ENSIGN COLLEGE OF PUBLIC HEALTH – KPONG EASTERN, REGION THE FEASIBILITY OF INTRODUCING SCREENING FOR NON- COMMUNICABLE DISEASES INTO PHARMACY SHOPS IN THREE (3) MUNICIPALITIES IN SOUTH-EASTERN GHANA BY AKUTEY RICHARD A thesis submitted to the Department of Community Health in the Faculty of Public Health in partial fulfillment of the requirements for the degree MASTER OF PUBLIC HEALTH JUNE, 2016 i DECLARATION Candidate’s Declaration I hereby declare that this dissertation is the result of my own original research unless otherwise stated and that no part of it has been presented for another degree in this College or elsewhere. Name: Richard Akutey Signature:…………………… Date:…………………….............. Supervisors’ Declaration I hereby declare that the preparation and presentation of this dissertation was supervised in accordance with guidelines on supervision of dissertation laid down by the Ensign College of Public Health Name: Dr. Frank Baiden Signature: …………………… Date:…………………………..... ii ABSTRACT Background: The epidemiological transition with increasing prevalence of chronic non-communicable diseases (NCDs) is well established in many sub-Saharan African countries including Ghana. The introduction of screening for NCDs into pharmacy shops in Ghana is a recent development and remains largely informal. Aim: The aim of this research is to assess the feasibility of introducing screening for non-communicable diseases into pharmacy shops in three (3) Municipalities of south- eastern Ghana aged 18 years and above. Method: Three hundred and thirty (183 males and 137 females) clients of six pharmacy shops were surveyed. Information on Age, Sex, Marital status, Occupation, Level of education, income level, Religion, Ethnicity, knowledge about NCDs (hypertension, diabetes, obesity) and willingness to be screened in pharmacy shops was collected using questionnaires, and analyzed using Stata software (version 14.1). Result/discussion: Clients have knowledge about NCDs risk factors (family history (27%), overweight (75%), smoking (82%), and excessive salt intake (92%)). 98.5% of clients agreed to be screened and 52.0% accepted to receive health promotion messages from pharmacy shops. About 30% of the respondents were concerned that promotional messages sent using mobile health resource could invade their privacy. Conclusion: The introduction of screening for non-communicable diseases into pharmacy shops is acceptable to clients. This approach if formalised could expand access to NCD screening and early detection in Ghana. A similar study among clients of licensed chemical sellers is recommended. iii ACKNOWLEDGEMENT I wish to give my sincere gratitude to my supervisor Dr. Frank Baiden for his leadership, support, and guidance. I wish to thank Mr. Stephen N. Akutey, Mrs. Christiana Dede Akutey and Mr. Eric T. Akuteh for their generosity, contribution and financial assistance. I would like to acknowledge the love, support, and suggestions received from my brothers and sisters, family members, and friends. Finally, I wish to thank the almighty God for his immense love, support, protection, guidance, and for helping me with my project as well as my two (2) year education. iv DEDICATION To my father, Mr. Stephen N. Akutey v TABLE OF CONTENTS Contents Page Declaration i Abstract ii Acknowledgement iii Dedication iv Table of contents v List of tables viii List of figures ix CHAPTER 1 INTRODUCTION 1.0 Background of the study 1 1.1 Problem of statement 3 1.2 Significance of Study 4 1.3 Objectives 4 1.3.1. Overall objectives 4 1.3.2. Specific aims 4 1.4 Hypothesis 5 vi CHAPTER 2 LITERATURE REVIEW 2.1 Definition and introduction of non-communicable diseases 6 2.2 Key diseases of non-communicable diseases 7 2.3 Risk factors of non-communicable diseases 13 2.4 Effects of non-communicable diseases 14 2.5 Prevention and control of non-communicable diseases 15 CHAPTER 3 MATERIALS AND METHODS 3.0 Study area 18 3.1 Sample technique 18 3.2 Data analysis strategies 19 CHAPTER 4 RESULTS 20 CHAPTER 5 DISCUSSION 32 CHAPTER 6 CONCLUSION, LIMITATION AND RECOMMENDATION 5.1 Conclusion 36 5.2 Limitation 37 5.3 Recommendation 38 REFERENCES 39 vii APPENDIX (QUESTIONAIRRE) 52 viii LIST OF TABLES List of Tables Pages Table 4.1: Demographic characteristics of clients 21 Table 4.2: The association between clients status of hyper tension, the last time they had their BP checked, and family history of hypertension 25 Table 4.3: The association between client’s acceptability and privacy consent to receive health promotion messages from pharmacy shops 28 Table 4.4: The association between Demographic characteristics and clients acceptability and privacy consent to receive health promotion messages from pharmacy shops 29 ix LISTS OF FIGURES List of Figures Page Figure 4.1 A bar chart showing the clients awareness of risk factors of Hypertension and Diabetes 22 Figure 4.2 A bar chart showing the client knowledge of his or her weight 23 Figure 4.3 A pie chart showing the last time clients had their weight checked 23 Figure 4.4 A bar chart showing the clients knowledge of his or her BP 24 Figure 4.5 A pie chart showing the last time clients had their BP checked 24 Figure 4.6 Pie charts showing clients family history of Hypertension and Diabetes 26 Figure 4.7 Pie chart showing clients agreement to be screened for hypertension and diabetes at the pharmacy shops 26 Figure 4.8 Pie chart showing client respond to pay or not for screening and amount to be paid 27 Figure 4.9 Bar charts showing clients acceptability and privacy consent to receive health promotion messages from pharmacy shops 28 1 CHAPTER ONE INTRODUCTION 1.0 Background of the study The epidemiological transition with increasing prevalence of chronic non- communicable diseases (NCDs) is already underway in sub-Saharan Africa (Damasceno et al, 2009; Addo et al, 2007; Agyemang et al, 2005; Pereira et al, 2009; Wamala et al, 2009; Maher et al, 2011; Walker et al, 2010; World Health Organization, 2009; Bosu, 2012) including Ghana (Agyemang et al, 2005; Bosu, 2012). The commonest NCDs experienced during this early stage of the epidemiological transition are hypertension (Maher et al, 2011; World Health Organization, 2009) and cerebral vascular accidents (strokes) with strokes in sub-Saharan Africa mainly attributable to uncontrolled hypertension (Walker et al, 2010; World Health Organization, 2009). Hypertension is the leading risk factor for death worldwide and is beginning to be recognized as a significant public health problem in developing countries (WHO, 2009). In 2004, 12.8% of global deaths and 12.1% of deaths in low and middle income countries were attributed to hypertension (WHO, 2009). Furthermore, hypertension is a significant risk factor in CVD which is the world’s number one killer (WHO, 2009). In 2004, 30% of global deaths could be attributed to CVD and a striking 82% of these deaths occurred in low to middle income countries (WHO, 2009). If current trends are allowed to continue, the World Health Organization predicts that 23.6 million people will die of cardiovascular diseases by 2030 (WHO, 2009). In the low income countries in sub-Saharan Africa; hypertension is increasing and affecting young people less than 2 50 years, many of whom die prematurely (Walker et al, 2010; World Health Organization, 2009). Ghana in West Africa has already seen significant increase in the prevalence of hypertension. In Ghana, Chronic non-communicable diseases (NCDs) have caused significant illness and death for many years. Yet, until recently, they have been neglected and not considered a health priority (Bosu, 2012). In a survey in 1950 among 255 persons aged 0-75 years (95% of them less than 50 years) in Kwansakrom, a village 60 miles from Accra, 14 (5.5%) were found to have cardiovascular disease with an organic cardiac murmur or a diastolic blood pressure of more than 100 mmHg (Colbourne et al, 1950). Over the period from 1960 to 1968, strokes accounted for 6-10% of deaths in adult patient and approximately 8% of medical admissions at the Korle Bu Teaching Hospital (KBTH), Accra (Haddock, 1970). Between 1990 and 1993, the proportions increased to 17% and 11% respectively (Nyame et al, 1994). The first major community-based systematic study of cardiovascular diseases was undertaken in Mamprobi, Accra in 1974-1976 by the University of Ghana Medical School with support from the World Health Organization (WHO). The study found that 25% of urban population aged 15-64 years had abnormal cardiovascular (CVD) finding (Ikeme et al, 1978). Thirteen percent of respondents had raised blood pressure ≥160/95 mmHg and 3.4% had rheumatic heart disease. In a five year follow up survey from 1975, CVDs accounted for 48% of the adult deaths in this community (Pobee, 1993; 2006). By 2003, an epidemic of chronic disease risk factor among women in Accra had emerged with 35% of them being obese, 40% hypertensive and 23% hypercholesterolaemic (Hill et al, 2007). Comparable results from a 2005 study in the Ashanti region, located in central Ghana, determined 3 the prevalence of hypertension to be 33.4% in urban areas and 27.0% in rural areas (Agyemang, 2006). In Accra, Kumasi and rural areas, the estimated adult prevalence of hypertension is 28%- 40% (Hill et al, 2007; Agyemang et al, 2006; Amoah, 2006; Cappuccio, 2004; Agyemang, 2006). Nationally, hypertension has moved from being the ninth to tenth commonest cause of new outpatient morbidity in all ages in 1985- 2001 to become the fifth since 2002. Stroke and hypertension have regularly been among the leading causes of deaths in hospitals in Ghana for more than 20 years. This drastic increase in the prevalence of hypertension indicates a need for further review of the condition in Ghana Also, the estimated 6%-7% adult prevalence of diabetes in Accra in 1998-2002 (Amoah et al, 2002; Hill et al, 2007) and 9.5% in Kumasi in 2005 (Owiredu et al, 2008), is markedly higher than previous estimates of 0.4% in 1956 (Dodu, 1958). Consistent with the reported increases in chronic NCDs, obesity levels have been increasing (Hill et al, 2007; Ghana Statistical Service, 2009; Martorell et al, 2000) and fruit and vegetable consumption is among the lowest in Africa (Hall et al, 2009). 1.1.Problem statement In the face of the high and increasing burden of chronic NCDs in Ghana, this research attempts to pilot the feasibility of introducing screening for non-communicable diseases into pharmacies in three (3) Municipalities of south-eastern Ghana. Ultimately, the data that would be collected from this study would help to develop public health interventions that can be deployed in the study region, Ghana, Africa, and whole wide 4 world to increase education about NCDs, the modifiable risk factors, and ways to prevent future morbidity and mortality. 1.2. Significance of the study This research has many important applications some of which include: 1. It would give the true picture about the burden of NCDs in the three (3) Municipalities of south-eastern Ghana. 2. It would be used to make inference about the burden of NCDs in Ghana. 3. It would be used by policy makers to make public health interventions. For instance, advising pharmacies to start offering NCDs screening services. 4. It would also provide information about NCDs to the public and ways of preventing them at the early stages. 5. It would also help to reduce pressure on the health facilities. 6. It would help to reduce the pressure on the health workers. 1.3. OBJECTIVES 1.3.1. Overall Objectives To assess the feasibility of introducing screening for non-communicable diseases into pharmacies in three (3) Municipalities of south-eastern Ghana 1.3.2. Specific Aims 5 1. To assess knowledge of clients about NCDs (hypertension, diabetes and obesity) and the related risk factors 2. To assess how screening for NCDs in pharmacies may be acceptable to clients of these facilities 3. To explore the factors that influence acceptability 4. To explore clients acceptability of the use of m-health resources in follow-up after screening at the facility 1.4 . Hypothesis The introduction of screening for non-communicable diseases into pharmacy shops will be acceptable to clients. 6 CHAPTER TWO LITERTURE REVIEW 2.1. DEFINITION AND INTRODUCTION OF NON-COMMUNICABLE DISEASES Non-communicable disease (NCD) is a medical condition or disease that is non- infectious or non-transmissible. NCDs can refer to chronic diseases which last for long periods of time and progress slowly are the major cause of adult mortality and morbidity worldwide (WHO, 2005a). Sometimes, NCDs result in rapid deaths such as seen in certain diseases such as autoimmune diseases, heart diseases, stroke, cancers, diabetes, chronic kidney disease, osteoporosis, Alzheimer's disease, cataracts, and others. While sometimes (incorrectly) referred to as synonymous with "chronic diseases", NCDs are distinguished only by their non-infectious cause, not necessarily by their duration. Some viral diseases are chronic diseases of long duration, such as HIV/AIDS and hepatitis C, are caused by infections. Chronic diseases require chronic care management as do all diseases that are slow to develop and of long duration. NCDs are the leading cause of death globally. About half were under age 70 and half were women. Risk factors such as a person's background, lifestyle and environment increase the likelihood of certain NCDs. Every year, at least 5 million people die because of tobacco use and about 2.8 million die from being overweight. High cholesterol accounts for roughly 2.6 million deaths and 7.5 million die because of high blood pressure (WHO, 2011b). https://en.wikipedia.org/wiki/Autoimmune_disease https://en.wikipedia.org/wiki/Heart_disease https://en.wikipedia.org/wiki/Stroke https://en.wikipedia.org/wiki/Cancer https://en.wikipedia.org/wiki/Diabetes_mellitus https://en.wikipedia.org/wiki/Chronic_kidney_disease https://en.wikipedia.org/wiki/Osteoporosis https://en.wikipedia.org/wiki/Alzheimer%27s_disease https://en.wikipedia.org/wiki/Cataract https://en.wikipedia.org/wiki/Chronic_diseases https://en.wikipedia.org/wiki/Chronic_diseases https://en.wikipedia.org/wiki/Viral_diseases https://en.wikipedia.org/wiki/HIV/AIDS https://en.wikipedia.org/wiki/Hepatitis_C https://en.wikipedia.org/wiki/Infection https://en.wikipedia.org/wiki/Chronic_care_management https://en.wikipedia.org/wiki/Chronic_care_management https://en.wikipedia.org/wiki/Risk_factor https://en.wikipedia.org/wiki/High_blood_pressure 7 2.2. KEY DISEASES OF NON-COMMUNICABLE DISEASES Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. Cardiovascular disease includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs are stroke, hypertensive heart disease, rheumatic heart disease, cardiomyopathy, heart arrhythmia, congenital heart disease, valvular heart disease, carditis, aortic aneurysms, peripheral artery disease, and venous thrombosis. The underlying mechanisms vary depending on the disease in question. Coronary artery disease, stroke, and peripheral artery disease involve atherosclerosis. This may be caused by high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, and excessive alcohol consumption, among others. High blood pressure results in 13% of CVD deaths, while tobacco results in 9%, diabetes 6%, lack of exercise 6% and obesity 5%. Rheumatic heart disease may follow untreated strep throat (Mendis et al., 2011; Gaziano et al., 2010). Cardiovascular diseases are the leading cause of death globally. This is true in all areas of the world except Africa. Together they resulted in 17.3 million deaths (31.5%) in 2013 up from 12.3 million (25.8%) in 1990. Deaths, at a given age, from CVD are more common and have been increasing in much of the developing world, while rates have declined in most of the developed world since the 1970s (Fuster et al., 2010; Moran et al., 2014) Coronary artery disease and stroke account for 80% of CVD deaths in males and 75% of CVD deaths in females (Mendis et al., 2011). Most cardiovascular disease affects older adults. In the United States 11% of people between 20 and 40 have CVD, while 37% between 40 and 60, 71% of people between 60 and 80, and 85% of people over 80 have CVD (Go et al., 2013) The average age of death from coronary https://en.wikipedia.org/wiki/Heart https://en.wikipedia.org/wiki/Blood_vessel https://en.wikipedia.org/wiki/Blood_vessel https://en.wikipedia.org/wiki/Coronary_artery_disease https://en.wikipedia.org/wiki/Angina_pectoris https://en.wikipedia.org/wiki/Myocardial_infarction https://en.wikipedia.org/wiki/Stroke https://en.wikipedia.org/wiki/Hypertensive_heart_disease https://en.wikipedia.org/wiki/Rheumatic_heart_disease https://en.wikipedia.org/wiki/Cardiomyopathy https://en.wikipedia.org/wiki/Heart_arrhythmia https://en.wikipedia.org/wiki/Congenital_heart_disease https://en.wikipedia.org/wiki/Valvular_heart_disease https://en.wikipedia.org/wiki/Carditis https://en.wikipedia.org/wiki/Aortic_aneurysm https://en.wikipedia.org/wiki/Peripheral_artery_disease https://en.wikipedia.org/wiki/Peripheral_artery_disease https://en.wikipedia.org/wiki/Venous_thrombosis https://en.wikipedia.org/wiki/Atherosclerosis https://en.wikipedia.org/wiki/Hypertension https://en.wikipedia.org/wiki/Tobacco_smoking https://en.wikipedia.org/wiki/Diabetes_mellitus https://en.wikipedia.org/wiki/Physical_exercise https://en.wikipedia.org/wiki/Obesity https://en.wikipedia.org/wiki/Hypercholesterolaemia https://en.wikipedia.org/wiki/Alcoholic_beverage https://en.wikipedia.org/wiki/Streptococcal_pharyngitis https://en.wikipedia.org/wiki/Age_standardized_deaths https://en.wikipedia.org/wiki/Developing_world https://en.wikipedia.org/wiki/Developed_world 8 artery disease in the developed world is around 80 while it is around 68 in the developing world (Fuster et al., 2010). Disease onset is typically seven to ten years earlier in men as compared to women (Mendis et al., 2011). Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. Not all tumors are cancerous; benign tumors do not spread to other parts of the body. Possible signs and symptoms include: a new lump, abnormal bleeding, a prolonged cough, unexplained weight loss, and a change in bowel movements among others. While these symptoms may indicate cancer, they may also occur due to other issues. There are over 100 different known cancers that affect humans (WHO, 2014). Tobacco use is the cause of about 22% of cancer deaths. Another 10% is due to obesity, a poor diet, lack of physical activity, and consumption of alcohol. Other factors include certain infections, exposure to ionizing radiation, and environmental pollutants. In the developing world nearly 20% of cancers are due to infections such as hepatitis B, hepatitis C, and human papillomavirus (HPV) (WHO, 2014; NCI, 2012; Anand et al., 2008). These factors act, at least partly, by changing the genes of a cell. Typically many such genetic changes are required before cancer develops. Approximately 5–10% of cancers are due to genetic defects inherited from a person's parents. Cancer can be detected by certain signs and symptoms or screening tests. It is then typically further investigated by medical imaging and confirmed by biopsy humans (WHO, 2014; American Cancer Society, 2013). In 2012 about 14.1 million new cases of cancer occurred globally (not including skin cancer other than melanoma). It caused about 8.2 million deaths or 14.6% of all human deaths. The most common types of cancer in males are lung cancer, prostate cancer, colorectal https://en.wikipedia.org/wiki/Cell_growth https://en.wikipedia.org/wiki/Benign_tumor https://en.wikipedia.org/wiki/Benign_tumor https://en.wikipedia.org/wiki/Cancer_signs_and_symptoms https://en.wikipedia.org/wiki/Weight_loss https://en.wikipedia.org/wiki/Bowel_movement https://en.wikipedia.org/wiki/Tobacco https://en.wikipedia.org/wiki/Obesity https://en.wikipedia.org/wiki/Diet_%28nutrition%29 https://en.wikipedia.org/wiki/Lack_of_physical_activity https://en.wikipedia.org/wiki/Alcoholic_beverage https://en.wikipedia.org/wiki/Infection https://en.wikipedia.org/wiki/Ionizing_radiation https://en.wikipedia.org/wiki/Ionizing_radiation https://en.wikipedia.org/wiki/Developing_world https://en.wikipedia.org/wiki/Hepatitis_B https://en.wikipedia.org/wiki/Hepatitis_C https://en.wikipedia.org/wiki/Human_papillomavirus https://en.wikipedia.org/wiki/Gene https://en.wikipedia.org/wiki/Cancer_screening https://en.wikipedia.org/wiki/Medical_imaging https://en.wikipedia.org/wiki/Biopsy https://en.wikipedia.org/wiki/Non-melanoma_skin_cancer https://en.wikipedia.org/wiki/Non-melanoma_skin_cancer https://en.wikipedia.org/wiki/Causes_of_death https://en.wikipedia.org/wiki/Lung_cancer https://en.wikipedia.org/wiki/Prostate_cancer https://en.wikipedia.org/wiki/Colorectal_cancer 9 cancer, and stomach cancer, and in females, the most common types are breast cancer, colorectal cancer, lung cancer, and cervical cancer (WHO, 2014). If skin cancer other than melanoma were included in total new cancers each year it would account for around 40% of cases (Dubas & Ingraffea, 2013; Cakir et al, 2012). In children, acute lymphoblastic leukaemia and brain tumors are most common except in Africa where non-Hodgkin lymphoma occurs more often. In 2012, about 165,000 children under 15 years of age were diagnosed with cancer. The risk of cancer increases significantly with age and many cancers occur more commonly in developed countries (WHO, 2014). Rates are increasing as more people live to an old age and as lifestyle changes occur in the developing world (Jemal et al., 2011). The financial costs of cancer have been estimated at $1.16 trillion US dollars per year as of 2010 (WHO, 2014). Diabetes mellitus (DM), commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period. Symptoms of high blood sugar include frequent urination, increased thirst, and increased hunger. If left untreated, diabetes can cause many complications. Acute complications include diabetic ketoacidosis and nonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, stroke, chronic kidney failure, foot ulcers, and damage to the eyes (WHO, 2013; Kitabchi et al, 2009). Diabetes is due to either the pancreas not producing enough insulin or the cells of the body not responding properly to the insulin produced.[5] There are three main types of diabetes mellitus: Type 1 DM results from the pancreas's failure to produce enough insulin. This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes". The cause is unknown. Type 2 DM begins with insulin resistance, a condition in which cells https://en.wikipedia.org/wiki/Colorectal_cancer https://en.wikipedia.org/wiki/Stomach_cancer https://en.wikipedia.org/wiki/Breast_cancer https://en.wikipedia.org/wiki/Cervical_cancer https://en.wikipedia.org/wiki/Skin_cancer https://en.wikipedia.org/wiki/Melanoma https://en.wikipedia.org/wiki/Acute_lymphoblastic_leukaemia https://en.wikipedia.org/wiki/Acute_lymphoblastic_leukaemia https://en.wikipedia.org/wiki/Brain_tumors https://en.wikipedia.org/wiki/Non-Hodgkin_lymphoma https://en.wikipedia.org/wiki/Developed_countries https://en.wikipedia.org/wiki/Population_ageing https://en.wikipedia.org/wiki/US_dollar https://en.wikipedia.org/wiki/Metabolic_disease https://en.wikipedia.org/wiki/Metabolic_disease https://en.wikipedia.org/wiki/Blood_sugar https://en.wikipedia.org/wiki/Polyuria https://en.wikipedia.org/wiki/Polydipsia https://en.wikipedia.org/wiki/Polyphagia https://en.wikipedia.org/wiki/Acute_%28medical%29 https://en.wikipedia.org/wiki/Diabetic_ketoacidosis https://en.wikipedia.org/wiki/Nonketotic_hyperosmolar_coma https://en.wikipedia.org/wiki/Cardiovascular_disease https://en.wikipedia.org/wiki/Stroke https://en.wikipedia.org/wiki/Chronic_renal_failure https://en.wikipedia.org/wiki/Diabetic_foot_ulcer https://en.wikipedia.org/wiki/Diabetic_retinopathy https://en.wikipedia.org/wiki/Pancreas https://en.wikipedia.org/wiki/Insulin https://en.wikipedia.org/wiki/Cell_%28biology%29 https://en.wikipedia.org/wiki/Diabetes_mellitus#cite_note-Green2011-5 https://en.wikipedia.org/wiki/Diabetes_mellitus_type_1 https://en.wikipedia.org/wiki/Diabetes_mellitus_type_2 https://en.wikipedia.org/wiki/Insulin_resistance 10 fail to respond to insulin properly. As the disease progresses a lack of insulin may also develop. This form was previously referred to as "non-insulin-dependent diabetes mellitus" (NIDDM) or "adult-onset diabetes". The primary cause is excessive body weight and not enough exercise. Gestational diabetes, is the third main form and occurs when pregnant women without a previous history of diabetes develop high blood-sugar levels (RSSDI, 2012; WHO, 2013). As of 2015, an estimated 415 million people have diabetes worldwide. With type 2 DM making up about 90% of the cases. This represents 8.3% of the adult population, with equal rates in both women and men. From 2012 to 2015, diabetes is estimated to have resulted in 1.5 to 5.0 million deaths each year. Diabetes at least doubles a person's risk of death (Shi, 2014; Vos, 2012; WHO, 2013). The number of people with diabetes is expected to rise to 592 million by 2035. The global economic cost of diabetes in 2014 was estimated to be $612 billion USD (IDF, 2013). Chronic respiratory conditions and COPD are respiratory conditions affect the airways, including the lungs as well as the passages that transfer air from the mouth and nose into the lungs. They can be long lasting (chronic) or short term (acute) and can cause ill health, disability and death. Chronic respiratory conditions can be grouped together in a variety of ways. One common grouping is obstructive lung diseases (diseases affecting the flow of air in and out of the lungs), such as asthma, chronic obstructive pulmonary disease and bronchiectasis, versus other respiratory conditions, such as chronic sinusitis and occupational lung disease (ABS, 2012). https://en.wikipedia.org/wiki/Gestational_diabetes https://en.wikipedia.org/wiki/USD 11 According to the Australian Health Survey, an estimated 6.3 million Australians suffered from a chronic respiratory condition in 2011–12 (ABS, 2012). Respiratory conditions are believed to be the most commonly managed problems in general practice. Data from the Bettering the Evaluation and Care of Health survey of general practitioners suggest that respiratory conditions were managed in approximately 1 in 5 encounters from 2004–05 to 2013–14 (Britt et al., 2014). In 2012, there were 12,465 deaths where the underlying cause was a respiratory condition (acute or chronic) (ABS, 2015). Chronic obstructive pulmonary disease (COPD) is a leading cause of death in Australia and internationally, and asthma deaths rates in Australia are high in comparison with many other countries (AIHW: Poulos et al., 2014). Chronic kidney disease (CKD), also known as chronic renal disease, is progressive loss in kidney function over a period of months or years. The symptoms of worsening kidney function are not specific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with CKD. This disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia, pericarditis or renal osteodystrophy (the latter included in the novel term CKD-MBD) (National Kidney Foundation, 2002; KDIGO, 2009). CKD is a long-term form of kidney disease; thus, it is differentiated from acute kidney disease (acute kidney injury) in that the reduction in kidney function must be present for https://en.wikipedia.org/wiki/Kidney_function https://en.wikipedia.org/wiki/Malaise https://en.wikipedia.org/wiki/Anorexia_%28symptom%29 https://en.wikipedia.org/wiki/Screening_%28medicine%29 https://en.wikipedia.org/wiki/Hypertension https://en.wikipedia.org/wiki/Hypertension https://en.wikipedia.org/wiki/Diabetes_mellitus https://en.wikipedia.org/wiki/Cardiovascular_disease https://en.wikipedia.org/wiki/Anemia https://en.wikipedia.org/wiki/Pericarditis https://en.wikipedia.org/wiki/Renal_osteodystrophy https://en.wikipedia.org/wiki/Chronic_kidney_disease-mineral_and_bone_disorder https://en.wikipedia.org/wiki/Kidney_disease https://en.wikipedia.org/wiki/Acute_kidney_injury 12 over 3 months. CKD is an internationally recognized public health problem affecting 5– 10% of the world population (Eknoyan et al., 2004; Martínez-Castelao et al., 2014). Chronic kidney disease is identified by a blood test for creatinine, which is a breakdown product of muscle metabolism. Higher levels of creatinine indicate a lower glomerular filtration rate and as a result a decreased capability of the kidneys to excrete waste products. Creatinine levels may be normal in the early stages of CKD, and the condition is discovered if urinalysis (testing of a urine sample) shows the kidney is allowing the loss of protein or red blood cells into the urine. To fully investigate the underlying cause of kidney damage, various forms of medical imaging, blood tests, and sometimes a kidney biopsy (removing a small sample of kidney tissue) are employed to find out if a reversible cause for the kidney malfunction is present (National Kidney Foundation, 2002). Previous professional guidelines classified the severity of CKD in five stages, with stage 1 being the mildest and usually causing few symptoms and stage 5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is often called end-stage kidney disease, end-stage renal disease, or end-stage kidney failure, and is largely synonymous with the now outdated terms chronic renal failure or chronic kidney failure; and usually means the patient requires renal replacement therapy, which may involve a form of dialysis, but ideally constitutes a kidney transplant. Recent international guidelines reclassified CKD based on cause, glomerular filtration rate category (G1, G2, G3a, G3b, G4 and G5), and albuminuria category (A1, A2, A3) (KDIGO, 2012). https://en.wikipedia.org/wiki/Blood_test https://en.wikipedia.org/wiki/Creatinine https://en.wikipedia.org/wiki/Glomerular_filtration_rate https://en.wikipedia.org/wiki/Glomerular_filtration_rate https://en.wikipedia.org/wiki/Urinalysis https://en.wikipedia.org/wiki/Protein https://en.wikipedia.org/wiki/Red_blood_cell https://en.wikipedia.org/wiki/Medical_imaging https://en.wikipedia.org/wiki/Biopsy https://en.wikipedia.org/wiki/Renal_replacement_therapy https://en.wikipedia.org/wiki/Dialysis https://en.wikipedia.org/wiki/Kidney_transplantation https://en.wikipedia.org/wiki/Glomerular_filtration_rate https://en.wikipedia.org/wiki/Albuminuria 13 Screening of at-risk people is important because treatments exist that delay the progression of CKD (Plantinga et al., 2010). If an underlying cause of CKD, such as vasculitis, or obstructive nephropathy (blockage to the drainage system of the kidneys) is found, it may be treated directly to slow the damage. In more advanced stages, treatments may be required for anemia and kidney bone disease [also called renal osteodystrophy, secondary hyperparathyroidism or chronic kidney disease - mineral bone disorder (CKD-MBD)]. Chronic kidney disease resulted in 956,000 deaths in 2013 up from 409,000 deaths in 1990 (GDB et al., 2014). 2.3. RISK FACTORS OF NON-COMMUNICABLE DISEASES There are several risk factors for non-communicable diseases. Risk factors such as a person's background; lifestyle and environment are known to increase the likelihood of certain non-communicable diseases. They include age, gender, genetics, exposure to air pollution (Kelly et al., 2010; Mendis et al., 2011), and behaviors such as smoking, unhealthy diet and physical inactivity which can lead to hypertension and obesity, in turn leading to increased risk of many NCDs (Frinks et al., 2012). While the individual contribution of each risk factor varies between different communities or ethnic groups the overall contribution of these risk factors is very consistent. Some of these risk factors, such as age, gender or family history, are immutable; however, many important non-communicable risk factors are modifiable by lifestyle change, social change, drug treatment and prevention of hypertension, hyperlipidemia, and diabetes (Yusuf et al., 2004). The WHO's World Health Report 2002 identified five important risk factors for non-communicable disease in the top ten leading risks to health. These are raised blood https://en.wikipedia.org/wiki/Vasculitis https://en.wikipedia.org/wiki/Bone_disease https://en.wikipedia.org/wiki/Renal_osteodystrophy https://en.wikipedia.org/wiki/Renal_osteodystrophy https://en.wikipedia.org/wiki/Secondary_hyperparathyroidism https://en.wikipedia.org/wiki/Risk_factor https://en.wikipedia.org/wiki/Gender https://en.wikipedia.org/wiki/Genetics https://en.wikipedia.org/wiki/Air_pollution https://en.wikipedia.org/wiki/Air_pollution https://en.wikipedia.org/wiki/Smoking https://en.wikipedia.org/wiki/Healthy_diet https://en.wikipedia.org/wiki/Sedentary_lifestyle https://en.wikipedia.org/wiki/Hypertension https://en.wikipedia.org/wiki/Obesity https://en.wikipedia.org/wiki/World_Health_Report 14 pressure, raised cholesterol, tobacco use, alcohol consumption, and overweight. The other factors associated with higher risk of NCDs include a person's economic and social conditions, also known as the "[social determinants of health]".It has been estimated that if the primary risk factors were eliminated, 80% of the cases of heart disease, stroke and type 2 diabetes and 40% of cancers could be prevented. Interventions targeting the main risk factors could have a significant impact on reducing the burden of disease worldwide. Efforts focused on better diet and increased physical activity have been shown to control the prevalence of NCDs (Frinks et al., 2012; Micha et al, 2012) 2.4. EFFECTS OF NON-COMMUNICABLE DISEASES Previously, chronic NCDs were considered a problem limited mostly to high income countries, while infectious diseases seemed to affect low income countries. The burden of disease attributed to NCDs has been estimated at 85% in industrialized nations, 70% in middle income nations, and nearly 50% in countries with the lowest national incomes (WHO, 2005). In 2008, chronic NCDs accounted for more than 60% (over 35 million) of the 57 million deaths worldwide. Given the global population distribution, almost 80% of deaths due to chronic NCDs worldwide now occur in low and middle income countries, while only 20% occur in higher income countries (WHO, 2011b). National economies are reportedly suffering significant losses because of premature deaths or inability to work resulting from heart disease, stroke and diabetes. For instance, China is expected to lose roughly $558 billion in national income between 2005 and 2015 due to early deaths. In 2005, heart disease, stroke and diabetes caused an https://en.wikipedia.org/wiki/Cholesterol https://en.wikipedia.org/wiki/Type_2_diabetes https://en.wikipedia.org/wiki/High_income_economy https://en.wikipedia.org/wiki/High_income_economy https://en.wikipedia.org/wiki/Infectious_diseases https://en.wikipedia.org/wiki/Low_income_countries 15 estimated loss in international dollars of national income of 9 billion in India and 3 billion in Brazil (WHO, 2005). The burden of chronic NCDs including mental health conditions is felt in workplaces around the world, notably due to elevated levels of absenteeism, or absence from work because of illness, and presenteeism, or productivity lost from staff coming to work and performing below normal standards due to poor health. For example, the United Kingdom experienced a loss of about 175 million days in 2006 to absence from illness among a working population of 37.7 million people. The estimated cost of absences due to illness was over 20 billion pounds in the same year. The cost due to presenteeism is likely even larger, although methods of analyzing the economic impacts of presenteeism are still being developed. Methods for analyzing the distinct workplace impacts of NCDs versus other types of health conditions are also still being developed (Cooper & Dewe, 2008) 2.5. PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES Most NCDs are considered preventable because they are caused by modifiable risk factors. Greater number of deaths could be prevented by avoiding risk factors including: tobacco, overweight or obesity, an insufficient diet, physical inactivity, alcohol, sexually transmitted infections, and air pollution (WHO, 2005a). For instance, it is estimated that 90% of CVD is preventable (McGill et al., 2008). Prevention of atherosclerosis is by decreasing risk factors through: healthy eating, exercise, avoidance of tobacco smoke and limiting alcohol intake. Treating high blood https://en.wikipedia.org/wiki/International_dollar https://en.wikipedia.org/wiki/Mental_health https://en.wikipedia.org/wiki/Absenteeism https://en.wikipedia.org/wiki/Presenteeism https://en.wikipedia.org/wiki/Health https://en.wikipedia.org/wiki/Tobacco https://en.wikipedia.org/wiki/Overweight https://en.wikipedia.org/wiki/Obesity https://en.wikipedia.org/wiki/Physical_inactivity https://en.wikipedia.org/wiki/Alcohol https://en.wikipedia.org/wiki/Sexually_transmitted_infection https://en.wikipedia.org/wiki/Air_pollution https://en.wikipedia.org/wiki/Healthy_eating 16 pressure and diabetes is also beneficial (Mendis et al., 2011). Treating people who have strep throat with antibiotics can decrease the risk of rheumatic heart disease (Spinks et al., 2013). The effect of the use of aspirin in people who are otherwise healthy is of unclear benefit (Sutcliffe et al., 2013). The United States Preventive Services Task Force recommends against its use for prevention in women less than 55 and men less than 45 years old; however, in those who are older it is recommends in some individuals (US Preventive Services Task Force, 2009). Treatment of those who have CVD improves outcomes (Mendis et al., 2011). Also, Greater than 30% of cancer deaths could be prevented by avoiding risk factors including: tobacco, overweight or obesity, an insufficient diet, physical inactivity, alcohol, sexually transmitted infections, and air pollution (WHO, 2014). Many cancers can be prevented by not smoking, maintaining a healthy weight, not drinking too much alcohol, eating plenty of vegetables, fruits and whole grains, being vaccinated against certain infectious diseases, not eating too much processed and red meat, and avoiding too much exposure to sunlight (Kushi et al., 2012; Parkin et al., 2011). Early detection through screening is useful for cervical and colorectal cancer (WHO, 2014). The benefits of screening in breast cancer are controversial (WHO, 2014; Gøtzsche & Jørgensen, 2013). Cancer is often treated with some combination of radiation therapy, surgery, chemotherapy, and targeted therapy. Pain and symptom management are an important part of care. Palliative care is particularly important in those with advanced disease. The chance of survival depends on the type of cancer and extent of disease at the start of treatment. In children under 15 at diagnosis the five-year survival rate in the https://en.wikipedia.org/wiki/Antibiotic https://en.wikipedia.org/wiki/Aspirin https://en.wikipedia.org/wiki/United_States_Preventive_Services_Task_Force https://en.wikipedia.org/wiki/United_States_Preventive_Services_Task_Force https://en.wikipedia.org/wiki/Tobacco https://en.wikipedia.org/wiki/Overweight https://en.wikipedia.org/wiki/Obesity https://en.wikipedia.org/wiki/Physical_inactivity https://en.wikipedia.org/wiki/Alcohol https://en.wikipedia.org/wiki/Sexually_transmitted_infection https://en.wikipedia.org/wiki/Air_pollution https://en.wikipedia.org/wiki/Alcohol https://en.wikipedia.org/wiki/Vaccination https://en.wikipedia.org/wiki/Cancer_screening https://en.wikipedia.org/wiki/Radiation_therapy https://en.wikipedia.org/wiki/Surgery https://en.wikipedia.org/wiki/Chemotherapy https://en.wikipedia.org/wiki/Targeted_therapy https://en.wikipedia.org/wiki/Palliative_care https://en.wikipedia.org/wiki/Cancer_stage https://en.wikipedia.org/wiki/Five-year_survival_rate 17 developed world is on average 80%. For cancer in the United States the average five- year survival rate is 66% (WHO, 2014). Furthermore, Prevention and treatment involve a healthy diet, physical exercise, maintaining a normal body weight, and avoiding use of tobacco. Control of blood pressure and maintaining proper foot care are important for people with the disease. Type 1 DM must be managed with insulin injections. Type 2 DM may be treated with medications with or without insulin. Insulin and some oral medications can cause low blood sugar (Rippe et al., 2010). Weight loss surgery in those with obesity is sometimes an effective measure in those with type 2 DM (Picot et al., 2009). Type 2 diabetes can also be prevented by a person being a normal body weight, physical exercise, and following a healthful diet. Dietary changes known to be effective in helping to prevent diabetes include a diet rich in whole grains and fiber, and choosing good fats, such as polyunsaturated fats found in nuts, vegetable oils, and fish. Limiting sugary beverages and eating less red meat and other sources of saturated fat can also help in the prevention of diabetes. Active smoking is also associated with an increased risk of diabetes, so smoking cessation can be an important preventive measure as well (Willi et al., 2007). Gestational diabetes usually resolves after the birth of the baby (Cash, 2014). It has been estimated that if the primary risk factors were eliminated, 80% of the cases of heart disease, stroke and type 2 diabetes and 40% of cancers could be prevented. Interventions targeting the main risk factors could have a significant impact on reducing the burden of disease worldwide. Efforts focused on better diet and increased physical activity has been shown to control the prevalence of NCDs (WHO, 2005a). https://en.wikipedia.org/wiki/Healthy_diet https://en.wikipedia.org/wiki/Physical_exercise https://en.wikipedia.org/wiki/Normal_body_weight https://en.wikipedia.org/wiki/Tobacco https://en.wikipedia.org/wiki/Blood_pressure https://en.wikipedia.org/wiki/Blood_pressure https://en.wikipedia.org/wiki/Insulin https://en.wikipedia.org/wiki/Hypoglycemia https://en.wikipedia.org/wiki/Hypoglycemia https://en.wikipedia.org/wiki/Bariatric_surgery https://en.wikipedia.org/wiki/Obesity https://en.wikipedia.org/wiki/Normal_body_weight https://en.wikipedia.org/wiki/Whole_grain https://en.wikipedia.org/wiki/Fiber https://en.wikipedia.org/wiki/Polyunsaturated_fat https://en.wikipedia.org/wiki/Saturated_fat https://en.wikipedia.org/wiki/Smoking_cessation https://en.wikipedia.org/wiki/Gestational_diabetes https://en.wikipedia.org/wiki/Type_2_diabetes 18 CHAPTER THREE MATERIALS AND METHODS 3.0. STUDY AREA The Yilo Krobo, Lower Manya Krobo, and Asuogyaman Districts are one of the twenty-six Districts in the Eastern Region of Ghana. They are located in the south eastern part of the Ghana and lie between latitude 6.05S and 6.30N and longitude 0008E and 0.20W. The Yilo Krobo, Lower Manya Krobo, and Asuogyaman Districts cover land areas of 805, 1,476 and 1,507 square kilometers with population sizes of 95,462, 99,019 and 106,545 respectively. 3.1. SAMPLING TECHNIQUE No formal sample size estimation was applied in this study. All clients (age 18 years and above) to the selected pharmacy shops over the six (6) week period from 1st February to 7th march, 2016 were approached and interviewed. Six pharmacy shops were conveniently-selected for this study: one (1) at Atimpoku, one (1) at Agormanya, one (1) at Atua, and three (3) at Somanya. With the use of questionnaires the following information were obtained from participants who agreed to participate in the study: Age, Sex, Marital status, Occupation, Level of education, income level, Religion, Ethnicity, knowledge about NCDs (hypertension, diabetes, obesity) and willingness to be screened any time they visit these pharmacy shops. 3.2. DATA ANALYSIS STRATEGIES 19 The data collected was analyzed using Stata software (version 14.1). The Statistical significance was determined at P < 0.05. The analysis was largely descriptive. Although logistic regression to determine predictors of acceptability was planned, this was not feasible because of the overwhelming number of respondents who consider the practice acceptable. 20 CHAPTER FOUR RESULTS A total of 330 participants took part in the study over a six-week period from 1st February to 7th march, 2016. They were made of 58% males and 42% females. The youngest and oldest participants interviewed were 18yrs and 85yrs respectively. The median, mean and standard deviation ages were 34 years (interquartile range of 27- 43years), 36 years, and 10years respectively. The majority of participants were Christians (90%). The rest were Muslims and traditionalists (10%). Most of the participants were married (45%), followed by single (40%), and Divorced, separated or widowed (15%). The level of education of the participants showed some have no education (16%), JHS (25%), SHS and middle form or A-level (27%), and post- secondary or vocational (polytechnic), graduate and post-graduate level (32%). The place of residence of the participants showed that, some were within 30 minutes (56%), between 30-60 minutes (31%), and more than 60 minutes (13%) from the pharmacy shops. With the ethnicity, Ga-adangbes formed 50%, whiles Akans, Ewes, Moshi- Dagbanis and others formed 50%. The occupational status of the participants showed that unemployed (19%), informal occupation (58%), and formal occupation (23%). Also the median, mean and standard deviation of the income level of the participants were GH 800 Cedis (interquartile range of GH 500-1000 Cedis), GH 897Cedis, and GH 949 Cedis respectively. 21 Table 4.1 Demographic characteristics of respondents Variables Number Percentage Age 18-30 Years 133 40.30 31-50 Years 158 47.88 51-85years 39 11.82 Sex Female 134 42.27 Male 183 57.73 Religion Christians 292 89.85 Muslims & Traditionalists 33 10.15 Marital Status Married 148 44.85 Single 134 40.60 Divorced, Separated, & Widowed 48 14.55 Level Of Education None 54 16.36 Jhs 82 24.85 Shs & Middle Form/A- Level 89 26.97 Post- Secondary/Vocational, Graduate Degree, & Post- Graduate Level 105 31.81 Ethnicity Ga-Adangbes 160 49.54 Ewes, Akans, Moshi- Dagbani, & Others 163 50.46 Place Of Residence Within 30 Minutes 181 55.52 Between 30-60 Minutes 102 31.39 More Than 60 Minutes 43 13.19 Occupational Status Unemployed 51 18.82 Informal Occupation 156 57.56 Formal Occupation 64 23.63 Income Level Decline 212 64.24 Less Than Gh 500 Cedis 42 12.73 Between Gh 500-1000 Cedis 48 14.55 More Than Gh 1000 Cedis 28 8.48 22 The result showed that, majority of the participants was aware that overweight (75%), smoking (82%), and excessive salt intake (92%) were risk factors of hypertension and diabetes. Awareness of family history as a risk factor was somehow low (27%). A high proportion of respondents did not consider family history as a risk factor for hypertension and diabetes (73%). This was shown in figure 4.1 below. Figure 4.1 A bar chart showing the clients awareness of the risk factors of Hypertension and Diabetes. Only 35.4% of the respondents were aware of their current weight at the time of the interview (Figure 4.2). Figure 4.2 showed the client knowledge of his or her weight. It showed that majority of the participants (64.6%) did not know their weight. 75.2% 27.0% 81.9% 91.7% 7.0% 31.9% 4.9% 3.7% 17.8% 41.1% 13.2% 4.6% 0 50 100 150 200 250 300 350 Overweight Family hisyory SmokingExcessive salt intake N u m b er O f R es p o n d en ts Awareness Of Risk Factors Of Hypertension And Diabetes Yes No Don’t know 23 Figure 4.2 A bar chart showing the client knowledge of current weight Many (44.1%) respondents however indicated they did not remember the last time they had a weight check. Among those who remember, 34.2% had done so between 1-6 months ago, 4.5% between 6-12 months, and 17.2% about a year ago (Figure 4.3). Figure 4.3 A pie chart showing the last time clients had their weight checked. Figure 4.4 showed that majority of the clients (79%) did not know their BP level. 35.4% 64.6% 0 50 100 150 200 250 Yes No N u m b er O f R es p o n d en ts Client Knowledge Of Current Weight 34.2% 4.5% 17.2% 44.1% Last Time Clients Had Their Weight Checked 1-6 Months 6-12 Months Over a year ago So long ago 24 Figure 4.4 A bar chart showing the clients knowledge of current BP Furthermore, figure 4.5 also showed the last time the clients had their BP checked as: so long ago (64.0%), over a year ago (7.2%), 6-12 months (3.3%), and 1-6 months (25.5%). Figure 4.5 A pie chart showing the last time clients had their BP checked 79.3% 20.7% No Yes 0 50 100 150 200 250 300 N u m b er O f R es p o n d en ts Client Knowledge Of Current Bp 25.5% 3.3% 7.2%64.0% Last Time Clients Had Their Bp Checked 1-6 Months 6-12 Months Over a year ago So long ago 25 About a third (35.7%) of the clients who were hypertensive had not had their BP check for over a year. Similarly 21.4% of clients who were aware that they had a family history of hypertension did not know their Bp status and 42.9% of those who did not know whether there was a family history of hypertension or not and had not checked their Bp at the time of interview status (Table 4.2). Table 4.2 The association between clients status of hyper tension, the last time they had their BP checked, and family history of hypertension. Client hypertension status Hypertensive Not hypertensive Don’t know Last time blood pressure was checked Within past 6months 19 (55.9%) 44 (24.4%) 21 (19.1%) Between 6-12 months ago 3 (8.8%) 6 (3.3%) 3 (2.7%) Over a year ago 3(8.8%) 18 (10.0%) 1(0.9%) So long ago, it is forgotten 9 (26.5%) 112 (62.2%) 85 (77.3%) Client has family history of hypertension Yes 17 (50.0%) 41 (22.9%) 24 (21.4%) No 7 (20.6%) 94 (52.5%) 40 (35.7%) Don’t know 10 (29.4%) 44(24.6%) 48 (42.9%) About a quarter (24.8%) and 14.1% respectively of clients interviewed had family histories of hypertension and diabetes (Figure 4.6). 26 Figure 4.6 Pie charts showing clients family history of Hypertension and Diabetes Figure 4.7 showed clients agreement to be screened for hypertension and diabetes at the pharmacy shops. Majority of the clients (98.5%) agreed to be screened for hypertension and diabetes at the pharmacy shops. Figure 4.7 Pie chart showing clients agreement to be screened for hypertension and diabetes at the pharmacy shops 24.8% 43.2% 32.0% Clients Family History Of Hypertension Yes No Don’t know 14.1% 48.2% 37.7% Clients Family History Of Diabetes Yes No Don’t know 98.5% 1.2% 0.3%0 50 100 150 200 250 300 350 Yes No Don’t know N u m b er O f R es p o n d en ts Clients Agreement To Be Screened For Diabetes And Hypertension At Pharmacy Shops 27 Majority of the clients (56.7%) wanted screening for hypertension and diabetes to be done for free at pharmacy shops. For clients who wanted to pay, 77%, 21% and 2% suggested one Ghana cedis or less, between 1-2 Ghana cedis, and between 2-5 Ghana cedis respectively to be paid for the cost of screening (Figure 4.8). Figure 4.8 Pie charts showing client responds to pay or not for screening and amount to be paid Majority of the clients (52.0%) agreed to receive health promotion messages from pharmacy shops. For privacy issues, 60.9% of the clients considered receiving health promotion messages from pharmacy shops as non-invasion of their privacy (Figure 4.9). 56.7% 43.3% 0 20 40 60 80 100 120 140 160 180 200 FREE PAY FOR N u m b er O f R es p o n d en ts Willingness To Pay For NCD Screening At Pharmacy Shops 76.7% 21.1% 2.2% Amount To Be Paid By Clients GH 1CEDIS OR LESS BETWEEN GH 1-2 CEDIS BETWEEN GH 2-5 CEDIS 28 Figure 4.9 Bar charts showing clients acceptability and privacy consent to receive health promotion messages from pharmacy shops The majority of clients (83.3%) indicated a willingness to receive health promotion text messages sent by phone from the pharmacy shops. However 40.5% regards such messages as potentially their privacy (Table 4.3). Table 4.3 The association between clients acceptability and privacy consent to receive health promotion messages from pharmacy shops 1. Clients Privacy Consent Of Receiving Health Promotion Messages From Pharmacy Shops Client Acceptability To Receive Health Promotion Messages From Pharmacy Shops Agree Disagree 269 (83.3%) 54 (16.7%) Yes 125 (39.1%) 107 (40.5%) 18 (34.0%) No 195 (60.9%) 159 (59.5%) 36 (66.0%) 31.3% 52.0% 15.1% 1.6%0 20 40 60 80 100 120 140 160 180 Strongly agree Agree Disagree Strongly disagree N u m b er O f R es p o n d en ts Clients Acceptablity To Receive Health Promotion Messages From Pharmacy Shops 39.1% 60.9% 0 50 100 150 200 250 Yes No N u m b er O f R es p o n d en ts Clients Privacy Consent Of Receiving Health Promotion Messages From Pharmacy Shops 29 Table 4.4 showed the association between demographic characteristics and client’s acceptability and privacy consent to receive health promotion messages from pharmacy shops. It revealed that there was a strong association between demographic characteristics such as age, sex, religion, marital status, and level of education and client’s acceptability to receive health promotion messages from pharmacy shops with p-values 0.00, 0.01, 0.03, 0.01, and 0.00 respectively. Also, there was a strong association between demographic characteristics such as marital status, level of education, and income level and clients privacy consent to receive health promotion messages from pharmacy shops with p-values of 0.00, 0.00, and 0.03 respectively Table 4.4 The association between Demographic characteristics and clients acceptability and privacy consent to receive health promotion messages from pharmacy shops Client Acceptability To Receive Health Promotion Messages From Pharmacy Shops P- Value Clients Privacy Consent Of Receiving Health Promotion Messages From Pharmacy Shops P- Value Agree Disagree Yes No Variables Age 0.00 0.17 18-30 Years 123(45.7%) 8(14.8%) 58(46.4%) 70(35.9%) 31-50 Years 113(42.0%) 40(74.1%) 54(43.2%) 102(52.3%) 51-85years 33 (12.3%) 6 (11.1%) 13(10.4%) 23 (11.8%) 30 Sex 0.01 0.37 Female 115(44.9%) 14(25.9%) 54(45.4%) 76 (40.2%) Male 141(55.1%) 40(74.1%) 65(54.6%) 113(59.8%) Religion 0.03 0.70 Christians 234(88.0%) 51(98.1%) 110(88.7%) 172(90.1%) Muslims & Traditionalists 31 (12.0%) 2 (1.9%) 14 (11.3%) 19 (9.9%) Marital Status 0.01 0.00 Married 116(43.1%) 28(51.8%) 43 (34.4%) 99 (50.8%) Single 119(44.2%) 13(24.1%) 65 (52.0%) 65 (33.3%) Divorced, Separated, & Widowed 34 (12.7%) 13(24.1%) 17 (13.6%) 31 (15.9%) Level Of Education 0.00 0.00 None 40 (14.9%) 13(24.1%) 17 (13.6%) 37 (19.0%) Jhs 58 (21.6%) 23(42.5%) 21 (16.8%) 60 (30.8%) Shs & Middle Form/A-Level 82 (30.5%) 5 (9.3%) 49 (39.2%) 34 (17.4%) Post- Secondary/Vocational, Graduate Degree, & Post-Graduate Level 89 (33.0%) 13(24.1%) 38 (30.4%) 64 (32.8%) Ethnicity 0.96 0.41 Ga-Adangbes 130(49.6%) 27(50.0%) 64 (52.5%) 91 (47.6%) Ewes, Akans, Moshi- Dagbani, & Others 132(50.4%) 27(50.0%) 58 (47.5%) 100(52.4%) Place Of Residence 0.08 0.56 Within 30 Minutes 155(58.3%) 23(43.4%) 72 (58.0%) 102(53.1%) Between 30-60 Minutes 75 (28.2%) 23(43.4%) 38 (30.7%) 61 (31.8) More Than 60 Minutes 36 (13.5%) 7(13.2%) 14 (11.3%) 29 (15.1) 31 Occupational Status 0.12 0.54 Unemployed 47 (21.1%) 3 (7.3%) 20 (19.2%) 29 (18.4%) Informal Occupation 124(55.6%) 27(65.9%) 56 (53.9%) 95 (60.1%) Formal Occupation 52 (23.3%) 11(26.8%) 28 (26.9%) 34 (21.5%) Income Level 0.25 0.03 Decline 166(61.7%) 41(75.9%) 90 (72.0%) 114(58.5%) Less Than Gh 500 Cedis 38 (14.1%) 4(7.4%) 10 (8.0%) 32 (16.4%) Between Gh 500-1000 Cedis 40 (14.9) 6 (11.0%) 13 (10.4%) 33 (16.9%) More Than Gh 1000 Cedis 25 (9.3) 3 (5.7%) 12 (9.6%) 16 (8.2%) 32 CHAPTER FIVE DISCUSSION There are several risk factors for non-communicable diseases. Risk factors such as a person's background; lifestyle and environment are known to increase the likelihood of certain non-communicable diseases. They include age, gender, genetics, exposure to air pollution (Kelly et al., 2010; Mendis et al., 2011), and behaviors such as smoking, unhealthy diet and physical inactivity which can lead to hypertension and obesity, in turn leading to increased risk of many NCDs (Frinks et al., 2012). This was confirmed by figure 4.1 when the knowledge of the clients was tested, with the results revealing that except family history (27%), majority of the participants were aware that overweight (75%), smoking (82%), and excessive salt intake (92%) were risk factors of hypertension and diabetes. however, in spite of the clients awareness of risk factors of hypertension and diabetes, figure 4.2 and 4.4 showed that majority of the clients (65% and 79%) did not know their weight and BP level respectively. Figure 4.3 and 4.5 also revealed that majority of the clients (44% and 64%) did not know their weight and BP level respectively for so long ago. This result can be used to explain previous works indicating that epidemiological transition with increasing prevalence of chronic non- communicable diseases (NCDs) is already underway in sub-Saharan Africa (Damasceno et al, 2009; Addo et al, 2007; Agyemang et al, 2005; Pereira et al, 2009; Wamala et al, 2009; Maher et al, 2011; Walker et al, 2010; World Health Organization, 2009; Bosu, 2012) including Ghana (Agyemang et al, 2005; Bosu, 2012). This is a serious public health concern because there are a lot of people out there that do not go for regular check up to know their status of BMI and hypertension. https://en.wikipedia.org/wiki/Risk_factor https://en.wikipedia.org/wiki/Gender https://en.wikipedia.org/wiki/Genetics https://en.wikipedia.org/wiki/Air_pollution https://en.wikipedia.org/wiki/Air_pollution https://en.wikipedia.org/wiki/Smoking https://en.wikipedia.org/wiki/Healthy_diet https://en.wikipedia.org/wiki/Sedentary_lifestyle https://en.wikipedia.org/wiki/Hypertension https://en.wikipedia.org/wiki/Obesity 33 Furthermore, when association between client’s status of hyper tension and the last time they had their BP checked was done by Table 4.2, it gave a significant p-value of 0.00. It revealed that 35% of the clients were hypertensive but did not check their BP over a year ago. Table 4.2 showed the association between client’s status of hyper tension and their family history. From the result, 21% of clients were aware that there was family history of hypertension yet they did not know their status. Also, 43% of them did not know whether there was a family history of hypertension or not and they too did not border to check their status of hypertension. Figure 4.6 showed clients family history of Hypertension and Diabetes. It revealed that 25% and 14% of the clients have family history of hypertension and diabetes respectively. This result can be used to explain former works revealing that, in the low income countries hypertension is increasingly affecting young people less than 50 years, many of whom die prematurely as compared to the developed countries (Walker et al, 2010; World Health Organization, 2009). In 2004, 30% of global deaths could be attributed to CVD and a striking 82% of these deaths occurred in low to middle income countries (WHO, 2009), which Ghana could be of no exception. Also, when the clients were asked about their acceptability to be screened for hypertension and diabetes whenever they visit these pharmacy shops, figure 4.7 showed that majority of them (98.5%) agreed to be screened. In addition to the above, when the clients were asked whether they would pay or not for the screening, Figure 4.8 showed that majority of them (56.7%) wanted it to be done for free. For clients who wanted to pay, 77%, 21% and 2% of them suggested GH 1 cedis and below, between GH 1-2 cedis, and between GH 2-5cedis respectively to be paid for the cost of screening. 34 Lastly, results from 2005 study in the Ashanti region, located in central Ghana, determined the prevalence of hypertension to be 33.4% in urban areas and 27.0% in rural areas (Agyemang, 2006). In Accra, Kumasi and rural areas, the estimated adult prevalence of hypertension is 28%- 40% (Hill et al, 2007; Agyemang et al, 2006; Amoah, 2006; Cappuccio, 2004; Agyemang, 2006). Nationally, hypertension has moved from being the ninth to tenth commonest cause of new outpatient morbidity in all ages in 1985-2001 to become the fifth since 2002. Stroke and hypertension have regularly been among the leading causes of deaths in hospitals in Ghana for more than 20 years. This drastic increase in the prevalence of hypertension indicates a need for further review of the condition in Ghana, and can be done by including mobile health. Mobile text messages have been used to improve health outcomes in a wide range of contexts because of their low cost and convenience (Krishna et al, 2009). For instance, text messages have been used in health programmes for smoking cessation (Chen et al, 2012), disease management (Holtz & Lauckner, 2012) and weight reduction (Stephens & Allen, 2013) and to improve adherence to medication (Horvath et al, 2012) and attendance at health-care appointments (Car et al, 2012). In general, text messages seem to be effective for communicating information in a health-care context and have been well accepted by users (Yeager & Menachemi, 2011). Research also indicates that text messages could serve as a powerful tool for behaviour change (Cole-Lewis & Kershaw, 2010), both in developed and developing countries (Déglise et al, 2012). This has been revealed in this study when client’s acceptability and privacy consent to receive health promotion messages from pharmacy shops were done by figure 4.9. It revealed that majority of the clients (52.0%) agreed to receive health promotion messages from 35 pharmacy shops. For privacy issues, 60.9% of the clients considered receiving health promotion messages from pharmacy shops as non-invasion of their privacy. However, when the association between client’s acceptability and privacy consent to receive health promotion messages from pharmacy shops was done by Table 4.3, it revealed that majority of the clients (83.3%) agree to receive health promotion messages from pharmacy shops but 40.5% of them consider it as invasion of their privacy. This means that although most of the clients agree to receive health promotion messages from pharmacy shops, however about half of them have issues with it as invasion of their privacy. Also, when the association between demographic characteristics and client’s acceptability and privacy consent to receive health promotion messages from pharmacy shops was done by Table 4.4, it revealed that there was a strong association between demographic characteristics such as age, sex, religion, marital status, and level of education and client’s acceptability to receive health promotion messages from pharmacy shops with p-values of 0.00, 0.01, 0.03, 0.01, and 0.00 respectively. Also, there was a strong association between demographic characteristics such as marital status, level of education, and income level and clients privacy consent to receive health promotion messages from pharmacy shops with p-values of 0.00, 0.00, and 0.03 respectively. Hence, user guidelines need to be established for mobile-Health programs to help manage privacy and security issues especially considering mobile phones are often shared among family and community members (Srinath et al, 2005). 36 CHAPTER SIX CONCLUSION, LIMITATION, AND RECOMMENDATION 6.1 CONCLUSION The acceptability of introducing screening for non-communicable diseases into pharmacies was conducted in three (3) municipalities of south-eastern Ghana. Three hundred and thirty (330) participants were used for the study (58%) males and (42%) females with ages starting from eighteen (18) years and above. Except family history (27%) majority of the participants were aware that overweight (75%), smoking (82%), and excessive salt intake (92%) were risk factors of hypertension and diabetes. Majority of the clients (65% and 79%) did not know their weight and BP level respectively, and majority of them (44% and 64%) did know not their weight and BP level respectively for so long ago. Association between client’s status of hypertension and the last time they had their BP checked gave a significant p-value of 0.00 with 35% of the clients being hypertensive but did not check their BP over a year ago. Association between client’s status of hypertension and their family history showed that 21% of clients were aware that there was family history of hypertension yet they did not know their status. Also, 43% of them did not know whether there was a family history of hypertension or not and they too did not border to check their status of hypertension. Family history of Hypertension and Diabetes revealed that 25% and 14% of the clients have family history of hypertension and diabetes respectively. Client’s acceptability to be screened for hypertension and diabetes whenever they visit these pharmacy shops revealed that, majority of them (98.5%) agreed to be screened with 56.7% wanting screening to be 37 done for free. For clients who wanted to pay, 77%, 21% and 2% of them suggested GH 1 cedis and below, between GH 1-2 cedis, and between GH 2-5cedis respectively to be paid for the cost of screening. Furthermore, client’s acceptability and privacy consent to receive health promotion messages from pharmacy shops revealed that majority of the clients (52.0%) agreed to receive health promotion messages from pharmacy shops. For privacy issues, 60.9% of the clients considered receiving health promotion messages from pharmacy shops as non-invasion of their privacy. However, association between client’s acceptability and privacy consent to receive health promotion messages from pharmacy shops revealed that majority of the clients (83.3%) agree to receive health promotion messages from pharmacy shops but 40.5% of them consider it as invasion of their privacy. Also, association between demographic characteristics and client’s acceptability and privacy consent to receive health promotion messages from pharmacy shops revealed that there was a strong association between demographic characteristics such as age, sex, religion, marital status, and level of education and client’s acceptability to receive health promotion messages from pharmacy shops with p-values of 0.00, 0.01, 0.03, 0.01, and 0.00 respectively. Also, there was a strong association between demographic characteristics such as marital status, level of education, and income level and clients privacy consent to receive health promotion messages from pharmacy shops with p- values of 0.00, 0.00, and 0.03 respectively. 38 6.2 LIMITATION The participants of this study were clients that come to buy drugs from these pharmacy shops; hence it was very difficult to obtain information from them. This was because almost all the clients were in hurry to go back from where they were coming from after buying whatever drug they were in for. This made them not to have time for any interrogations or questions. Either the client coming to buy the drug was sick him or herself or being sent by somebody seriously sick. Also, some clients went to the extent of asking for further explanation and lot of questions, after which a decision would be made of not being interested. 5.3 RECOMMENDATION Ghana is a developing country with an increasing prevalence of chronic non- communicable diseases (NCDs), hence I recommend that: 1. Pharmacy shops should be encouraged to offer screening services for non- communicable diseases. 2. Public awareness of various risk factors of non-communicable diseases should be increased. 3. There must be increased public education to encourage people to go for regular check-ups at these pharmacy shops. 4. This study should be conducted at the licensed chemical shops which are many and much closer to the people. 39 REFERENCES ABS (2012). Australian Health Survey: First Results, 2011–12 . ABS cat. no. 4364.0.55.001. Canberra: ABS. Viewed on 10 September, 2015 . ABS (2015). Causes of Death, 2013, ABS cat. no. 3303.0. Canberra: ABS. Viewed on 10 September, 2015. . Addo J, Smeeth L, Leon DA (2007) Hypertension In Sub-Saharan Africa. Hypertension 50: 1012–8. doi: 10.1161/hypertensionaha.107.093336 Agyemang C, Bruijnzeels MA, Owusu-Dabo E (2005) Factors associated with hypertension awareness, treatment, and control in Ghana, West Africa. J Hum Hypertens 20: 67–71. doi: 10.1038/sj.jhh.1001923 Agyemang C. Rural and urban differences in blood pressure and hypertension in Ghana, West Africa. Public Health 2006;120(6):525-533. American Cancer Society (2013). "How is cancer diagnosed?". Retrieved 10 September, 2015 Amoah AG, Owusu SK, Adjei S. Diabetes in Ghana: a community based prevalence study in Greater Accra. Diabetes Research and Clinical Practice. 2002; 56:197-205. http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0012011-12?OpenDocument http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0012011-12?OpenDocument http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3303.02013?OpenDocument http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3303.02013?OpenDocument http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/testingbiopsyandcytologyspecimensforcancer/testing-biopsy-and-cytology-specimens-for-cancer-how-is-cancer-diagnosed 40 Amoah AGB. Hypertension in Ghana: A cross-sectional community prevalence study in Greater Accra. Ethn Dis 2003;13:310-315. Anand, P.; Kunnumakkara, A.B.; Sundaram C., Harikumar K.B., Tharakan S.T., Lai O.S.; Sung B., Aggarwal, B.B. (2008). "Cancer is a preventable disease that requires major lifestyle changes". Pharm. Res. 25 (9): 2097–116. doi:10.1007/s11095-008- 9661-9. PMC 2515569. PMID 18626751. Australian Institute of Health and Welfare, Poulos LM, Cooper SJ, Ampon R, Reddel HK and Marks GB (2014). Mortality from asthma and COPD in Australia. Cat. no. ACM 30. Canberra: AIHW. Bosu W. K. (2012). A Comprehensive review of the policy and programmatic response to chronic non-communicable disease in Ghana. Ghana Medical Journal 46: 1-2 . Brew A. (1950). A medical survey in a gold coast village. Trans R Soc Trop Med Hyg 44:271-290. Bridget B. Kelly; Institute of Medicine; Fuster, Valentin (2010). Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, D.C: National Academies Press. ISBN 0-309-14774-3. Britt H, Miller G, Henderson J, Bayram C, Valenti L, Harrison C, Pan Y, Wong C, Charles J, Chambers T, Gordon J, Pollack AJ (2014). A decade of Australian general practice activity 2004–05 to 2013–14. General practice series no. 37. Sydney: Sydney University Press https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515569 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515569 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1007%2Fs11095-008-9661-9 https://dx.doi.org/10.1007%2Fs11095-008-9661-9 https://en.wikipedia.org/wiki/PubMed_Central https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515569 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/18626751 https://en.wikipedia.org/wiki/International_Standard_Book_Number https://en.wikipedia.org/wiki/Special:BookSources/0-309-14774-3 41 Cakir, BÖ; Adamson, P; Cingi, C (2012). "Epidemiology and economic burden of nonmelanoma skin cancer.". Facial plastic surgery clinics of North America 20 (4): 419–22. doi:10.1016/j.fsc.2012.07.004. PMID 23084294. Cappuccio FP, Micah FB, Emmett L, Kerry SM, Antwi S, Martin-Peprah R, et al (2004). Prevalence, detection, management, and control of hypertension in Ashanti, West Africa. Hypertens. 43:1017- 1022. Car J, Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R (2012). Mobile phone messaging reminders for attendance at healthcare appointments Cochrane Database Syst Rev.;7:CD007458. pmid: 22786507 Cash, Jill (2014). Family Practice Guidelines (3rd ed.). Springer. p. 396. ISBN 9780826168757. Chen YF, Madan J, Welton N, Yahaya I, Aveyard P, Bauld L, et al. (2012). Effectiveness and cost-effectiveness of computer and other electronic aids for smoking cessation: a systematic review and network meta-analysis. Health Technol Assess.;16(38):1-205, iii-v. pmid: 23046909 Cole-Lewis H, Kershaw T. (2010). Text messaging as a tool for behavior change in disease prevention & management. Epidemiol Rev.;32(1):56-69. http://dx.doi.org/10.1093/epirev/mxq004 pmid: 20354039 Cooper C; Dewe P (2008). "Well-being—absenteeism, presenteeism, costs and challenges". Occup Med (Lond) 58 (8): 522–4. doi:10.1093/occmed/kqn124. PMID 19054749. https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1016%2Fj.fsc.2012.07.004 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/23084294 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=22786507&dopt=Abstract https://books.google.com/books?id=nCjcAgAAQBAJ&pg=PA396 https://en.wikipedia.org/wiki/International_Standard_Book_Number https://en.wikipedia.org/wiki/Special:BookSources/9780826168757 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=23046909&dopt=Abstract http://dx.doi.org/10.1093/epirev/mxq004 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=20354039&dopt=Abstract https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1093%2Foccmed%2Fkqn124 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/19054749 42 Damasceno A, Azevedo A, Siva matos C, Prista A, Diogo D, et al. (2009) Hypertension Prevalence, Awareness, treatment, and control in Mozambique (urban/rural gap during epidemiological Transition). Hypertension 54: 77–83. doi:10.1161/hypertensionaha.109.132423 Déglise C, Suggs LS, Odermatt P. (2012). SMS for disease control in developing countries: a systematic review of mobile health applications. J Telemed Telecare.;18(5):273-81. http://dx.doi.org/10.1258/jtt.2012.110810 pmid: 22826375 Dodu SRA. The incidence of diabetes mellitus in Accra (Ghana): A study of 4000 patients. West Afr Med J 1958:129-134. Dubas, LE; Ingraffea, A. (2013). "Nonmelanoma skin cancer." Facial plastic surgery clinics of North America 21 (1): 43–53. doi:10.1016/j.fsc.2012.10.003. PMID 23369588. Eknoyan G, Lameire N, Barsoum R; et al. (2004). "The burden of kidney disease: improving global outcomes". Kidney Int 66: 1310–4. doi:10.1111/j.1523- 1755.2004.00894.x. PMID 15458424. Finks, SW; Airee, A; Chow, SL; Macaulay, TE; Moranville, MP; Rogers, KC; Trujillo, TC (2012). "Key articles of dietary interventions that influence cardiovascular mortality.". Pharmacotherapy 32 (4): e54–87. doi:10.1002/j.1875- 9114.2011.01087.x. PMID 22392596. Fuster, Board on Global Health ; Valentin; Academies, Bridget B. Kelly, editors ; Institute of Medicine of the National (2010). Promoting cardiovascular health in the developing world : a critical challenge to achieve global health. Washington, D.C.: National Academies Press. pp. Chapter 2. ISBN 978-0-309-14774-3. http://dx.doi.org/10.1258/jtt.2012.110810 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=22826375&dopt=Abstract https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1016%2Fj.fsc.2012.10.003 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/23369588 http://linkinghub.elsevier.com/retrieve/pii/KID894 http://linkinghub.elsevier.com/retrieve/pii/KID894 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1111%2Fj.1523-1755.2004.00894.x https://dx.doi.org/10.1111%2Fj.1523-1755.2004.00894.x https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/15458424 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1002%2Fj.1875-9114.2011.01087.x https://dx.doi.org/10.1002%2Fj.1875-9114.2011.01087.x https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/22392596 http://www.ncbi.nlm.nih.gov/books/NBK45688/ http://www.ncbi.nlm.nih.gov/books/NBK45688/ https://en.wikipedia.org/wiki/International_Standard_Book_Number https://en.wikipedia.org/wiki/Special:BookSources/978-0-309-14774-3 43 Gaziano, T. A., Bitton, A., Anand, S., Abrahams-Gessel, S., & Murphy, A. (2010). Growing Epidemic of Coronary Heart Disease in Low- and Middle-Income Countries. Current problems in cardiology, 35(2), 72-115. GBD 2013; Mortality and Causes of Death, Collaborators (2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.". Lancet 385 (9963): 117–171. doi:10.1016/S0140-6736(14)61682-2. PMC 4340604. PMID 25530442. Ghana Statistical Service (GSS), Ghana Health Service (GHS), ICF Macro. Ghana Demographic and Health Survey 2008. Accra, Ghana: GSS, GHS and ICF Macro; 2009. Go, AS; Mozaffarian, D; Roger, VL; Benjamin, EJ; Berry, JD; Borden, WB; Bravata, DM; Dai, S; Ford, ES; Fox, CS; Franco, S; Fullerton, HJ; Gillespie, C; Hailpern, SM; Heit, JA; Howard, VJ; Huffman, MD; Kissela, BM; Kittner, SJ; Lackland, DT; Lichtman, JH; Lisabeth, LD; Magid, D; Marcus, GM; Marelli, A; Matchar, DB; McGuire, DK; Mohler, ER; Moy, CS; Mussolino, ME; Nichol, G; Paynter, NP; Schreiner, PJ; Sorlie, PD; Stein, J; Turan, TN; Virani, SS; Wong, ND; Woo, D; Turner, MB; American Heart Association Statistics Committee and Stroke Statistics, Subcommittee (2013). "Heart disease and stroke statistics--2013 update: a report from the American Heart Association.". Circulation 127 (1): e6–e245. doi:10.1161/cir.0b013e31828124ad. PMID 23239837 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340604 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340604 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340604 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340604 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1016%2FS0140-6736%2814%2961682-2 https://en.wikipedia.org/wiki/PubMed_Central https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340604 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/25530442 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1161%2Fcir.0b013e31828124ad https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/23239837 44 Gøtzsche PC, Jørgensen KJ (2013). "Screening for breast cancer with mammography.". The Cochrane database of systematic reviews 6: CD001877. doi:10.1002/14651858.CD001877.pub5. PMID 23737396. Haddock DRW. Cerebrovascular accidents in Ghana. Trans R Soc Trop Med Hyg 1970;64:300- 310. Hall JN, Moore S, Harper SB, Lynch JW. Global variability in fruit and vegetable consumption. Am J Prev Med 2009 36:402-409. Hill AG, Darko R, Seffah J, Adanu RMK, Anarfi JK, Duda RB. Health of urban Ghanaian women as identified by the Women’s Health Study of Accra. Int J Gyn Obstet 2007;99:150-156. Holtz B, Lauckner C. (2012). Diabetes management via mobile phones: a systematic review. Telemed J E Health.;18(3):175-84. http://dx.doi.org/10.1089/tmj.2011.0119 pmid: 22356525 Horvath T, Azman H, Kennedy GE, Rutherford GW (2012). Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection, Cochrane Database Syst Rev.; 3:CD009756. pmid: 22419345 Howard, BV; Wylie-Rosett, J (2002). "Sugar and cardiovascular disease: A statement for healthcare professionals from the Committee on Nutrition of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association.". Circulation 106 (4): 523–7. doi:10.1161/01.cir.0000019552.77778.04. PMID 12135957. IDF DIABETES ATLAS (2013). International Diabetes Federation.(6th ed.). p. 7. https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1002%2F14651858.CD001877.pub5 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/23737396 http://dx.doi.org/10.1089/tmj.2011.0119 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=22356525&dopt=Abstract http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=22419345&dopt=Abstract https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1161%2F01.cir.0000019552.77778.04 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/12135957 http://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf 45 Ikeme AC, Pole DJ, Pobee JO, Larbi E, Blankson J, Williams H. Cardiovascular status and blood pressure in a population sample in Ghana—the Mamprobi survey. Trop Geogr Med 1978; 30:313- 329. International Diabetes Federation (2006). "Diabetes Blue Circle Symbol". Retrieved 10 September, 2015. ISBN 2930229853. Jemal A, Bray, F, Center, MM, Ferlay, J, Ward, E, Forman, D (2011). "Global cancer statistics". CA: a cancer journal for clinicians 61 (2): 69–90. doi:10.3322/caac.20107. PMID 21296855. KDIGO (Kidney Disease Improving Global Outcomes (2013). "KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease" (PDF). Kidney Int Suppl 3 (1): 1–150. Retrieved 5 February 2016. KDIGO: Kidney Disease Improving Global Outcomes (2009). "KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD)" (PDF). Kidney Int 76 (Suppl 113). Kitabchi, AE; Umpierrez, GE; Miles, JM; Fisher, JN (2009). "Hyperglycemic crises in adult patients with diabetes.". Diabetes Care 32 (7): 1335–43. doi:10.2337/dc09- 9032. PMC 2699725. PMID 19564476. Krishna S, Boren SA, Balas EA. (2009). Healthcare via cell phones: a systematic review. Telemed J E Health.;15(3):231-40.http://dx.doi.org/10.1089/tmj.2008.0099 pmid: 19382860 Kushi LH, Doyle C, McCullough M; et al. (2012). "American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk http://www.diabetesbluecircle.org/ https://en.wikipedia.org/wiki/International_Standard_Book_Number https://en.wikipedia.org/wiki/Special:BookSources/2930229853 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.3322%2Fcaac.20107 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/21296855 http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO%20CKD-MBD%20GL%20KI%20Suppl%20113.pdf http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO%20CKD-MBD%20GL%20KI%20Suppl%20113.pdf http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO%20CKD-MBD%20GL%20KI%20Suppl%20113.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699725 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699725 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.2337%2Fdc09-9032 https://dx.doi.org/10.2337%2Fdc09-9032 https://en.wikipedia.org/wiki/PubMed_Central https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699725 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/19564476 http://dx.doi.org/10.1089/tmj.2008.0099 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=19382860&dopt=Abstract 46 of cancer with healthy food choices and physical activity". CA Cancer J Clin 62 (1): 30–67. doi:10.3322/caac.20140. PMID 22237782. Maher D, Waswa L, Baisley K, Karabarinde A, Unwin N (2011) Epidemiology of hypertension in low-income countries: a cross-sectional population-based survey in rural Uganda. J Hypertens 29: 1061–8. doi: 10.1097/hjh.0b013e3283466e90 Maher D, Waswa L, Baisley K, Karabarinde A, Unwin N, et al. (2011) Distribution of hyperglycaemia and related cardiovascular disease risk factors in low-income countries: a cross-sectional population-based survey in rural Uganda. Int J Epidemiol 40: 160–71. doi: 10.1093/ije/dyq156 Martínez-Castelao, A; JL. Górriz; J Bover; et al. (2014). "Consensus document for the detection and management of chronic kidney disease". Nefrologia 34 (2): 243– 62. doi:10.3265/Nefrologia.pre2014.Feb.12455. PMID 4658201. Martorell R, Khan KL, Hughes ML, Grummer- Strawn LM. Obesity in women from developing countries. Eur J Clin Nutr 2000;54:247-252. McGill HC, McMahan CA, Gidding SS (2008). "Preventing heart disease in the 21st century: implications of the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study". Circulation 117 (9): 1216–27. doi:10.1161/CIRCULATIONAHA.107.717033. PMID 18316498. Mendis, S.; Puska, P.; Norrving, Bo (2011). Global Atlas on Cardiovascular Disease Prevention and Control (PDF). World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization. pp. 3–48. ISBN 978-92-4-156437-3. https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.3322%2Fcaac.20140 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/22237782 http://www.revistanefrologia.com/linksolver/ft/ivp/0211-6995/34/243 http://www.revistanefrologia.com/linksolver/ft/ivp/0211-6995/34/243 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.3265%2FNefrologia.pre2014.Feb.12455 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/4658201 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1161%2FCIRCULATIONAHA.107.717033 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/18316498 http://whqlibdoc.who.int/publications/2011/9789241564373_eng.pdf?ua=1 http://whqlibdoc.who.int/publications/2011/9789241564373_eng.pdf?ua=1 https://en.wikipedia.org/wiki/International_Standard_Book_Number https://en.wikipedia.org/wiki/Special:BookSources/978-92-4-156437-3 47 Micha, R; Michas, G; Mozaffarian, D (2012). "Unprocessed red and processed meats and risk of coronary artery disease and type 2 diabetes—an updated review of the evidence.". Current atherosclerosis reports 14 (6): 515–24. doi:10.1007/s11883- 012-0282-8. PMC 3483430. PMID 23001745. Moran, AE; Forouzanfar, MH; Roth, GA; Mensah, GA; Ezzati, M; Murray, CJ; Naghavi, M (2014). "Temporal trends in ischemic heart disease mortality in 21 world regions, 1980 to 2010: the Global Burden of Disease 2010 study.". Circulation 129 (14): 1483–92. doi:10.1161/circulationaha.113.004042. PMID 24573352. National Cancer Institute (2012). "Obesity and Cancer Risk" .Retrieved 10 September, 2015 National Kidney Foundation (2002). "K/DOQI clinical practice guidelines for chronic kidney disease". Retrieved on 10 September, 2015 NCI (2014). "Targeted Cancer Therapies". Retrieved 10 September, 2015 Nyame PK, Bonsu-Bruce N, Amoah AG, Adjei S, Nyarko E, Amuah EA, et al. Current trends in the incidence of cerebrovascular accidents in Accra. West Afr J Med 1994;13:183-186. Owiredu WKBA, Adamu MS, Amidu N, Woode E, Bam V, Plange-Rhule J, et al. Obesity and Cardiovascular Risk Factors in a Pentecostal Population in Kumasi- Ghana. J Med Sci 2008; 8:682-690. Parkin, DM; Boyd, L; Walker, LC (2011). "16. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010.". British Journal of Cancer. 105 Suppl 2: S77–81. doi:10.1038/bjc.2011.489. PMC 3252065. PMID 22158327. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483430 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483430 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483430 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1007%2Fs11883-012-0282-8 https://dx.doi.org/10.1007%2Fs11883-012-0282-8 https://en.wikipedia.org/wiki/PubMed_Central https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483430 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/23001745 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1161%2Fcirculationaha.113.004042 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/24573352 http://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet#q3 http://www.kidney.org/professionals/KDOQI/guidelines_ckd http://www.kidney.org/professionals/KDOQI/guidelines_ckd http://www.cancer.gov/cancertopics/factsheet/Therapy/targeted https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252065 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252065 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1038%2Fbjc.2011.489 https://en.wikipedia.org/wiki/PubMed_Central https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252065 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/22158327 48 Pereira M, Lunet N, Azevedo A, Barros H (2009) Differences in prevalence, awareness, treatment and control of hypertension between developing and developed countries. J Hypertens (27): 963–975. doi: 10.1097/hjh.0b013e3283282f65 Picot, J; Jones, J; Colquitt, JL; Gospodarevskaya, E; Loveman, E; Baxter, L; Clegg, AJ (2009). "The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation". Health Technology Assessment (Winchester, England) 13 (41): 1–190, 215–357, iii–iv. doi:10.3310/hta13410. PMID 19726018. Plantinga LC, Tuot DS, Powe NR (2010). "Awareness of chronic kidney disease among patients and providers". Adv Chronic Kidney Dis 17 (3): 225–236. doi:10.1053/j.ackd.2010.03.002. PMC 2864779. PMID 20439091. Pobee JOM. Community-based high blood pressure programs in sub-Saharan Africa. Ethn Dis 1993;3 Suppl:S38-45. Pobee JOM. The Heart of the Matter: Community profile of cardiovascular diseases of a sub-Saharan African country. The Ghanaian Paradigm. The Mamprobi Cardiovascular Health Project 1975-1983. Accra: University of Ghana; 2006. Rippe, edited by Richard S. Irwin, James M. (2010). Manual of intensive care medicine (5th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 549. ISBN 9780781799928. RSSDI (2012).”Diabetes mellitus”. (Rev. 2nd ed.). New Delhi: Jaypee Brothers Medical Publishers. p. 235. ISBN 9789350254899. https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.3310%2Fhta13410 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/19726018 http://linkinghub.elsevier.com/retrieve/pii/S1548-5595%2810%2900045-5 http://linkinghub.elsevier.com/retrieve/pii/S1548-5595%2810%2900045-5 https://en.wikipedia.org/wiki/Digital_object_identifier https://dx.doi.org/10.1053%2Fj.ackd.2010.03.002 https://en.wikipedia.org/wiki/PubMed_Central https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2864779 https://en.wikipedia.org/wiki/PubMed_Identifier https://www.ncbi.nlm.nih.gov/pubmed/20439091 https://books.google.com/books?id=FbxupW1EHIcC&pg=PA549 https://books.google.com/books?id=FbxupW1EHIcC&pg=PA549 https://en.wikipedia.org/wiki/International_Standard_Book_Number https://en.wikipedia.org/wiki/Special:BookSources/9780781799928 https://books.google.com/books?id=7H6mYolrtUMC&pg=PA235 https://en.wikipedia.org/wiki/International_Standard_Book_Number https://en.wikipedia.org/wiki/Special:BookSources/9789350254899 49 Shi, Yuankai; Hu, Frank B (2014). "The global implications of diabetes and cancer". The Lancet 383 (9933): 1947–8. doi:10.1016/S0140-6736(14)60886-2. PMID 24910221. Spinks, A; Glasziou, PP; Del Mar, CB (2013). "Antibiotics for sore throat.". The Cochrane database of systematic reviews 11: CD000023. doi:10.1002/14651858.CD000023.pub4. PMID 24190439. Stephens J, Allen J. (2013). Mobile phone interventions to increase physical activity and reduce weight: a systematic review. J Cardiovasc Nurs.;28(4):320-9. http://dx.doi.org/10.1097/JCN.0b013e318250a3e7 pmid: 22635061 Sutcliffe, P; Connock, M; Gurung, T; Freeman, K; Johnson, S; Kandala, NB; Grove, A; Gurung, B; Morrow, S; Clarke, A (2013). "As