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Background: Advances in health and technology have reduced HIV to a more manageable communicable disease. Yet, stigma and discrimination against people with HIV remain critical barriers to ending the pandemic by 2030. Due to limited literature on stigma and discrimination in Ghana, we aimed to assess the experiences and predictors of stigma among PWH seeking healthcare in selected health facilities., Methods: This convergent parallel mixed-methods study involved 420 people with HIV responding to a quantitative survey and 25 PWH participating in qualitative interviews (9 in-depth interviews and 16 in focus group discussions). Respondents were recruited through systematic and purposive sampling techniques for the quantitative and qualitative aspects, respectively. Quantitative data were analyzed using Stata/SE version 16.0, with logistic regression models fitted to measure associations between predictor variables and experienced stigma. Qualitative data were analyzed thematically using NVivo software, employing an inductive approach., Results: Of the 420 participants, 58 (13.8%) reported ever experiencing stigma due to their HIV status. Among those who experienced stigma, 44 (75.9%) reported stigma in their communities, 24 (41.4%) in their homes, 15 (25.9%) at their workplaces, and 13 (22.4%) at health facilities. The most common forms of stigma were being gossiped about (26.0%), verbal insults/harassment (15.2%), and physical assault (8.3%). Qualitative findings corroborated these experiences, revealing impacts on healthcare access, social relationships, and mental health. Females (aOR = 13.10, 95% CI: 1.64-104.55) and persons with TB-HIV co-infection (aOR = 20.53, 95% CI: 3.28-128.56) had greater odds of experiencing stigma. PWH who were self-employed had lower odds of experiencing stigma at the HIV clinic (aOR = 0.07, 95% CI: 0.01-0.53, p = 0.009)., Conclusion: Experienced stigma ranged from low to moderate in different settings, with communities being the most common location. We observed differences in stigma experienced among PWH based on gender, employment status, and TB co-infection. These findings suggest a need for targeted, context-specific interventions to reduce HIV-related stigma in Ghana, with a particular focus on community-level interventions., Competing Interests: Declarations. Ethics approval and consent to participate: To abide by the Declaration of Helsinki, ethical approval was obtained from the Committee of Human Research Publications and Ethics at the Kwame Nkrumah University of Science and Technology (Reference number: CHRPE/AP/218/20). In addition, permission to access health facilities was obtained from the Christian Health Association of Ghana as part of an assessment of 40 facilities however only 20 were carried out due to inadequate funds. Written and/or verbal consent was obtained from the study participants after the data collectors explained the study procedures and assured them of the confidentiality of the information provided by the study participants. All ethical procedures and protocols were duly followed. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Hypertension and type 2 diabetes mellitus (T2DM) are important contributors to noncommunicable disease related morbidity and mortality. Health systems could benefit from exploring the use of Faith-Based Centres (FBC) to screen and link suspected cases for further care in order to help achieve Sustainable Development Goal (SDG) 3. The study investigated the role of faith-based screening for T2DM and hypertension and the linkage of cases to the healthcare system and examined the care cascade in the Kassena Nankana Districts of Northern Ghana., Methods: We screened individuals from 6 FBCs for elevated blood pressure and hyperglycaemia. Suspected hypertension and T2DM cases were referred to health facilities for confirmation and subsequently followed them up for 3 months. We assessed the prevalence of behavioural and metabolic risk factors, including hypertension and T2DM, and the retention of referred cases in the healthcare system over follow up period. We further assessed levels of awareness, treatment and adequate control of hypertension and T2DM., Results: A total of 631 participants were screened, (mean age 49 ± 16years, 73% female) from 6 Faith based Centres. More males than females reported smoking tobacco (14.5% vs. 0.7%) and been physically active (64.5% vs. 52.7%) while more females were obese (29.6 kg/m 2 vs. 14.5 kg/m 2 ) and had a higher mean waist circumference (89.0 cm IQR 75-116 cm vs. 84.2 cm IQR 72-107 cm), hip circumference (101.5 ± 10.6 cm vs. 96.4 ± 8.6 cm) and waist-to-hip ratio (0.86 ± 0.1 cm vs. 0.87 ± 0.1 cm) than males. The prevalence of confirmed hypertension and T2DM was 27.9% and 3.5% respectively with no observed sex differences. We observed deficits in the hypertension and T2DM care cascade with reported low awareness, treatment and uncontrolled levels. A 3-month follow up showed a retention in care of 100% in month one and 94.9% in the third month. There was an increase in treatment (39.4% in month-1 and 82.8% in month-3) and control (26.3% in month-1 and 76.3% in month-3) of hypertension and T2DM combined., Conclusion: Faith-based centres have the potential to enhance the screening, linkage to the healthcare system, and management of hypertension and T2DM. This improvement over the routine system could lead to earlier diagnoses, a reduction in complications, and decreased premature mortality from cardiovascular diseases. Consequently, these efforts would contribute significantly to achieving SDG 3., (© 2024. The Author(s).)

Background: A series of modifiable lifestyle factors, such as diet quality, physical activity, alcohol intake, and smoking, may drive the rising burden of type 2 diabetes (T2DM) among sub-Saharan Africans globally. It is unclear whether epigenetic changes play a mediatory role in the associations between these lifestyle factors and T2DM. We assessed the associations between a comprehensive lifestyle index, DNA methylation and T2DM among Ghanaian adults., Methods: We used whole-blood Illumina 450 k DNA methylation data from 713 Ghanaians from the Research on Obesity and Diabetes among African Migrants (RODAM) study. We constructed a comprehensive lifestyle index based on established cut-offs for diet quality, physical activity, alcohol intake, and smoking status. In the T2DM-free discovery cohort (n = 457), linear models were fitted to identify differentially methylated positions (DMPs) and differentially methylated regions (DMRs) associated with the lifestyle index after adjustment for age, sex, body mass index (BMI), and technical covariates. Associations between the identified DMPs and the primary outcome (T2DM), as well as secondary outcomes (fasting blood glucose (FBG) and HbA1c), were determined via logistic and linear regression models, respectively., Results: In the present study population (mean age: 52 ± 10 years; male: 42.6%), the comprehensive lifestyle index showed a significant association with one DMP annotated to an intergenic region on chromosome 7 (false discovery rate (FDR) = 0.024). Others were annotated to ADCY7, SMARCE1, AHRR, LOXL2, and PTBP1 genes. One DMR was identified and annotated to the GFPT2 gene (familywise error rate (FWER) from bumphunter bootstrap = 0.036). None of the DMPs showed significant associations with T2DM; directions of effect were positive for the DMP in the AHRR and inverse for all the other DMPs. Higher methylation of the ADCY7 DMP was associated with higher FBG (p = 0.024); LOXL2 DMP was associated with lower FBG (p = 0.023) and HbA1c (p = 0.049); and PTBP1 DMP was associated with lower HbA1c (p = 0.002)., Conclusions: In this explorative epigenome-wide association study among Ghanaians, we identified one DMP and DMR associated with a comprehensive lifestyle index not previously associated with individual lifestyle factors. Based on our findings, we infer that lifestyle factors in combination, affect DNA methylation, thereby influencing the risk of T2DM among Ghanaian adults living in different contexts., (© 2024. The Author(s).)

Background: The sustainability of diets consumed by African populations under socio-economic transition remains to be determined. This study developed and characterized a multi-dimensional Sustainable Diet Index (SDI) reflecting healthfulness, climate-friendliness, sociocultural benefits, and financial affordability using individual-level data of adults in rural and urban Ghana and Ghanaian migrants in Europe to identify the role of living environment in dietary sustainability., Methods: We used cross-sectional data from the multi-centre Research on Obesity and Diabetes among African Migrants Study (N = 3169; age range: 25-70 years). For the SDI construct (0-16 score points), we used the Diet Quality Index-International, food-related greenhouse gas emission, the ratio of natural to processed foods, and the proportion of food expenditure from income. In linear regression analyses, we estimated the adjusted ß-coefficients and 95% confidence intervals (CIs) for the differences in mean SDI across study sites (using rural Ghana as a reference), accounting for sociodemographic and lifestyle factors., Results: The overall mean SDI was 8.0 (95% CI: 7.9, 8.1). Participants in the highest SDI-quintile compared to lower quintiles were older, more often women, non-smokers, and alcohol abstainers. The highest mean SDI was seen in London (9.1; 95% CI: 8.9, 9.3), followed by rural Ghana (8.2; 95% CI: 8.0, 8.3), Amsterdam (7.9; 95% CI: 7.7, 8.1), Berlin (7.8; 95% CI: 7.6, 8.0), and urban Ghana (7.7; 95% CI: 7.5, 7.8). Compared to rural Ghana, the differences between study sites were attenuated after accounting for age, gender and energy intake. No further changes were observed after adjustment for lifestyle factors., Conclusion: The multi-dimensional SDI describes four dimensions of dietary sustainability in this Ghanaian population. Our findings suggest that living in Europe improved dietary sustainability, but the opposite seems true for urbanization in Ghana., (© 2024. The Author(s).)

Background: Health care is an indispensable element for economic growth and development of individuals and nations. Healthcare service quality is associated with patient satisfaction, ensuring the safety and security of patients, reducing mortality and morbidity, and improving the quality of life. Patient satisfaction with health service is linked to increased utilization following contendness with healthcare received from health providers. There is an increasing public perception of poor quality of care among patients visiting public health facilities in Ghana which translates into service dissatisfaction. Meanwhile, patient dissatisfaction will more likely result in poor utilization, disregard for medical advice, and treatment non-adherence. The study was conducted to assess patients' satisfaction with quality of care at the outpatient departments of selected health facilities in Kumasi, Ghana., Methods: An institutional-based analytical cross-sectional study was conducted among patients (aged ≥ 18 years) visiting outpatient departments of selected health facilities in Kumasi from October - December, 2019. A systematic sampling technique was adopted to collect quantitative information from 385 respondents using a structured questionnaire. At 95% confidence interval and 5% alpha level, two-level logistic regression models were performed. Model I estimated the crude associations and the effect of covariates was accounted for in Model II. The results were presented in odds ratio with a corresponding 95% confidence interval. All analysis were performed using STATA statistical software version 16.0., Results: Out of the 385 participants, 90.9% of the participants were satisfied with the services they received. Being married [AOR = 3.06, 95%CI = 1.07-8.74], agreeing that the facility is disability-friendly [AOR = 7.93, 95%CI = 2.07-14.43], facility has directional signs for navigation [AOR = 3.12, 95%=1.92-10.59] and the facility has comfortable and attractive waiting area [AOR = 10.02, 95%CI = 2.35-22.63] were associated with satisfaction with health service among patients. Spending more than 2 h at the health facility [AOR = 0.45, 95%CI = 0.04-0.93] and having perceived rude and irritating provider [AOR = 0.14, 95%CI = 0.04-0.51] had lower odds of satisfaction with health service received., Conclusion: There is a high patient satisfaction with services received at out-patient departments which is influenced by a multiplicity of factors; being married, and agreeing that the facility is disability-friendly, has directional signs for navigation, and the waiting area is comfortable and attractive. The study findings call for the need to develop and implement health delivery interventions and strategies (i.e. patient-centered interventions, disability-friendly facilities, and sustainability and improvement of quality service) to improve and sustain patient satisfaction levels with health care service. These strategies must be directed towards addressing inequalities in infrastructural development and inputs needed for healthcare delivery in the health system., (© 2024. The Author(s).)

Background: Globally, the population is rapidly ageing, stemming from a recent decline in mortality, and an increase in life expectancy. About 727 million people globally were aged ≥65 in 2020, and 1 in 6 people will be ≥65 years by 2050. About 7% of Ghana's population was over 60 years in 2010, and projected to be 12% by 2050. However, the aged are confronted with degenerative conditions that translate into difficulty with mobility. The study was conducted to investigate the difficulty with mobility among the aged in Ghana., Methods: The study utilised a cross-sectional dataset of the 2014/2015 (wave 2) Study on Global Ageing and Adult Health and included 1,856 participants aged ≥50 years. The survey command was applied to adjust for sampling biases and the design of the study. At 5% alpha level, a chi-square test of independence was conducted to determine the association between dependent and independent variables. At 95% confidence interval and 5% alpha level, three-level multilevel logistic regression models were performed. The fixed-effects were presented in odds ratio and the random effects were presented using the Intra-Class Correlation. All analysis were performed using STATA statistical software version 16.0., Results: Out of the 1,856 participants, 40.3% had difficulty with mobility. Additionally, age (80 and above) [AOR = 3.05, 95%CI = 1.78-5.22], self-reported poor/bad health status [AOR = 2.39, 95%CI = 1.35-4.23], having severe/extreme difficulty performing household activities [AOR = 25.12, 95%CI = 11.49-44.91], experienced severe/extreme bodily pains [AOR = 4.56, 95%CI = 2.16-9.64], severe/extreme sleep problems [AOR = 4.15, 95%CI = 1.68-10.29], and participants with difficulty with sight/vision [AOR = 1.56, 95%CI = 1.16-2.10] had higher odds of difficulty with mobility., Conclusion: The aged in Ghana had relatively higher prevalence (40.3%) of difficulty with mobility which is influenced by demographics, health status, and degeneration associated with ageing. This highlights the need to provide social support and strengthen social capital for the aged in Ghana, especially those with difficulty with vision, experiencing bodily pains and had poor health status. Additionally, the Government and stakeholders should provide assistive devices for the aged and geriatric care including recreational fields and care homes to address the health and physical needs of the aged in Ghana., Competing Interests: The authors have declared that no competing interests exist, (Copyright: © 2024 Boakye et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: This study assessed knowledge, behaviors, and perceptions towards hypertension following community dissemination on cardiovascular disease (CVD) risk within the Navrongo Health and Demographic Surveillance Site in Northern Ghana., Methods: A cross-sectional mixed methods study was conducted among middle aged men and women following education on CVD and their risk factors. Knowledge and attitudes of participants regarding hypertension were measured in 310 participants using a survey tool and the resultant data was analyzed with descriptive statistics. Focus group discussions (FDG) were used to assess perceptions of 40 study participants on their lived experiences with hypertension. Recorded interviews were transcribed verbatim and coded into themes using Nvivo 12 software before thematic analysis., Results: Of the 310 surveyed participants, 54% were women and the mean age was 50 ± 6 years. The results showed that 84% of participants had heard about hypertension, 70% knew it was an increase in blood pressure and could be caused by excess salt intake, poor diet and physical inactivity. About 22.3% of participants were aware of the had hypertension. In terms of management, majority of the participants were aware that hypertension could be treated with antihypertensive medication and that untreated or uncontrolled hypertension could result in adverse health consequences. Few participants had ever had their blood pressure measured and did not access screening or healthcare care services and rather perceived the health system as inadequate to screen, and manage hypertension., Conclusion: Though, knowledge on hypertension was high, awareness of hypertension status and access to screening and healthcare services was low. Community beliefs and perceptions strongly influence treatment, and control of hypertension. Effective sustained community dissemination efforts addressing misperceptions could improve hypertension treatment and control., (© 2024. The Author(s).)

Introduction: Environmental exposures, such as ambient air pollution and household fuel use affect health and under-5 mortality (U5M) but there is a paucity of data in the Global South. This study examined early-life exposure to ambient particulate matter with a diameter of 2.5 µm or less (PM 2.5 ), alongside household characteristics (including self-reported household fuel use), and their relationship with U5M in the Navrongo Health and Demographic Surveillance Site (HDSS) in northern Ghana., Methods: We employed Satellite-based spatiotemporal models to estimate the annual average PM 2.5 concentrations with the Navrongo HDSS area (1998 to 2016). Early-life exposure levels were determined by pollution estimates at birth year. Socio-demographic and household data, including cooking fuel, were gathered during routine surveillance. Cox proportional hazards models were applied to assess the link between early-life PM2.5 exposure and U5M, accounting for child, maternal, and household factors., Findings: We retrospectively studied 48,352 children born between 2007 and 2017, with 1872 recorded deaths, primarily due to malaria, sepsis, and acute respiratory infection. Mean early-life PM 2.5 was 39.3 µg/m 3 , and no significant association with U5M was observed. However, Children from households using "unclean" cooking fuels (wood, charcoal, dung, and agricultural waste) faced a 73 % higher risk of death compared to those using clean fuels (adjusted HR = 1.73; 95 % CI: 1.29, 2.33). Being born female or to mothers aged 20-34 years were linked to increased survival probabilities., Interpretation: The use of "unclean" cooking fuel in the Navrongo HDSS was associated with under-5 mortality, highlighting the need to improve indoor air quality by introducing cleaner fuels., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [AM is supported by the Global Health Support Program of the University Medical Center Utrecht (UMCU), University of Utrecht, the Netherlands. All other authors declare no competing interests]., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Loneliness is understood as a subjective experience resulting from unmet social relationship expectations. As most loneliness research has been conducted in higher-income-countries, there is limited understanding of loneliness in relation to diverse cultural, economic, and socio-political factors. To address this gap, the present review systematically synthesises existing qualitative studies on the experience of loneliness and social relationship expectations in lower- and middle-income countries (LMICs). Between June and July 2022, six online databases (Embase, Ovid Medline, APA PsycINFO, Global Health, Web of Science, Google Scholar) were searched for peer-reviewed studies from LMICs on loneliness using qualitative methods. There were no restrictions on publication date, language, or study setting. Studies that solely focused on social isolation or were conducted with children (<16 years) were excluded. Risk of bias was assessed with the Critical Appraisal Skills Programme. After deduplication, a total of 7866 records were identified and screened for inclusion, resulting in 24 studies published between 2002 and 2022. The included studies represent data from 728 participants in 15 countries across West Africa (Ghana, Nigeria, Niger, Mali), East Africa (Uganda, Kenya), North Africa (Egypt), West Asia (Iran), South Asia (India, Pakistan, Sri Lanka) and Southeast Asia (Myanmar, Cambodia, Indonesia, Philippines). Data were analysed combining inductive and deductive coding, summarised using narrative synthesis, and examined by geographical region. Common features of loneliness included rejection, overthinking, and pain. Loneliness was related to depression across regions. Whereas loneliness tended to be distinguished from social isolation in studies from Africa, it tended to be related with being alone in studies from Asia. Poverty and stigma were common barriers to fulfilling social relationship expectations. This review illustrates how loneliness and expectations are contextually embedded, with some expectations possibly being specific to a certain culture or life stage, having implications for assessment of and interventions for loneliness worldwide., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: "Choosing All Together" (CHAT), is a community engagement tool designed to give the public a voice in how best to allocate limited resources to improve population health. This process evaluation explored the mechanisms through which CHAT generates community engagement., Method: The CHAT tool was adapted and implemented for use in two rural communities (Nanoro, Burkina Faso, and Navrongo, Ghana) and one urban township (Soweto, South Africa) to prioritize maternal and child nutrition interventions. Community discussions were audio-recorded, transcribed, and translated into English. Twenty-two transcripts, including six each from Navrongo and Soweto and 10 from Nanoro, were analysed thematically to generate data driven codes and themes to explain mechanisms underlying the CHAT process. The process evaluation was based on the UK MRC process evaluation guidance., Results: Seven themes describing the functions and outcomes of CHAT were identified. Themes described participants deliberating trade-offs, working together, agreeing on priorities, having a shared vision, and increasing their knowledge, also the skills of the facilitator, and a process of power sharing between participants and researchers. Participants came to an agreement of priorities when they had a shared vision. Trained facilitators are important to facilitate meaningful discussion between participants and those with lower levels of literacy to participate fully., Conclusion: CHAT has been shown to be adaptable and useful in prioritising maternal and child nutrition interventions in communities in Burkina Faso, Ghana, and South Africa. Conducting CHAT in communities over a longer period and involving policy-makers would increase trust, mutual respect and develop partnerships., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Watson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: To explore how specific measures of antenatal care utilization are associated with outcomes in pregnancies complicated by preeclampsia and eclampsia in Ghana., Study Design: Participants were adult pregnant women with preeclampsia or eclampsia at a tertiary hospital in Ghana. Antenatal care utilization measures included timing of first visit, total visits, facility and provider type, and referral status. Antenatal visits were characterized by former and current World Health Organization recommendations, and by gestational age-based adequacy., Main Outcome Measures: Composites of maternal complications and poor neonatal outcomes. Multivariate logistic regressions identified associations with antenatal care factors., Results: Among 1176 participants, median number of antenatal visits was 5.0 (IQR 3.0-7.0), with 72.9% attending ≥4 visits, 19.4% attending ≥8 visits, and 54.9% attending adequate visits adjusted for gestational age. Care was most frequently provided in a government polyclinic (n = 522, 47.2%) and by a midwife (n = 704, 65.1%). Odds of the composite maternal complications were lower in women receiving antenatal care at a tertiary hospital (aOR 0.47, p = 0.01). Odds of poor neonatal outcomes were lower in women receiving antenatal care at a tertiary hospital (aOR 0.56, p < 0.001), by a specialist Obstetrician/Gynecologist (aOR 0.58, p < 0.001), and who attended ≥8 visits (aOR 0.67, p = 0.04). Referred women had twice the odds of a maternal complication (aOR 2.12, p = 0.007) and poor neonatal outcome (aOR 1.68, p = 0.002)., Conclusions: Fewer complications are seen after receiving antenatal care at tertiary facilities. Attending ≥8 visits reduced poor neonatal outcomes, but didn't impact maternal complications. Quality, not just quantity, of antenatal care is essential., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 International Society for the Study of Hypertension in Pregnancy. All rights reserved.)

Introduction: Diabetes is largely a self-managed disease; thus, care outcomes are closely linked to self-management behaviours. Structured self-management education (DSME) interventions are, however, largely unavailable in Africa., Aim: We sought to characterise DSME interventions in two urban low-resource primary settings; and to explore diabetes self-management knowledge and behaviours, of persons living with diabetes (PLD)., Research Design and Methods: A convergent parallel mixed-methods study was conducted between January and February 2021 in Accra, Ghana. The sampling methods used for selecting participants were total enumeration, consecutive sampling, purposive and judgemental sampling. Multivariable regression models were used to study the association between diabetes self-management knowledge and behaviours. We employed inductive content analysis of informants' experiences and context, to complement the quantitative findings., Results: In total, 425 PLD (70.1% (n = 298) females, mean age 58 years (SD 12), with a mean blood glucose of 9.4 mmol/l (SD 6.4)) participated in the quantitative study. Two managers, five professionals, two diabetes experts and 16 PLD participated in in-depth interviews. Finally, 24 PLD were involved in four focus group discussions. The median diabetes self-management knowledge score was 40% ((IQR 20-60). For every one unit increase in diabetes self-management knowledge, there were corresponding increases in the diet (5%;[95% CI: 2%-9%, p<0.05]), exercise (5%; [95% CI:2%-8%, p<0.05]) and glucose monitoring (4%;[95% CI:2%-5%, p<0.05]) domains of the diabetes self-care activities scale respectively. The DSME interventions studied, were unstructured and limited by resources. Financial constraints, conflicting messages, beliefs, and stigma were the themes underpinning self-management behaviour., Conclusions: The DSME interventions studied were under-resourced, and unstructured. Diabetes self-management knowledge though limited, was associated with self-management behaviour. DSME interventions in low resource settings should be culturally tailored and should incorporate sessions on mitigating financial constraints. Future studies should focus on creating structured DSME interventions suited to resource-constrained settings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lamptey et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Adult-onset diabetes mellitus (here: aDM) is not a uniform disease entity. In European populations, five diabetes subgroups have been identified by cluster analysis using simple clinical variables; these may elucidate diabetes aetiology and disease prognosis. We aimed at reproducing these subgroups among Ghanaians with aDM, and establishing their importance for diabetic complications in different health system contexts. We used data of 541 Ghanaians with aDM (age: 25-70 years; male sex: 44%) from the multi-center, cross-sectional Research on Obesity and Diabetes among African Migrants (RODAM) Study. Adult-onset DM was defined as fasting plasma glucose (FPG) ≥ 7.0 mmol/L, documented use of glucose-lowering medication or self-reported diabetes, and age of onset ≥ 18 years. We derived subgroups by cluster analysis using (i) a previously published set of variables: age at diabetes onset, HbA1c, body mass index, HOMA-beta, HOMA-IR, positivity of glutamic acid decarboxylase autoantibodies (GAD65Ab), and (ii) Ghana-specific variables: age at onset, waist circumference, FPG, and fasting insulin. For each subgroup, we calculated the clinical, treatment-related and morphometric characteristics, and the proportions of objectively measured and self-reported diabetic complications. We reproduced the five subgroups: cluster 1 (obesity-related, 73%) and cluster 5 (insulin-resistant, 5%) with no dominant diabetic complication patterns; cluster 2 (age-related, 10%) characterized by the highest proportions of coronary artery disease (CAD, 18%) and stroke (13%); cluster 3 (autoimmune-related, 5%) showing the highest proportions of kidney dysfunction (40%) and peripheral artery disease (PAD, 14%); and cluster 4 (insulin-deficient, 7%) characterized by the highest proportion of retinopathy (14%). The second approach yielded four subgroups: obesity- and age-related (68%) characterized by the highest proportion of CAD (9%); body fat-related and insulin-resistant (18%) showing the highest proportions of PAD (6%) and stroke (5%); malnutrition-related (8%) exhibiting the lowest mean waist circumference and the highest proportion of retinopathy (20%); and ketosis-prone (6%) with the highest proportion of kidney dysfunction (30%) and urinary ketones (6%). With the same set of clinical variables, the previously published aDM subgroups can largely be reproduced by cluster analysis in this Ghanaian population. This method may generate in-depth understanding of the aetiology and prognosis of aDM, particularly when choosing variables that are clinically relevant for the target population., (© 2023. The Author(s).)

Background: Caesarean section (CS) rates are rising. Shared decision making (SDM) is a component of patient-centered communication which requires adequate information and awareness. Women in Ghana have varying perceptions about the procedure. We sought to explore mothers' knowledge. perceptions and SDM-influencing factors about CSs., Methods: A transdisciplinary mixed-methods study was conducted at the maternity unit of Korle-Bu Teaching Hospital in Accra, Ghana from March to May, 2019. Data collection was done in four phases: in-depth interviews (n = 38), pretesting questionnaires (n = 15), three focus group discussions (n = 18) and 180 interviewer administered questionnaires about SDM preferences. Factors associated with SDM were analyzed using Pearson's Chi-square test and multiple logistic regression., Results: Mothers depicted a high level of knowledge regarding medical indications for their CS but had low level of awareness of SDM. The perception of a CS varied from dangerous, unnatural and taking away their strength to a life-saving procedure. The mothers had poor knowledge about pain relief in labour and at Caesarean section. Health care professionals attributed the willingness of mothers to be involved in SDM to their level of education. Husbands and religious leaders are key stakeholders in SDM. Insufficient consultation time was a challenge to SDM according to health care professionals and post-partum mothers. Women with parity ≥ 5 have a reduced desire to be more involved in shared decision making for Caesarean section. AOR = 0.09, CI (0.02-0.46)., Conclusion: There is a high knowledge about the indications for CS but low level of awareness of and barriers to SDM. The fewer antenatal care visits mothers had, the more likely they were to desire more involvement in decision making. Aligned to respectful maternity care principles, greater involvement of pregnant women and their partners in decision making process could contribute to a positive pregnancy experience. Education, including religious leaders and decision- making tools could contribute to the process of SDM., (© 2023. The Author(s).)

Background: Hypertensive disorders of pregnancy (HDP) remain a leading global health problem with complex clinical presentations and potentially grim birth outcomes for both mother and fetus. Improvement in the quality of maternal care provision and positive women's experiences are indispensable measures to reduce maternal and perinatal adverse outcomes., Objective: To explore the perspectives and lived experiences of healthcare provision among women with HDP and the associated challenges., Methods: A multi-center qualitative study using in-depth interviews (IDIs) and focus group discussions (FGDs) was conducted in five major referral hospitals in the Greater Accra Region of Ghana between June 2018 and March 2019. Women between 26 and 34 weeks' gestation with confirmed HDP who received maternity care services were eligible to participate. Thematic content analysis was performed using the inductive analytic framework approach., Results: Fifty IDIs and three FGDs (with 22 participants) were conducted. Most women were between 20 and 30 years, Akans (ethnicity), married/cohabiting, self-employed and secondary school graduates. Women reported mixed (positive and negative) experiences of maternal care. Positive experiences reported include receiving optimal quality of care, satisfaction with care and good counselling and reassurance from the health professionals. Negative experiences of care comprised ineffective provider-client communication, inappropriate attitudes by the health professionals and disrespectful treatment including verbal and physical abuse. Major health system factors influencing women's experiences of care included lack of logistics, substandard professionalism, inefficient national health insurance system and unexplained delays at health facilities. Patient-related factors that influenced provision of care enumerated were financial limitations, chronic psychosocial stress and inadequate awareness about HDP., Conclusion: Women with HDP reported both positive and negative experiences of care stemming from the healthcare system, health providers and individual factors. Given the importance of positive women's experiences and respectful maternal care, dedicated multidisciplinary women-centered care is recommended to optimize the care for pregnant women with HDP., (© 2023. The Author(s).)

Background: DNA-methylation has been associated with plasma lipid concentration in populations of diverse ethnic backgrounds, but epigenome-wide association studies (EWAS) in West-Africans are lacking. The aim of this study was to identify DNA-methylation loci associated with plasma lipids in Ghanaians., Methods: We conducted an EWAS using Illumina 450k DNA-methylation array profiles of extracted DNA from 663 Ghanaian participants. Differentially methylated positions (DMPs) were examined for association with plasma total cholesterol (TC), LDL-cholesterol, HDL-cholesterol, and triglycerides concentrations using linear regression models adjusted for age, sex, body mass index, diabetes mellitus, and technical covariates. Findings were replicated in independent cohorts of different ethnicities., Findings: We identified one significantly associated DMP with triglycerides (cg19693031 annotated to TXNIP, regression coefficient beta -0.26, false discovery rate adjusted p-value 0.001), which replicated in-silico in South African Batswana, African American, and European populations. From the top five DMPs with the lowest nominal p-values, two additional DMPs for triglycerides (CPT1A, ABCG1), two DMPs for LDL-cholesterol (EPSTI1, cg13781819), and one for TC (TXNIP) replicated. With the exception of EPSTI1, these loci are involved in lipid transport/metabolism or are known GWAS-associated loci. The top 5 DMPs per lipid trait explained 9.5% in the variance of TC, 8.3% in LDL-cholesterol, 6.1% in HDL-cholesterol, and 11.0% in triglycerides., Interpretation: The top DMPs identified in this study are in loci that play a role in lipid metabolism across populations, including West-Africans. Future studies including larger sample size, longitudinal study design and translational research is needed to increase our understanding on the epigenetic regulation of lipid metabolism among West-African populations., Funding: European Commission under the Framework Programme (grant number: 278901)., Competing Interests: Declaration of interests E.L.L. is a voluntary member of the junior council of Amsterdam Public Health Research Institute, Global Health section. All other authors declared no conflicts., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The extent to which psychosocial stress relates to type 2 diabetes among sub-Saharan Africans is not well understood. We assessed associations of psychosocial stresses with type 2 diabetes status and glycaemic control among Ghanaians., Methods: We used data from Research on Obesity and Diabetes among African Migrants (RODAM) study. We performed logistic and linear regression models to assess association of psychosocial stresses with type 2 diabetes and HbA1c respectively with adjustments for age, sex, education and other stresses. We also assessed moderation effects of migration status (migrant Ghanaians vs. non-migrant Ghanaians), age, sex and education by adding interaction terms in models., Results: Four thousand eight hundred and forty one Ghanaians were included with 44% resident in Ghana, 62% women, mean age of 46 years and 10% having type 2 diabetes. Psychosocial stress at home and at work were not associated with type 2 diabetes or HbA1c levels. Negative life events in past 12 months were negatively associated with type 2 diabetes (adjusted odds ratio = 0.93, 95% CI 0.87-0.99). Perceived discrimination was positively associated with type 2 diabetes (aOR = 1.01, 95% CI 1.004-1.03). Both associations were more pronounced in men. Perceived discrimination was also positively associated with HbA1c levels, especially among those with type 2 diabetes (adjusted β = 0.01, 95% CI 0.007-0.02)., Conclusions: Perceived discrimination and negative life events are associated with type 2 diabetes and glycaemic control among Ghanaians, especially in men. Further studies are needed to identify context-specific mechanisms underlying these associations., (© 2022 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Objective: To describe the capacity of primary health care facilities to manage obstetric referrals, the reasons, and processes for managing obstetric referrals, and how an enhanced inter-facility communication system may have influenced these., Design: Mixed methods comparing data before and during the intervention period., Setting: Three districts in the Greater Accra region, Ghana from May 2017 to February 2018., Participants: Referred pregnant women and their relatives, health workers at referring and referral facilities, facility and district health managers., Intervention: An enhanced inter-facility communication system for obstetric referrals., Results: Twenty-two facilities and 673 referrals were assessed over the period. The major reason for referrals was pregnancy complications (85.5%). Emergency obstetric medicines - oxytocin and magnesium sulfate (MgSO 4 ) were available in 81.8% and 54.5% facilities, respectively, and a health worker accompanied 110(16.3%) women to the referral centre. Inter-facility communication about the referral occurred for 240 (35.7%) patients. During the intervention period, referrals joining queues at the referral facility decreased (7.8% to 0.0%; p=0.01), referrals coming in with referral notes improved (78.4% to 91.2%) and referrals with inter-facility communication improved (43.1% to 52.9%). Health workers and managers reported improvement in feedback to lower-level facilities and better filling of referral forms., Conclusion: Facilities had varying levels of availability of infrastructure, protocols, guidelines, services, equipment, and logistics for managing obstetric referrals. Enhanced inter-facility communication for obstetric referrals which engages health workers and provides requisite tools, can facilitate an efficient referral process for desired outcomes., Funding: This study was funded by the WHO/TDR Postdoctoral grant number B40347 to the NMIMR., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

Background: Type 2 diabetes is a significant public health problem globally and associated with significant morbidity and mortality. Diabetes self-management education and support (DSMES) programmes are associated with improved psychological and clinical outcomes. There are currently no structured DSMES available in Ghana. We sought to adapt an evidence-based DSMES intervention for the Ghanaian population in collaboration with the local Ghanaian people., Methods: We used virtual engagements with UK-based DSMES trainers, produced locally culturally and linguistically appropriate content and modified the logistics needed for the delivery of the self-management programme to suit people with low literacy and low health literacy levels., Conclusions: A respectful understanding of the socio-cultural belief systems in Ghana as well as the peculiar challenges of low resources settings and low health literacy is necessary for adaptation of any DSMES programme for Ghana. We identified key cultural, linguistic, and logistic considerations to incorporate into a DSMES programme for Ghanaians, guided by the Ecological Validity Model. These insights can be used further to scale up availability of structured DSMES in Ghana and other low- middle- income countries., (© 2022. The Author(s).)

Background: Women at risk of cardiovascular disease (CVD) may be missed with current eligibility criteria for CVD risk screening, particularly those from ethnic minority groups, among whom high risk is prevalent at a younger age. Early menopause (EM; menopause before 45 years) is associated with increased risk of CVD, and may be a potential eligibility criterion for CVD risk screening., Aims and Objectives: To determine the contribution of EM to current criteria from patient history (having a family history of CVD, current smoking, obesity and age over 50 years) for identifying women eligible for CVD risk screening in a multi-ethnic population., Methods and Results: We used baseline data (2011-2015) from 4512 women aged 45-70 years of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan ethnic origin from the HELIUS study (Amsterdam, Netherlands). Models based on current eligibility criteria with and without EM were compared on area under the curve (AUC) with regard to estimated 10-year CVD risk using the Dutch SCORE. Overall, models with EM had a higher AUC, but changes were not statistically significant. In our total sample of women aged between 45 and 70 years, the AUC changed from 0.70 (95%CI 0.69-0.72) to 0.71 (95%CI 0.69-0.72). Among women aged 45-50 years the AUC changed from 0.66 (95%CI 0.58-0.74) to 0.68 (95%CI 0.59-0.74). Results were consistent across ethnic groups., Conclusions: The addition of EM to current eligibility criteria did not improve the detection of women at high CVD risk in a multi-ethnic sample of women aged 45-70 years., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: Hypertension prevalence is high among African migrants, but the determinants of hypertension in migrants in Europe in relation to the population in the country of origin still needs to be elucidated. Therefore, the aim of this study was to assess the determinants of hypertension in Ghanaians residing in Ghana and Europe., Methods: The current study used baseline data of 5659 participants, aged 25-70 years, of the Research on Obesity and Diabetes among African Migrants study. Multivariate logistic regression analysis was used to assess sociodemographic, lifestyle, psychosocial, anthropometric and health factors independently associated with hypertension in Ghanaians living in rural and urban Ghana, and Ghanaian migrants living in Europe., Results: Across all sites, older age (both sexes; odds ratio 1.07, 95% confidence interval 1.06-1.08) and diabetes (females only; 2.02, 1.54-1.67) were independently associated with hypertension. The other determinants of hypertension differed between geographical locations. Higher waist circumference (1.12, 1.05-1.20) was independently associated with hypertension in rural-Ghanaian males, as was higher body mass index (1.15, 1.03- 1.28) in urban-Ghanaian males, higher waist circumference (1.04, 1.01-1.07) and diabetes (1.75, 1.17-2.63) in European-Ghanaian males. In European-Ghanaian females, high alcohol intake (1.88, 1.01 -3.53) and waist circumference (1.04, 1.02- 1.06) were associated with hypertension, whereas in rural-Ghanaian females, a higher educational level (0.28, 0.08-0.98) was inversely associated with hypertension., Conclusion: The current study identified several modifiable determinants of hypertension in Ghanaians, with differences between populations residing in various geographical locations. This highlights the importance of development and implementation of context-specific interventions targeting these determinants to reduce the burden of hypertension among Ghanaian migrants and nonmigrants., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Heightened food insecurity in the hunger season increases the risk of severe acute malnutrition (SAM) in childhood. This study examined the association of season of birth with SAM in a Guinean Sahelian ecological zone. We analyzed routine health and sociodemographic surveillance data from the Navrongo Health and Socio-demographic Surveillance System collected between 2011 and 2018. January-June, the period of highest food insecurity, was defined as the hunger season. We defined moderate acute malnutrition as child mid-upper arm circumference (MUAC) between 115 mm and 135 mm and SAM as MAUC ≤ 115 mm. We used adjusted logistic regression to quantify the association between the season of birth and SAM in children aged 6-35 months. From the 29,452 children studied, 24% had moderate acute malnutrition. Overall, 1.4% had SAM, with a higher prevalence (1.8%) in the hunger season of birth. Compared with those born October-December, adjusted odds ratios (aOR) and 95% confidence interval (95% CI) for SAM were increased for children born in the hunger season: January-March (1.77 [1.31-2.39]) and April-June (1.92 [1.44-2.56]). Low birth weight, age at an assessment of nutritional status, and ethno-linguistic group were also significantly associated with SAM in adjusted analyses. Our study established that being born in the hunger season is associated with a higher risk of severe acute malnutrition. The result implies improvement in the food supply to pregnant and lactating mothers through sustainable agriculture or food system change targeting the hunger season may reduce the burden of severe acute malnutrition., (© 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Importance: Carotid atherosclerosis and microalbuminuria are associated with atherosclerotic cardiovascular disease (ASCVD) but are understudied in sub-Saharan Africa., Objective: To evaluate the association of carotid atherosclerosis and microalbuminuria with 10-year ASCVD risk in middle-aged sub-Saharan African individuals., Design, Setting, and Participants: This cross-sectional study conducted analyses of baseline data from the African-Wits-INDEPTH (International Network for the Demographic Evaluation of Populations and Their Health in Low- and Middle-Income Countries) genomic study (AWI-Gen). Women and men aged 40 to 60 years without baseline CVD and drawn from Burkina Faso, Ghana, Kenya, and South Africa were included., Main Outcomes and Measures: Hypotheses for the analyses were formulated after data collection. The main exposures were carotid atherosclerosis, assessed using carotid intima-media thickness (CIMT) using B-mode ultrasonography, and microalbuminuria, measured using spot urine albumin (SUA) and urine albumin-creatinine ratio (uACR). The main outcome was high ASCVD risk, defined as a 2018 Pooled Cohort Equations score of 7.5% or greater. Associations were estimated using adjusted multivariable logistic regression analyses., Findings: A total of 9010 participants with a mean (SD) age of 50 (6) years and 4533 (50.3%) women were included. High CIMT, SUA, and uACR were each associated with older age (eg, mean [SD] age of participants with high vs reference range CIMT: 55 [5] years vs 50 [6] years; P < .001) and high prevalence of both diabetes and hypertension (eg, hypertension among those with high vs reference range SUA: 213 of 1117 [19.1%] vs 356 of 2549 [14.0%]; P < .001). Smokers were likely to have higher vs reference range SUA (210 [18.8%] vs 407 [16.0%]) and uACR (138 of 707 [19.5%] vs 456 of 2797 [16.3%]). Carotid atherosclerosis was common in Burkina Faso (82 of 262 [31.3%]) and Ghana (91 [34.7%]), while microalbuminuria, measured by SUA, was common in Kenya (272 [24.4%]) and South Africa (519 [46.5%]). SUA was associated with higher odds of carotid atherosclerosis (odds ratio [OR], 1.77; 95% CI, 1.04-3.01) compared with uACR (OR, 0.51; 95% CI, 0.27-0.95). Common CIMT, SUA, and uACR were associated with 10-year ASCVD risk, with CIMT having a stronger association with 10-year ASCVD risk in both women (OR, 1.95; 95% CI, 1.78-2.14) and men (OR, 1.73; 95% CI, 1.55-1.93) than SUA (women: OR, 1.29; 95% CI, 1.12-1.43; men: OR, 1.46; 95% CI, 1.26-1.55) and uACR (women: OR, 1.32; 95% CI, 1.10-1.54; men: OR, 1.35; 95% CI, 1.15-1.46)., Conclusions and Relevance: The presence of microalbuminuria measured by SUA may indicate risk of subclinical carotid atherosclerosis and high 10-year ASCVD risk in middle-aged residents of sub-Saharan Africa. These data should be confirmed in longitudinal studies of cardiovascular events.

Psychosocial stressors have significant health and socio-economic impacts on individuals. We examined the prevalence and correlates of psychosocial stressors among non-migrant and migrant Ghanaians as there is limited research in these populations. The study was cross-sectional and quantitative in design. A majority of the study participants had experienced stress, discrimination and negative life events. Increased age, female sex, strong social support and high sense of mastery were associated with lower odds of experiencing psychosocial stressors in both populations. Interventions should be multi-level in design, focusing on the correlates which significantly influence the experience of psychosocial stressors.

Background: Hypertension (HTN) is a growing public health problem in sub-Saharan Africa (SSA) and SSA migrants in Europe. Elevated levels of inflammatory marker C-reactive protein (CRP) have been linked to HTN but the relationship of CRP and HTN among SSA populations has not been studied. To address this knowledge gap, we studied the association between CRP and HTN in migrant and nonmigrant SSA populations residing in different settings., Methods: Cross-sectional data from the multicentre Research on Obesity and Diabetes among African Migrants (RODAM) study were analysed including 5683 Ghanaians aged at least 18 years, residing in rural and urban Ghana, and Europe. Multivariate logistic regression analyses were used to assess the association between high levels of CRP (≥3 mg/l) and HTN (SBP ≥140 mmHg and/or DBP ≥90 mmHg and/or use of antihypertensive medication) per geographical site and sex., Results: The association between CRP levels and HTN varied by sex and geographical location. In age-adjusted models, there was an association between high CRP levels and HTN in urban-Ghanaian women (odds ratio 1.50, 95% confidence interval 1.10-2.03), and European-Ghanaian men (1.68, 1.16-2.43) and women (1.63, 1.28-2.07). However, these associations were attenuated after adjustment for conventional risk factors, especially BMI. No association was found in rural-Ghanaians or urban-Ghanaian men., Conclusion: Our findings show an association between CRP and HTN among Ghanaian migrants and urban-Ghanaian women, however, this was largely explained by conventional risk factors. Thus, prevention of conventional risk factors, in particular obesity, may help to reduce the potentially low-grade inflammatory mechanism underlying HTN., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Aims: Low serum potassium concentration is associated with hypertension, but whether the same association can be found in African origin populations, is unknown. We assessed serum potassium concentration, and its association with hypertension among Ghanaians living in different geographical locations., Methods: Baseline data of 962 rural, 1420 urban, and 2947 migrant Ghanaians from the Research on Obesity and Diabetes among African Migrants study were analysed. Mean serum potassium concentration was compared between the groups, and the association between serum potassium and hypertension was assessed using multivariate regression analyses., Results: Mean serum potassium concentration was higher in rural Ghana (4.28, 95% confidence interval 4.25-4.32 mmol/L) than in Ghanaians living in Amsterdam (3.90, 3.88-3.92 mmol/L) and London (4.11, 4.07-4.14 mmol/L), but lower than in Ghanaians living in urban Ghana (4.38, 4.34-4.42 mmol/L) and Berlin (4.57, 4.51-4.62 mmol/L) in both sexes. In the age-adjusted analyses, serum potassium was associated with hypertension in urban- (odds ratio 0.44, 0.23-0.82), London- (0.34, 0.17-0.64) and Amsterdam-Ghanaian males (0.41, 0.20-0.86), and in rural- (0.49, 0.28-0.84), London- (0.29, 0.17-0.49) and Amsterdam-Ghanaian females (0.33, 0.17-0.64). However, after adjustment for demographic, lifestyle, and health factors, serum potassium was associated with hypertension in Amsterdam-Ghanaian males only (0.12, 0.02-0.59)., Conclusions: This study shows differences in mean serum potassium among Ghanaian populations living in different locations in Europe and Ghana, and different associations with hypertension between sites. Further research should focus on elucidating the mechanism underlying potassium handling and blood pressure regulation in African populations, in order to mitigate the burden of hypertension among these populations., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: Multimorbidity is a growing public health concern due to the increasing burden of non-communicable diseases, yet information about multimorbidity in low- and middle-income countries and migrant populations is scarce. We aimed to investigate the distribution and patterns of multimorbidity in rural and urban areas in Ghana and Ghanaian migrants in Europe. Methods: The RODAM cross-sectional study included 4,833 participants. Multimorbidity was defined as presence of multiple non-communicable chronic conditions. Patterns were determined from frequent combination of conditions. Prevalence ratios were estimated by logistic regression. Results: Prevalence of multimorbidity was higher in women and in urban Ghana and Europe. We observed a cardiometabolic pattern in all sites as well as circulatory-musculoskeletal and metabolic-musculoskeletal combinations in Ghana. Multimorbidity prevalence ratios were higher in Europe (men 1.47, 95% CI 1.34-1.59, women 1.18, 1.10-1.26) and urban Ghana (men 1.46, 1.31-1.59, women 1.27, 1.19-1.34). Conclusion: Distribution and patterns of multimorbidity differed by sex and site. With a higher burden of multimorbidity in urban areas, prevention strategies should focus on forestalling its increase in rapidly growing rural areas., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Marzà-Florensa, Boateng, Agyemang, Beune, Meeks, Bahendeka, Levitt and Klipstein-Grobusch.)

Background: Early-life factors (ELFs) such as childhood nutrition and childhood socio-economic status could be the drivers of the increase in metabolic syndrome (MetSyn) among African populations, but data are lacking. This study evaluated whether markers of childhood nutritional status and childhood socio-economic status were associated with MetSyn in adulthood among migrant Ghanaians living in Europe and non-migrant Ghanaians living in Ghana., Methods: Data from the Research on Obesity and Diabetes among African Migrants (RODAM) study, involving 2008 migrants and 2320 non-migrants aged ≥25 years, were analysed for this study. We used leg-length to height ratio (LHR), which is an anthropometric marker of childhood nutritional status, and parental education, which is a marker of childhood socio-economic status, as proxies. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) were calculated by logistic regression with adjustments for demographic and lifestyle factors., Results: Parental education was higher among Ghanaians in Europe than among residents in rural and urban Ghana. The prevalence of MetSyn was 18.5%, 27.7% and 33.5% for rural, urban, and migrant residents, respectively. LHR was inversely associated with MetSyn among migrants. Compared with high paternal education, individuals with low paternal education had lower odds of MetSyn in migrants (AOR 0.71 95% CI 0.54-0.94). In contrast, compared with high maternal education, individuals with intermediate maternal education had higher odds of MetSyn in urban Ghanaians (AOR 4.53 95% CI 1.50-3.74). No associations were found among rural Ghanaians., Conclusion: The magnitude and direction of the associations between ELFs and MetSyn differ across geographical locations. Intermediate maternal education was positively associated with MetSyn among urban Ghanaians, while LHR and low paternal education were inversely associated with MetSyn among migrant Ghanaians. Further research into the interplay of genetics, environment and behaviour is needed to elucidate the underlying pathological mechanisms of MetSyn amongst migrants.

This paper explores how care for women with hypertensive disorders of pregnancy (HDP) is practiced in a tertiary hospital in Ghana. Partly in response to the persistently high maternal and neonatal mortality rates in Low- and Middle-income countries, efforts to improve quality of maternity care have increased. Quality improvement initiatives are shaped by the underlying conceptualisation of quality of care, often driven by global (WHO) standards and protocols. However, there are tensions between global standards of care and local clients' and providers' understandings of care practices and quality of care. Implementation of standards is further complicated by structural and organisational restrictions that influence providers' possibilities and priorities. Based on ethnographic fieldwork, we explore how clinical guidelines and professionals' and patients' perspectives converge and, more importantly, diverge. We illuminate local, situated care practices and show how professionals creatively deal with tensions that arise on the ground. In this middle-income setting, caring for women with HDP involves tinkering and navigating in contexts of uncertainty, scarcity, varying responsibilities and conflicting interests. We unravelled a complex web of, at times, contradictory logics, from which various forms of care arise and in which different notions of good care co-exist. While practitioners navigated through and with these varying logics of care, the logic of survival permeated all practices. This study provides important initial insights into how professionals might implement and innovatively adapt the latest quality of maternity care guidelines which seek to marry clinical standards and patients' needs, preferences and experiences., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Importance: Serum uric acid (SUA) level is associated with vascular dysfunction in Eurasian populations, but little is known about this association in individuals from sub-Saharan Africa, who have a high prevalence of both relatively high SUA levels and vascular dysfunction., Objectives: To assess the associations of SUA levels with macrovascular and kidney microvascular dysfunction in individuals of sub-Saharan African ancestry and evaluate potential factors that could mediate these associations., Design, Setting, and Participants: Cross-sectional analyses of baseline data from the multicenter Research on Obesity and Diabetes Among African Migrants study, conducted from 2012 to 2015, were performed from January to March 2021. The population included Ghanaian individuals living in Ghana and Europe., Exposure: Abnormal SUA levels., Main Outcomes and Measures: Logistic regression was used to examine the associations of SUA level quartiles with microvascular (albuminuria) and macrovascular (peripheral artery disease and coronary artery disease) dysfunction, with adjustments for age, sex, estimated glomerular filtration rate, site of residence, socioeconomic status, alcohol, smoking, diabetes, hypertension, waist-hip ratio, and total cholesterol level. Mediation analysis was performed to assess whether the association was via elevated blood pressure, hemoglobin A1c, and high-sensitivity C-reactive protein levels or via weight-hip ratio. The research questions were formulated after data collection., Results: A total of 4919 Ghanaian individuals (3047 [61.9%] women) aged 25-75 years (mean [SD], 46.26 [11.08] years) were included. There was a significant positive association between SUA quartiles and albuminuria, but not coronary artery disease or peripheral artery disease, after adjustment for covariates. After full adjustment, individuals in the fourth SUA quartile had higher odds of albuminuria (adjusted odds ratio [aOR], 1.54; 95% CI, 1.07-2.21), but not peripheral artery disease (aOR, 1.35; 95% CI, 0.87-2.08) or coronary artery disease (aOR, 1.09; 95% CI, 0.77-1.55), compared with individuals in the first quartile. After full adjustment, systolic and diastolic blood pressure significantly mediated the association between SUA concentrations and albuminuria, accounting for 19.4% of the total association for systolic and 17.2% for diastolic blood pressure; hemoglobin A1c, high-sensitivity C-reactive protein, and waist-hip ratio did not mediate this association., Conclusions and Relevance: In this cross-sectional study among a sub-Saharan African population, elevated SUA levels were significantly associated with kidney microvascular dysfunction and mediated partly through elevated blood pressure. These findings suggest that individuals from sub-Saharan Africa with elevated SUA levels may benefit from periodic screening for kidney microvascular dysfunction to aid early detection or treatment.

Objectives: Rising antimicrobial resistance is a major threat worldwide. WHO has developed a Global Action Plan and has urged all countries to develop and implement a National Action Plan. We analysed the implementation of the Cameroon National Action Plan by identifying the prioritised activities and assessing possible challenges which could limit implementation., Methods: We conducted a review of national documents on the control of antimicrobial resistance, including regulations, policies and guidelines and assessed the health system structure. Publications and other supporting documents were obtained by a systematic literature search. We applied the policy analysis triangle framework and the theory of change to analyse the National Action Plan, actors involved and the process of implementation., Results: The National Action Plan consisted of six strategic objectives, with the first five being a direct translation of the five pillars of the Global Action Plan. The related activities were to be implemented using a phased approach with allocated targets for each year. Several gaps were identified. There was no timeline of activities set per year, the chronology of activities was not consistent, there were no activities or objectives to ensure the sustainability of the National Action Plan like creating awareness on antimicrobial resistance and the indicators for impact evaluation were not included. Among the actors involved, the Ministry of Public Health had the highest interest in the implementation as the lead stakeholder to oversee the overall implementation. However, there was no clear source of funding, and stakeholders at the primary level of the various sectors responsible for implementation were not clearly defined., Conclusion: Despite adequate multisectoral collaboration within the prioritised activities relevant to Cameroon, more is needed for effective implementation of the National Action Plan. The timeline of the different activities, as well as the involvement of key stakeholders at the primary level, needs to be improved. The government's overall commitment to healthcare should be increased and implementation of an action plan should commence at the district or regional level, while challenges in mobilising the necessary funds need to be overcome., (© 2021 John Wiley & Sons Ltd.)

Objective: Despite efforts to improve maternal and child nutrition, undernutrition remains a major public health challenge in Ghana. The current study explored community perceptions of undernutrition and context-specific interventions that could improve maternal and child nutrition in rural Northern Ghana., Design: This exploratory qualitative study used ten focus group discussions to gather primary data. The discussions were recorded, transcribed and coded into themes using Nvivo 12 software to aid thematic analysis., Setting: The study was conducted in rural Kassena-Nankana Districts of Northern Ghana., Study Participants: Thirty-three men and fifty-one women aged 18-50 years were randomly selected from the community., Results: Most participants reported poverty, lack of irrigated agricultural land and poor harvests as the main barriers to optimal nutrition. To improve maternal and child nutrition, study participants suggested that the construction of dams at the community level would facilitate all year round farming including rearing of animals. Participants perceived that the provision of agricultural materials such as high yield seedlings, pesticides and fertiliser would help boost agricultural productivity. They also recommended community-based nutrition education by trained health volunteers, focused on types of locally produced foods and appropriate ways to prepare them to help improve maternal and child nutrition., Conclusion: Drawing on these findings and existing literature, we argue that supporting community initiated nutrition interventions such as improved irrigation for dry season farming, provision of agricultural inputs and community education could improve maternal and child nutrition.

Objectives: To assess whether the environmental context (i.e. rural vs urban) in which individuals in low- and middle-income countries have resided most of their lives is associated with estimated cardiovascular disease (CVD) risk after migration to a high-income country., Study Design: Data from the Research on Obesity and Diabetes among African Migrants (RODAM) study were used including 1699 Ghanaian participants aged 40-79 years who had migrated to Europe from Ghana (1549 of urban origin, 150 of rural origin)., Methods: Ten-year CVD risk was estimated using the Pooled Cohort Equation, with estimates ≥7.5% defining elevated CVD risk. Comparisons between urban and rural origin migrant groups were made using proportions and adjusted odds ratios (ORs)., Results: The proportion of migrants with an elevated CVD-risk score was substantially higher among rural migrants than among urban migrants (45% vs. 37%, OR = 1.44, 95% confidence interval [CI]:1.03-2.02), which persisted after adjustment for education level, site of residence in Europe (London, Amsterdam or Berlin), length of stay in Europe, physical activity, energy intake and alcohol consumption (OR = 1.67, 95% CI: 1.05-2.67)., Conclusion: Our findings indicate that migrants who spent most of their lives in a rural setting before migration to Europe may have a higher CVD risk than those of urban origins. Further work is needed to confirm these findings in other migrant populations and to unravel the mechanisms driving the differential CVD risk between urban and rural migrants., (Published by Elsevier Ltd.)

Background: Global health agendas have in common the goal of contributing to population health outcome improvement. In theory therefore, whenever possible, country level policy and program agenda setting, formulation and implementation towards their attainment should be synergistic such that efforts towards one agenda promote efforts towards the other agendas. Observation suggests that this is not what happens in practice. Potential synergies are often unrealized and fragmentation is not uncommon. In this paper we present findings from an exploration of how and why synergies and fragmentation occur in country level policy and program agenda setting, formulation and implementation for the global health agendas of Universal Health Coverage (UHC), Health Security (HS) and Health Promotion (HP) in Ghana and Sierra Leone. Our study design was a two country case study. Data collection involved document reviews and Key Informant interviews with national and sub-national level decision makers in both countries between July and December 2019. Additionally, in Ghana a stakeholder workshop in December 2019 was used to validate the draft analysis and conclusions., Results: National and global context, country health systems leadership and structure including resources were drivers of synergies and fragmentation. How global as well as country level actors mobilized power and exercised agency in policy and program agenda setting and implementation processes within country were also important drivers., Conclusions: There is potential in both countries to pull towards synergies and push against fragmentation in agenda setting, formulation and implementation of global health agendas despite the resource and other structural constraints. It however requires political and bureaucratic prioritization of synergies, as well as skilled leadership. It also requires considerable mobilization of country level actor exercise of agency to counter sometimes daunting contextual, systems and structural constraints.

Optimizing nutrition in the preconception and 1000 days periods have long-term benefits such as higher economic productivity, reduced risk of related non-communicable diseases and increased health and well-being. Despite Ghana's recent progress in reducing malnutrition, the situation is far from optimal. This qualitative study analyzed the maternal and child health nutrition policy framework in Ghana to identify the current barriers and facilitators to the implementation of nutrition policies and programs relating to the first 1000 days plus. Data analyzed included in-depth interviews and focus group discussions conducted in Ghana between March and April 2019. Participants were composed of experts from government agencies, civil society organizations, community-based organizations and international partners at national and subnational levels. Seven critical areas were identified: planning policy implementation, resources, leadership and stakeholders' engagement, implementation guidance and ongoing communication, organizational culture, accountability and governance and coverage. The study showed that, to eradicate malnutrition in Ghana, priorities of individual stakeholders have to be merged and aligned into a single 1000 days plus nutrition policy framework. Furthermore, this study may support stakeholders in implementing successfully the 1000 days plus nutrition policy activities in Ghana.

Background: African populations are experiencing health transitions due to rapid urbanization and international migration. However, the role of biological aging in this emerging burden of cardiometabolic diseases (CMD) among migrant and non-migrant Africans is unknown. We aimed to examine differences in epigenetic age acceleration (EAA) as measured by four clocks (Horvath, Hannum, PhenoAge and GrimAge) and their associations with cardiometabolic factors among migrant Ghanaians in Europe and non-migrant Ghanaians., Methods: Genome-wide DNA methylation (DNAm) data of 712 Ghanaians from cross-sectional RODAM study were used to quantify EAA. We assessed correlation of DNAmAge measures with chronological age, and then performed linear regressions to determine associations of body mass index (BMI), fasting blood glucose (FBG), blood pressure, alcohol consumption, smoking, physical activity, and one-carbon metabolism nutrients with EAA among migrant and non-migrants. We replicated our findings among 172 rural-urban sibling pairs from India migration study and among 120 native South Africans from PURE-SA-NW study., Findings: We found that Ghanaian migrants have lower EAA than non-migrants. Within migrants, higher FBG was positively associated with EAA measures. Within non-migrants, higher BMI, and Vitamin B9 (folate) intake were negatively associated with EAA measures. Our findings on FBG, BMI and folate were replicated in the independent cohorts., Interpretation: Our study shows that migration is negatively associated with EAA among Ghanaians. Moreover, cardiometabolic factors are differentially associated with EAA within migrant and non-migrant subgroups. Our results call for context-based interventions for CMD among transitioning populations that account for effects of biological aging., Funding: European Commission., Competing Interests: Declarations of interests We declare no competing interests.

Aim: We assessed epigenome-wide DNA methylation (DNAm) differences between migrant and non-migrant Ghanaians. Materials & methods: We used the Illumina Infinium ® HumanMethylation450 BeadChip to profile DNAm of 712 Ghanaians in whole blood. We used linear models to detect differentially methylated positions (DMPs) associated with migration. We performed multiple post hoc analyses to validate our findings. Results: We identified 13 DMPs associated with migration (delta-beta values: 0.2-4.5%). Seven DMPs in CPLX2 , EIF4E3 , MEF2D , TLX3 , ST8SIA1 , ANG and CHRM3 were independent of extrinsic genomic influences in public databases. Two DMPs in NLRC5 were associated with duration of stay in Europe among migrants. All DMPs were biologically linked to migration-related factors. Conclusion: Our findings provide the first insights into DNAm differences between migrants and non-migrants.

Background: Obesity and adipose tissue distribution contribute to an increased risk of cardiovascular disease (CVD) by promoting atherosclerosis. This association has been poorly studied in sub-Saharan Africa (SSA) despite the rising prevalence of cardiovascular disease., Objectives: We determined the association between various adiposity phenotypes and carotid intima-media thickness (CIMT), a proxy of subclinical atherosclerosis, in a large SSA population., Methods: A population-based cross-sectional study was performed from 2013-2016 in Burkina Faso, Ghana, Kenya and South Africa. Body mass index (BMI), waist (WC), hip circumferences (HC), visceral (VAT) and subcutaneous adipose tissue (SCAT) using B-mode ultrasound were measured. Ultrasonography of left and right far wall CIMT of the common carotid artery was used as an indicator of subclinical atherosclerosis. Individual participant data meta-analyses were used to determine the associations between adiposity phenotypes and CIMT in the pooled sample while adjusted multivariable linear regression analyses were used for site specific analyses., Results: Data were obtained from 9,010 adults (50.3% women and a mean age of 50± 6years). Men had higher levels of visceral fat than women while women had higher BMI, waist and hip circumference and subcutaneous fat than men at all sites except Burkina Faso. In the pooled analyses, BMI (β-value [95% CIs]: 19.5 [16.8, 22.3] μm) showed the strongest relationship with CIMT followed by VAT (5.86 [4.65, 7.07] μm), SCAT (5.00 [2.85, 7.15] μm), WC (1.27 [1.09, 1.44] μm) and HC (1.23 [1.04, 1.42] μm). Stronger associations were observed in men than in women., Conclusion: Obesity within SSA will likely result in higher levels of atherosclerosis and promote the occurrence of cardio- and cerebrovascular events, especially in males, unless addressed through primary prevention of obesity in both rural and urban communities across Africa. The inverse association of VAT with CIMT in Burkina Faso and Ghana requires further investigation., Highlights: All adiposity phenotypes were positively associated with common carotid intima-media thickness (CIMT) in the entire cohort (pooled analyses).BMI had the strongest association with CIMT compared to other phenotypes.The magnitude of association between adiposity phenotypes and CIMT was higher in men than in women.Subcutaneous adipose tissue was inversely associated with CIMT only in women.An unexpected finding was the inverse association of visceral adipose tissue with CIMT in Burkina Faso and Ghana., Competing Interests: The authors have no competing interest to declare., (Copyright: © 2021 The Author(s).)

(1) Background: Sub-Saharan African migrants residing in high-income countries are more affected by cardiovascular diseases (CVDs) and associated risk factors than host populations for unclear reasons. The aim was to explore the associations of religion and religious affiliations with CVD risk among Ghanaian non-migrants and migrants in Europe. (2) Methods: The 10-year CVD risk was estimated using pooled cohort equations for 3004 participants from the cross-sectional Research on Obesity and Diabetes among African Migrants (RODAM) study. Logistic regression analyses were conducted to assess associations between religion and elevated CVD risk (score ≥ 7.5) with adjustment for covariates. (3) Results: Religious men in Europe had a lower 10-year CVD risk compared with non-religious men (adjusted OR 0.51; 95% confidence interval 0.30-0.85), specifically men affiliated with Seventh-Day Adventism (0.24; 0.11-0.53) followed by other affiliations (0.32; 0.11-0.94) and Roman Catholicism (0.42; 0.21-0.86). The opposite was found in Ghana, with religious women having higher odds for elevated 10-year CVD risk (1.53; 1.02-2.30) compared with their non-religious counterparts, specifically women affiliated with Reformed Christianity (1.73; 1.03-2.90) and other denominations (2.81; 1.20-6.54). Associations were not significant for men in Ghana and women in Europe. Adjustments for social support, stress, and health behaviors did not meaningfully alter the associations. (4) Conclusions: Christian religious Ghanaian men living in Europe seem to have lower CVD risk compared with their non-religious counterparts, while Christian religious women in Ghana appear to have increased CVD risk. Further unravelling the contributing factors and the differences between sex and environmental settings is needed.

While there is a growing body of research documenting unregulated African wild meat imports into Europe from the Africa continent, the drivers of this demand are virtually unknown. This study employs focus group discussions and a survey questionnaire to examine the attitudes and practices related to African wild meat consumption in the city of Amsterdam, Netherlands. The Ghanaian community was selected as the object of this study, as it is the largest West African population in the Netherlands and represents an important part of Dutch society. We model our report on a recent US study of the Liberian community of Minneapolis, Minnesota, which allows for the comparison of results between two Western countries. The overall perceived health risk of consuming African wild meat in The Netherlands is low and unlikely to deter consumption. However, local prices for the meat may be prohibitive in some cases. Incentives include health benefits, cultural drivers and a strong preference for the taste of African wild meat over all local meat alternatives. The study calls for further research into the nature of the drivers of demand for African wild meat as well as its public health consequences, in the Netherlands and beyond., Competing Interests: The authors have declared that no competing interests exist.

Background: The cardiovascular health index (CVHI) introduced by the American Heart Association is a valid, accessible, simple, and translatable metric for monitoring cardiovascular health in a population. Components of the CVHI include the following seven cardiovascular risk factors (often captured as life's simple 7): smoking, dietary intake, physical activity, body mass index, blood pressure, glucose, and total cholesterol. We sought to expand the evidence for its utility to under-studied populations in sub-Saharan Africa, by determining its association with common carotid intima-media thickness (CIMT)., Methods: We conducted a cross-sectional study involving 9011 participants drawn from Burkina Faso, Ghana, Kenya, and South Africa. We assessed established classical cardiovascular risk factors and measured carotid intima-media thickness of the left and right common carotid arteries using B-mode ultrasonography. Adjusted multilevel mixed-effect linear regression was used to determine the association of CVHI with common CIMT. In the combined population, an individual participant data meta-analyses random-effects was used to conduct pooled comparative sub-group analyses for differences between countries, sex, and socio-economic status., Results: The mean age of the study population was 51 ± 7 years and 51% were women, with a mean common CIMT of 637 ± 117 μm and CVHI score of 10.3 ± 2.0. Inverse associations were found between CVHI and common CIMT (β-coefficients [95% confidence interval]: Burkina Faso, - 6.51 [- 9.83, - 3.20] μm; Ghana, - 5.42 [- 8.90, - 1.95]; Kenya, - 6.58 [- 9.05, - 4.10]; and South Africa, - 7.85 [- 9.65, - 6.05]). Inverse relations were observed for women (- 4.44 [- 6.23, - 2.65]) and men (- 6.27 [- 7.91, - 4.64]) in the pooled sample. Smoking (p < 0.001), physical activity (p < 0.001), and hyperglycemia (p < 0.001) were related to CIMT in women only, while blood pressure and obesity were related to CIMT in both women and men (p < 0.001)., Conclusion: This large pan-African population study demonstrates that CVHI is a strong marker of subclinical atherosclerosis, measured by common CIMT and importantly demonstrates that primary prevention of atherosclerotic cardiovascular disease in this understudied population should target physical activity, smoking, obesity, hypertension, and hyperglycemia.

Background: This study assessed health workers' adherence to neonatal health protocols before and during the implementation of a mobile health (mHealth) clinical decision-making support system (mCDMSS) that sought to bridge access to neonatal health protocol gap in a low-resource setting., Methods: We performed a cross-sectional document review within two purposively selected clusters (one poorly-resourced and one well-resourced), from each arm of a cluster-randomized trial at two different time points: before and during the trial. The total trial consisted of 16 clusters randomized into 8 intervention and 8 control clusters to assess the impact of an mCDMSS on neonatal mortality in Ghana. We evaluated health workers' adherence (expressed as percentages) to birth asphyxia, neonatal jaundice and cord sepsis protocols by reviewing medical records of neonatal in-patients using a checklist. Differences in adherence to neonatal health protocols within and between the study arms were assessed using Wilcoxon rank-sum and permutation tests for each morbidity type. In addition, we tracked concurrent neonatal health improvement activities in the clusters during the 18-month intervention period., Results: In the intervention arm, mean adherence was 35.2% (SD = 5.8%) and 43.6% (SD = 27.5%) for asphyxia; 25.0% (SD = 14.8%) and 39.3% (SD = 27.7%) for jaundice; 52.0% (SD = 11.0%) and 75.0% (SD = 21.2%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. In the control arm, mean adherence was 52.9% (SD = 16.4%) and 74.5% (SD = 14.7%) for asphyxia; 45.1% (SD = 12.8%) and 64.6% (SD = 8.2%) for jaundice; 53.8% (SD = 16.0%) and 60.8% (SD = 11.7%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. We observed nonsignificant improvement in protocol adherence in the intervention clusters but significant improvement in protocol adherence in the control clusters. There were 2 concurrent neonatal health improvement activities in the intervention clusters and over 12 in the control clusters during the intervention period., Conclusion: Whether mHealth interventions can improve adherence to neonatal health protocols in low-resource settings cannot be ascertained by this study. Neonatal health improvement activities are however likely to improve protocol adherence. Future mHealth evaluations of protocol adherence must account for other concurrent interventions in study contexts.

Background: Glycated hemoglobin (HbA1c) is often used to diagnose type 2 diabetes (T2D), but studies show that iron deficiency (ID) is associated with elevated HbA1c in the absence of hyperglycemia. It is unknown whether ID prevalence varies between sub-Saharan African populations living in different locations and whether ID influences HbA1c levels in these populations., Objectives: We assessed the prevalence of ID among Ghanaian migrants in Europe and nonmigrant Ghanaians, and the influence of ID on HbA1c categories among Ghanaians without T2D., Methods: We used the database from the cross-sectional RODAM (Research on Obesity and Diabetes among African Migrants) study. This contained data on 3377 Ghanaian men and women aged 25-70 y living in urban and rural Ghana and Ghanaian migrants living in Amsterdam, London, and Berlin. ID was defined as ferritin < 15 ng/mL or, if C-reactive protein was ≥5 mg/mL, as ferritin < 30 ng/mL according to the WHO. We used binary logistic regression to assess differences in ID between sites and its association with clinically defined HbA1c categories (<5.5%, ≥5.5% to <6.5%, ≥6.5%). Men and women were analyzed separately., Results: The prevalence of ID was higher in migrant [28.4%; adjusted OR (aOR): 3.08; 95% CI: 2.04, 4.65)] and urban (23.2%; aOR: 2.37; 95% CI: 1.56, 3.59) women than in rural women (11.9%). Among women, ID was associated with higher odds of HbA1c ≥ 5.5% to <6.5% in the absence of hyperglycemia (aOR: 1.43; 95% CI: 1.08, 1.87). This association was not found in men., Conclusions: Further research is needed to identify factors underlying the high prevalence of ID among urban and migrant Ghanaian women, and the association of ID with HbA1c ≥ 5.5% to <6.5% in women. In addition, our study reinforces the need to consider iron concentrations if interpreting HbA1c among African populations., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Background: The aim of the study was to determine the coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) and its relationship with delivery outcomes among obstetric referral cases at the district level of healthcare., Methods: An implementation research within three districts of the Greater Accra region was conducted from May 2017 to February 2018, to assess the role of an enhanced inter-facility communication system on processes and outcomes of obstetric referrals. A cross-sectional analysis of the data on IPTp coverage as well as delivery outcomes for the period of study was conducted, for all the referrals ending up in deliveries. Primary outcomes were maternal and neonatal complications at delivery. IPTp coverage was determined as percentages and classified as adequate or inadequate. Associated factors were determined using Chi square. Odds ratios (OR, 95% CI) were estimated for predictors of adequate IPTp dose coverage for associations with delivery outcomes, with statistical significance set at p = 0.05., Results: From a total of 460 obstetric referrals from 16 lower level facilities who delivered at the three district hospitals, only 223 (48.5%) received adequate (at least 3) doses of IPTp. The district, type of facility where ANC is attended, insurance status, marital status and number of antenatal clinic visits significantly affected IPTp doses received. Adjusted ORs show that adequate IPTp coverage was significantly associated with new-born complication [0.80 (0.65-0.98); p = 0.03], low birth weight [0.51 (0.38-0.68); p < 0.01], preterm delivery [0.71 (0.55-0.90); p = 0.01] and malaria as indication for referral [0.70 (0.56-0.87); p < 0.01]. Positive association with maternal complication at delivery was seen but was not significant., Conclusion: IPTp coverage remains low in the study setting and is affected by type of health facility that ANC is received at, access to health insurance and number of times a woman attends ANC during pregnancy. This study also confirmed earlier findings that, as an intervention IPTp prevents bad outcomes of pregnancy, even among women with obstetric referrals. It is important to facilitate IPTp service delivery to pregnant women across the country, improve coverage of required doses and maximize the benefits to both mothers and newborns.

Early-life environmental and nutritional exposures are considered to contribute to the differences in cardiovascular disease (CVD) burden. Among sub-Saharan African populations, the association between markers of early-life exposures such as leg length and sitting height and CVD risk is yet to be investigated. This study assessed the association between leg length, sitting height, and estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among Ghanaian-born populations in Europe and Ghana. We constructed sex-specific quintiles for sitting height and leg length for 3250 participants aged 40-70 years (mean age 52 years; men 39.6%; women 60.4%) in the cross-sectional multicenter Research on Diabetes and Obesity among African Migrants study. Ten-year risk of ASCVD was estimated using the Pooled Cohort Equations; risk ≥7.5% was defined as "elevated" CVD risk. Prevalence ratios (PR) were estimated to determine the associations between sitting height, leg length, and estimated 10-year ASCVD risk. For both men and women, mean sitting height and leg length were highest in Europe and lowest in rural Ghana. Sitting height was inversely associated with 10-year ASCVD risk among all women (PR for 1 standard deviation increase of sitting height: 0.75; 95% confidence interval: 0.67, 0.85). Among men, an inverse association between sitting height and 10-year ASCVD risk was significant on adjustment for study site, adult, and parental education but attenuated when further adjusted for height. No association was found between leg length and estimated 10-year ASCVD risk. Early-life and childhood exposures that influence sitting height could be the important determinants of ASCVD risk in this adult population.

Background: Female genital mutilation (FGM) is commonly practiced in sub-Saharan Africa and results in adverse pregnancy outcomes among affected women. This paper assessed the prevalence and effects of FGM on pregnancy outcomes in a rural Ghanaian setting., Methods: We analyzed 9306 delivery records between 2003 and 2013 from the Navrongo War Memorial Hospital. Multivariable logistic regression analyses were used to determine the effects of FGM on pregnancy outcomes such as stillbirth, birth weight, postpartum haemorrhage, caesarean and instrumental delivery. We also assessed differences in the duration of stay in the hospital by FGM status., Results: A greater proportion of mothers with FGM (24.7%) were older than 35 years compared with those without FGM (7.6%). FGM declined progressively from 28.4% in 2003 to 0.6% in 2013. Mothers with FGM were nearly twice as likely to have caesarean delivery (adjusted odds ratios = 1.85 with 95%CI [1.72, 1.99]) and stillbirths (1.60 [1.21, 2.11]) compared with those without. Similarly, they had a 4-fold increased risk of post-partum haemorrhage (4.69 [3.74, 5.88]) and more than 2-fold risk lacerations/episiotomy (2.57 [1.86, 3.21]) during delivery. Average duration of stay in the hospital was higher for mothers with FGM from 2003 to 2007., Conclusions: Despite significant decline in prevalence of FGM, adverse obstetric outcomes are still high among affected women. Increased public health education of circumcised women on these outcomes would help improve institutional deliveries and heighten awareness and prompt clinical decisions among healthcare workers. Further scale-up of community level interventions are required to completely eliminate FGM., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: Evidence suggests that the burden of peripheral artery disease (PAD) is rising more rapidly than other forms of cardiovascular diseases in sub-Saharan Africa, but the extent to which they differ between rural and urban settings in Africa and upon migration to Europe is unknown. We assessed the burden of PAD among Ghanaians living in rural- and urban-Ghana and Ghanaian migrants living in three European countries., Methods: Cross-sectional analyses of baseline data from the multicenter Research on Obesity and Diabetes among African Migrants (RODAM) study were done. Data from 5516 participants living in Europe (1487 Amsterdam, 546 Berlin, 1047 London) and Ghana [1419 urban and 1017 rural] aged 25-70years were included. PAD was defined as ankle brachial index≤0.90. Comparisons among sites were made using logistic regression analysis., Results: The age-standardized prevalence of PAD was higher in Ghanaians living in rural [7.52%, 95% CI = 5.87-9.51] and urban [8.93%, 7.44-10.64] Ghana than for their compatriots living in Europe [5.70%, 4.35-7.35 for London; 3.94%, 2.96-5.14 for Amsterdam; and 0.44%, 0.05-1.58 for Berlin]. The differences persisted even after adjustment for age, sex, education and the conventional cardiovascular risk factors [adjusted odds ratio = 3.16, 95% CI = 2.16-4.61, p < .001 for rural-Ghana; and 2.93, 1.87-4.58, p < .00 for urban-Ghana, compared with Ghanaian migrants in Europe]., Conclusions: Our study shows that Ghanaians living in Ghana have higher prevalence of PAD than their migrant compatriots. Further work is needed to identify potential factors driving the high prevalence of PAD among non-migrant Ghanaians to assist interventions aimed at reducing PAD burden., Competing Interests: Declaration of competing interest None declared., (Copyright © 2019. Published by Elsevier B.V.)

Background: The association between anthropometric variables and cardiovascular disease (CVD) risk among Africans is unclear. We examined the discriminative ability of anthropometric variables and estimate cutoffs for predicting CVD risk among Africans., Methods: The Research on Obesity and Diabetes among African Migrants (RODAM) study was a multisite cross-sectional study of Africans in Ghana and Europe. We calculated AHA/ACC Pooled Cohort Equations (PCE) scores for 3661 participants to ascertain CVD risk, and compared a body shape index (ABSI), body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), Relative Fat Mass (RFM), and Waist to Height Ratio (WHtR). Logistic regression and receiver operating curve analyses were performed to derive cutoffs for identifying high predicted CVD risk (PCE score ≥7.5%)., Results: Among men, WC (adjusted Odds Ratio (aOR): 2.25, 95% CI; 1:50-3:37) was strongly associated with CVD risk. Among women, WC (aOR: 1.69, 95% CI: 1:33-2:14) also displayed the strongest association with CVD risk in the BMI-adjusted model but WHR displayed the strongest fit. All variables were superior discriminators of high CVD risk in men (c-statistic range: 0.887-0.891) than women (c-statistic range: 0.677-0.707). The optimal WC cutoff for identifying participants at high CVD risk was 89 cm among men and identified the most cases (64%). Among women, the recommended WC cutoff of 94 cm or WHR cutoff of 0.90 identified the most cases (92%)., Conclusions: Anthropometric variables were stronger discriminators of high CVD risk in African men than women. Greater WC was associated with high CVD risk in men while WHR and WC were associated with high CVD risk in women., (Copyright © 2020 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.)

Evolutionary theories of seasonal migration generally assume that the costs of longer migrations are balanced by benefits at the non-breeding destinations. We tested, and rejected, the null hypothesis of equal survival and timing of spring migration for High Arctic breeding sanderling Calidris alba using six and eight winter destinations between 55°N and 25°S, respectively. Annual apparent survival was considerably lower for adult birds wintering in tropical West Africa (Mauritania: 0.74 and Ghana: 0.75) than in three European sites (0.84, 0.84 and 0.87) and in subtropical Namibia (0.85). Moreover, compared with adults, second calendar-year sanderlings in the tropics, but not in Europe, often refrained from migrating north during the first possible breeding season. During northward migration, tropical-wintering sanderlings occurred at their final staging site in Iceland 5-15 days later than birds wintering further north or south. Namibia-wintering sanderlings tracked with solar geolocators only staged in West Africa during southward migration. The low annual survival, the later age of first northward migration and the later passage through Iceland during northward migration of tropical-wintering sanderlings, in addition to the skipping of this area during northward but not southward migration by Namibia-wintering sanderlings, all suggest they face issues during the late non-breeding season in West Africa. Migrating sanderlings defy long distances but may end up in winter areas with poor fitness prospects. We suggest that ecological conditions in tropical West Africa make the fuelling prior to northward departure problematic., (© 2019 The Authors. Journal of Animal Ecology published by John Wiley & Sons Ltd on behalf of British Ecological Society.)

Background: Accruing epidemiological evidence suggests that prenatal exposure to emissions from cooking fuel is associated with increased risks of adverse maternal and perinatal outcomes including hypertensive disorders of pregnancy, low birth weight, stillbirth and infant mortality. We aimed to investigate the relationship between cooking fuel use and various pregnancy related outcomes in a cohort of urban women from the Accra region of Ghana., Methods: Self-reported cooking fuel use was divided into "polluting" (wood, charcoal, crop residue and kerosene) and "clean" fuels (liquid petroleum gas and electricity) to examine 12 obstetric outcomes in a prospective cohort of pregnant women (N = 1010) recruited at < 17 weeks of gestation from Accra, Ghana. Logistic and multivariate linear regression analyses adjusted for BMI, maternal age, maternal education and socio-economic status asset index was conducted., Results: 34% (n = 279) of 819 women with outcome data available for analysis used polluting fuel as their main cooking fuel. Using polluting cooking fuels was associated with perinatal mortality (aOR: 7.6, 95%CI: 1.67-36.0) and an adverse Apgar score (< 7) at 5 min (aOR:3.83, 95%CI: (1.44-10.11). The other outcomes (miscarriage, post-partum hemorrhage, pre-term birth, low birthweight, caesarian section, hypertensive disorders of pregnancy, small for gestational age, and Apgar score at 1 min) had non-statistically significant findings., Conclusions: We report an increased likelihood of perinatal mortality, and adverse 5-min Apgar scores in association with polluting fuel use. Further research including details on extent of household fuel use exposure is recommended to better quantify the consequences of household fuel use., Study Registration: Ghana Service Ethical Review Committee (GHS-ERC #: 07-9-11).