidisciplinary research on culture, development, health, and disease in Accra since the late nineteenth century, as well as relevant work on Ghana’s socio-economic and demographic changes and burden of chronic disease. Our review indicates that the epidemiological transition in Accra reflects a protracted polarized model. A “protracted” double burden of infectious and chronic disease constitutes major causes of morbidity and mortality. This double burden is polarized across social class. While wealthy communities experience higher risk of chronic diseases, poor communities experience higher risk of infectious diseases and a double burden of infectious and chronic diseases. Urbanization, urban poverty and globalization are key factors in the transition. We explore the structures and processes of these factors and consider the implications for the epidemiological transition in other African cities.

Tackling Africa's chronic disease burden: from the local to the global

Africa faces a double burden of infectious and chronic diseases. While infectious diseases still account for at least 69% of deaths on the continent, age specific mortality rates from chronic diseases as a whole are actually higher in sub Saharan Africa than in virtually all other regions of the world, in both men and women. Over the next ten years the continent is projected to experience the largest increase in death rates from cardiovascular disease, cancer, respiratory disease and diabetes. African health systems are weak and national investments in healthcare training and service delivery continue to prioritise infectious and parasitic diseases. There is a strong consensus that Africa faces significant challenges in chronic disease research, practice and policy. This editorial reviews eight original papers submitted to a Globalization and Health special issue themed: Africas chronic disease burden: local and global perspectives. The papers offer new empirical evidence and comprehensive reviews on diabetes in Tanzania, sickle cell disease in Nigeria, chronic mental illness in rural Ghana, HIV/AIDS care-giving among children in Kenya and chronic disease interventions in Ghana and Cameroon. Regional and international reviews are offered on cardiovascular risk in Africa, comorbidity between infectious and chronic diseases and cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe. We discuss insights from these papers within the contexts of medical, psychological, community and policy dimensions of chronic disease. There is an urgent need for primary and secondary interventions and for African health policymakers and governments to prioritise the development and implementation of chronic disease policies. Two gaps need critical attention. The first gap concerns the need for multidisciplinary models of research to properly inform the design of interventions. The second gap concerns understanding the processes and political economies of policy making in sub Saharan Africa. The economic impact of chronic diseases for families, health systems and governments and the relationships between national policy making and international economic and political pressures have a huge impact on the risk of chronic diseases and the ability of countries to respond to them.

Cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe: a literature review

BackgroundMost European countries are ethnically and culturally diverse. Globally, cardiovascular disease (CVD) is the leading cause of death. The major risk factors for CVD have been well established. This picture holds true for all regions of the world and in different ethnic groups. However, the prevalence of CVD and related risk factors vary among ethnic groups.MethodsThis article provides a review of current understanding of the epidemiology of vascular disease, principally coronary heart disease (CHD), stroke and related risk factors among populations of Sub-Sahara African descent (henceforth, African descent) in comparison with the European populations in Europe.ResultsCompared with European populations, populations of African descent have an increased risk of stroke, whereas CHD is less common. They also have higher rates of hypertension and diabetes than European populations. Obesity is highly prevalent, but smoking rate is lower among African descent women. Older people of African descent have more favourable lipid profile and dietary habits than their European counterparts. Alcohol consumption is less common among populations of African descent. The rate of physical activity differs between European countries. Dutch African-Suriname men and women are less physically active than the White-Dutch whereas British African women are more physically active than women in the general population. Literature on psychosocial stress shows inconsistent results.ConclusionHypertension and diabetes are highly prevalent among African populations, which may explain their high rate of stroke in Europe. The relatively low rate of CHD may be explained by the low rates of other risk factors including a more favourable lipid profile and the low prevalence of smoking. The risk factors are changing, and on the whole, getting worse especially among African women. Cohort studies and clinical trials are therefore needed among these groups to determine the relative contribution of vascular risk factors, and to help guide the prevention efforts. There is a clear need for intervention studies among these populations in Europe.

Rethinking health-care systems: a focus on chronicity

450 www.thelancet.com Vol 377 February 5, 2011 Health-care systems, including those in countries of the Organisation for Economic Co-operation and Development, face a crisis of an increasing burden of chronic disease aggravated by ageing populations and complicated by the continuing risks of infectious diseases and global pandemics. The issues for health-care systems in low-income and middle-income countries are compounded by persistent diseases of poverty, and the inadequately understood comorbidities of both infectious and noncommunicable diseases. The structure of health-care systems refl ects an underlying understanding of health and disease in which acute episodes result in help-seeking, with the expected outcome of a cure or death. In this model, chronic conditions are treated as serial acute episodes with multiple interactions with the health-care system. As the capacity to manage acute phases of chronic conditions improves, disease prevalence rises, resulting in a fi nancial burden that will begin to dwarf costs in other parts of the health system. For example, Uganda, supported by international aid, has achieved 16% coverage of its HIV-positive population with highly active antiretroviral therapy (HAART), moving the treated few from the category of acute to chronic. The expectation follows of a lifelong commitment to the already treated few, with an implicit promise to manage the remaining 84% as funds become available. Without ongoing global health funding, and in view of the cost of HAART and the cost to the health system of lifelong treatment, it is hard to imagine that this situation will be sustainable. Similarly, the cost of diabetes care per patient in Cameroon was US

Developing effective chronic disease interventions in Africa: insights from Ghana and Cameroon.

489 per year in 2002. This cost exceeds the annual per head income by 1·5 times, and exceeds the per-head governmental health spending by around 50 times. Cameroon is not alone with emerging evidence of a diabetes epidemic across many of the poorest countries in sub-Saharan Africa. In essence, as the technology to lengthen the lives of those with chronic conditions is developed, the fi xed costs of the health system increase. The fi nancial burden will necessitate socially and politically uncomfortable trade-off s. The current focus on health systems is therefore timely. However, discussions to date largely centre on delivering the familiar model of acute-centric care, albeit with some concentration on tackling the weaknesses in the six key components of health systems: service delivery, fi nance, governance, technologies, workforce, and information. Other issues under discussion include the need for universal coverage and equity. These issues are placed within the broader context of systems needed to deliver vertical disease-focused programmes for infectious and noncommunicable diseases. Although this approach might be appropriate for acute conditions, and arguably for higher-income countries, it is unaff ordable and unsustainable with the increasing burden of chronic disease in lowerincome and middle-income countries. And although reducing the burden of chronic diseases in younger and middle-aged people might succeed, the increasing burden of chronic conditions is an inescapable reality of ageing populations. The challenge for health-care systems is to explore and address the implications of chronicity which capture the complexity of addressing disease conditions—regardless of cause—characterised by long duration and often slow progression. Chronicity has wide-ranging implications for, among other things: health promotion and preventive strategies that address risk factors; fi nancing and planning of health-care systems; training of the health workforce; and the nature and location of health infrastructure. Chronicity provides a framework for exploring an Co bi s Published Online November 11, 2010 DOI:10.1016/S01406736(10)61856-9

Living with Diabetes in Rural and Urban Ghana: A Critical Social Psychological Examination of Illness Action and Scope for Intervention

BackgroundAfrica faces an urgent but neglected epidemic of chronic disease. In some countries stroke, hypertension, diabetes and cancers cause a greater number of adult medical admissions and deaths compared to communicable diseases such as HIV/AIDS or tuberculosis. Experts propose a three-pronged solution consisting of epidemiological surveillance, primary prevention and secondary prevention. In addition, interventions must be implemented through multifaceted multi-institutional strategies that make efficient use of limited economic and human resources. Epidemiological surveillance has been prioritised over primary and secondary prevention. We discuss the challenge of developing effective primary and secondary prevention to tackle Africas chronic disease epidemic through in-depth case studies of Ghanaian and Cameroonian responses.MethodsA review of chronic disease research, interventions and policy in Ghana and Cameroon instructed by an applied psychology conceptual framework. Data included published research and grey literature, health policy initiatives and reports, and available information on lay community responses to chronic diseases.ResultsThere are fundamental differences between Ghana and Cameroon in terms of multi-institutional and multi-faceted responses to chronic diseases. Ghana does not have a chronic disease policy but has a national health insurance policy that covers drug treatment of some chronic diseases, a culture of patient advocacy for a broad range of chronic conditions and mass media involvement in chronic disease education. Cameroon has a policy on diabetes and hypertension, has established diabetes clinics across the country and provided training to health workers to improve treatment and education, but lacks community and media engagement. In both countries churches provide public education on major chronic diseases. Neither country has conducted systematic evaluation of the impact of interventions on health outcomes and cost-effectiveness.ConclusionsBoth Ghana and Cameroon require a comprehensive and integrative approach to chronic disease intervention that combines structural, community and individual strategies. We outline research and practice gaps and best practice models within and outside Africa that can instruct the development of future interventions.

Homelessness and mental health in Ghana: everyday experiences of Accra’s migrant squatters

Current chronic illness research in Africa neglects the social psychological dimensions of illness experiences that present more appropriate frameworks for intervention. Informed by social representations theory, links between social knowledge of diabetes, illness experience and illness action were examined through semistructured individual interviews with rural and urban Ghanaians with diabetes. All respondents drew interchangeably from commonsense, scientized, and religious knowledge modalities in defining health, illness and diabetes. Diabetes caused disruption to: body-self, social identity, family/social relationships, economic circumstance and nutrition. Commonsense and scientized notions of health, illness and diabetes framed illness action goals that merged with biomedical goals, specifically drug and diet management. These goals were compromised by the nature, severity and duration of disruption(s) and emotional responses evoked. The paper dicusses implications of the findings and outlines recommendations for interventions that span individual/group, community and structural dimensions.

Health, Disease and Healthcare in Africa

This article discusses everyday experiences of transient homelessness in Ghanas capital, Accra. Episodic interviews with individuals living in squatter settlements in the wealthy East Legon suburb explored: (1) roots of homelessness; (2) everyday experiences and coping strategies; (3) relationship between experiences and (mental) health; (4) needs and interventions. Three intersecting forms of insecurity framed participants everyday experience: financial, legal and psychosocial. Physical and psychological stresses were common; physical illnesses rare. Coping strategies facilitated adaptation but not transformation of everyday circumstances. We explore possibilities for intervention and discuss relevance of this study to the health psychology and African literatures on homelessness.

Explanatory models of diabetes in urban poor communities in Accra, Ghana

This editorial introduction to `Health, disease and healthcare in Africa addresses some of the key issues for health psychology in the continent. African populations face a health crisis driven by a double burden of disease, a nutrition transition, war and conflict, and poverty. Health systems are under-funded and underresourced. Research suggests that the most prevalent diseases in Africa are preventable and treatable, and that most deaths are avoidable. Health practices and systems that may aid equitable, cost-effective and sustainable healthcare exist but remain untapped. We advocate a reflective, action-oriented health psychology that challenges social injustice and racism, and develops strategies that promote more just and healthy societies.

Culture, ethnicity and chronic conditions: reframing concepts and methods for research, interventions and policy in low- and middle-income countries

Objectives. The objective of the study was to examine explanatory models of diabetes and diabetes complications among urban poor Ghanaians living with diabetes and implications for developing secondary prevention strategies. Design. Twenty adults with type 2 diabetes were recruited from three poor communities in Accra. Qualitative data were obtained using interviews that run between 40 and 90 minutes. The interviews were audio-taped, transcribed and analysed thematically, informed by the ‘explanatory model of disease’ concept. Results. Respondents associated diabetes and its complications with diet, family history, lifestyle factors (smoking, excessive alcohol consumption and physical inactivity), psychological stress and supernatural factors (witchcraft and sorcery). These associations were informed by biomedical and cultural models of diabetes and disease. Subjective experience, through a process of ‘body-listening,’ constituted a third model on which respondents drew to theorise diabetes complications. Poverty was an important mediator of poor self-care practices, including treatment non-adherence. Conclusions. The biomedical model of diabetes was a major source of legitimate information for self-care practices. However, this was understood and applied through a complex framework of cultural theories of chronic disease, the biopsychological impact of everyday illness experience and the disempowering effects of poverty. An integrated biopsychosocial approach is proposed for diabetes intervention in this research community.