Healthy lifestyle behaviour among Ghanaian adults in the phase of a health policy change

The overall health of individuals is impacted by lifestyle behaviours including healthy diets, physical activity, smoking and alcohol consumption. Unhealthy lifestyle behaviours particularly poor dietary practices, physical inactivity and smoking are major risk factors for conditions like overweight, obesity and chronic non-communicable diseases [1–3]. Research in Ghana indicates that the prevalence of obesity is increasing especially among women [4]. The rising prevalence of obesity in Ghana is worrying because epidemiological studies have consistently shown an increased risk of morbidity, disability and mortality with obesity [5]. Findings from a study using data from a nationally representative sample survey (World Health Survey 2003) conducted in Ghana revealed that about 18% of the respondents had been diagnosed with one or more chronic non-communicable disease(s) with 45% of them currently receiving treatment (Tagoe, Household burden of chronic disease in Ghana, Unpublished). Health reports show that the prevalence of lifestyle diseases (chronic non-communicable diseases) such as stroke, hypertension, type 2 diabetes, and other cardiovascular diseases are on the increase and are now among the top ten in-patient cause of death in Ghana [6].

Urbanisation, globalisation and nutritional transition are major drivers of unhealthy lifestyle behaviours in developing countries [7–9]. Rapid urbanisation and globalisation is accompanied by behavioural change which exposes many individuals to the risk of chronic non-communicable diseases and mortality. Fast paced economic transition has also resulted in reduced physical activity levels, decreased hours of rest and increasing levels of stress [8, 9].

The progressive increase in the burden of chronic non-communicable diseases has been attributed to several factors including longer average lifespan and risky lifestyle behaviours [10]. Tobacco use, physical inactivity and diets high in saturated fat and salts constitute risk for conditions such as cardiovascular diseases, high blood pressure and elevated serum cholesterol levels [11–13]. While factors such age, sex and genetic susceptibility are non-modifiable many of the risks associated with chronic diseases are modifiable. Such modifiable risks include behavioural factors (e.g. diet, physical inactivity, tobacco use, alcohol consumption), medical conditions (e.g. dyslipidemia, hypertension, overweight, hyperinsulinaemia) and societal factors including include a complex mixture of interacting socioeconomic, cultural and environmental factors [14, 15]. Estimates by the World Health Organisation suggest that up to 80% of premature deaths from heart disease, stroke and diabetes can be averted with known behavioural and pharmaceutical interventions [16]. According to the Archives of Internal Medicine (1997) [17], the prevention of hypertension by means of dietary salt reduction and weight loss over a short term has been successfully accomplished in clinical trials. It has also been identified that diets high in fruits, vegetables and low-fat dairy products are extremely effective in lowering blood pressure [18].

From the foregoing, it is evident that the increase in the incidence and prevalence of non-communicable diseases are linked to risky healthy lifestyle behaviours [19]. Thus populations that exhibit risky lifestyle behaviours are also at risk of having a double burden of disease and poverty as is currently seen in developing also referred to as the Global South. In an effort to curb this pattern of disease and poverty many countries in the Global South have initiated and implemented health policies and intervention programs to help improve the health of their populations. Most of these interventions have, however, not yielded the expected results due to implementation problems and non-adherence to recommended healthy lifestyle behaviours.

The Ministry of Health (MOH) in Ghana as part of its effort to reduce the incidence of preventable diseases and to promote regenerative health in the country adopted the concept of "Regenerative Health and Nutrition (RHN)". The main objective of the program is to promote healthy lifestyles, dietary practices and mother and child care practices that would help eliminate the many diseases that impact on the health and well-being of Ghanaians. The concept of regenerative health and nutrition was adopted by the MOH from Dimona, Israel, where a community of more than 3,000 African Hebrews have lived for over 40 years without any recorded deaths among the people during this period [20]. Due to healthy lifestyle behaviours (including the adoption of vegan diets), the African Hebrews have been able to eliminate hypertension, diabetes, cancer and other chronic non-communicable diseases from their community [21].

The program covers three main modules; (a) mother and child care (b) healthy lifestyle and (c) regenerative nutrition [22]. Key interventions under the program are geared towards; healthy diet (increasing consumption of fruits and vegetables, drinking more water, reducing the intake of meat, salt and saturated oils/fats, reducing or eliminating smoking and alcohol intake); exercise (increasing daily physical activity including cardiovascular exercise); rest (adopting regular relaxation practices to minimise physical and emotional stress) and environmental sanitation (maintaining personal and environmental cleanliness and advocating for portable water use). Under these interventions it is recommended that individuals consume five servings each of fruits and vegetables and also drink eight glasses of water a day. Living in a clean environment is encouraged and smoking and alcohol consumption are to be avoided.

The Ghana Regenerative Health and Nutrition Program was adopted in 2005 and piloted in 2006. The initial pilot involved ten districts across seven administrative regions. As part of the pilot program about 700 change agents and 5000 advocates were trained [23]. Change agents and advocates of the program are members of the community who are trained in the principles and practices of RHN and they in turn educate their community members [22]. The program has trained over 50,000 change agents and advocates throughout the country over the four year period (2006 to 2010) [24]. Mass communication through the use of both print and electronic media serves as a means of reaching the population with the messages of the program.

In this paper the authors compare the prevalence of unhealthy lifestyle behaviours among Ghanaian adults before and after the adoption of the regenerative health and nutrition program with a focus on behaviours including fruit and vegetable consumption, physical activity, smoking and alcohol consumption. This paper also assesses the trend and the socio-economic and demographic determinants of healthy lifestyle behaviours among Ghanaian adults prior to and after the introduction of this policy. The paper also highlights the implication of unhealthy lifestyle behaviour on morbidity and mortality in the country. The authors hope this paper will generate a new research agenda and also bring to bear the health challenges risky lifestyle behaviours pose to developing countries.

This paper examined the trend in healthy lifestyle behaviour among Ghanaian adults in the phase of the "Regenerative Health and Nutrition" health policy. Our findings reveal an increase in risky lifestyle behaviour among males and a decrease in risky lifestyle behaviour among females after the RHN program was introduced. The results of this study also revealed that risky lifestyle behaviours are more common in urban areas compared to rural. This result buttresses the argument that urban areas in developing countries are increasing becoming unhealthy environments in terms of lifestyle behaviours compared to rural areas. This trend may be partly responsible for the higher prevalence of obesity and non-communicable diseases in urban areas of developing countries as reported by the World Health Organisation [25].

It was also found that prior to the introduction of the program, in 2003, Ghanaian adults who had some level of education were less likely to exhibit healthy lifestyle behaviours. In 2008, after the introduction of the program, a reversed trend between educational attainment and healthy lifestyle behaviour was observed. Ghanaian adults were more likely to live a healthier lifestyle with increasing levels of educational attainment. The significant decline in risky lifestyle behaviour among the highly educated and among professional workers in 2008 after the introduction of the regenerative health and nutrition health policy in Ghana brings to the fore issues of access to regenerative health and nutrition information and the financial ability to effect a lifestyle behaviour change. The relatively high income level of professional workers gives them the opportunity to access the appropriate nutrition in terms of fruits and vegetables recommended under the program. Having high education also means they are an audience who can be reached with the messages of the program and thus they are more likely to change their behaviour. Behaviour change among the highly educated and professional workers does not end there. It is also more likely to be sustained since people of such calibre are also able to integrate the changed behaviour into their everyday lives and this is because they have the financial means, the knowledge base and the autonomy to be able to do so [26].

Improvement in the economic conditions of people is an asset but can be a liability as well. As revealed by this study, increasing income levels is generally associated with living risky lifestyles. This is especially so because people tend to engage in luxurious lifestyles including unhealthy snacking, consumption of high fat diets and sedentary lifestyles as their economic condition improves. This is a common occurrence in developing countries because such luxurious lifestyles are deemed prestigious and are also seen as a sign of wealth [1]. Such lifestyle behaviours, however, are unhealthy and have implications for the incidence of non-communicable diseases and mortality in developing countries.

This study gives preliminary results and shows the changes in lifestyle behaviours immediately before and after the introduction of the regenerative health and nutrition policy in Ghana. While this study makes important contributions to this area of research the results are likely to be influenced by differences in survey design since data from two comparable but different surveys were used for the analysis. This notwithstanding, measures in both surveys are similar to each other and this allows for cross survey comparison. To effectively evaluate such a program it is important to continually monitor the program. The authors thus recommend that future rounds of the Ghana Demographic and Health Survey continue to collect data on the program. This will allow for continuous monitoring of the program while making data available for tracking changes over time.

The findings of this study has implications for the health and economic well being of Ghanaians and also for the future of the regenerative health and nutrition program in Ghana. The decreasing prevalence of risky lifestyle behaviours among females will help promote healthy living among females and potentially lead to a reduction in the prevalence of obesity among females which would counter the recent rise in obesity levels among Ghanaian women. The increase in risky lifestyle behaviour among males in spite of the regenerative health and nutrition program could lead to an increased risk of non-communicable diseases among males. This will not only defeat the objective of the program but also lead to morbidity and mortality.

While efforts aimed at promoting healthy lifestyle among females should be sustained more efforts need to be channelled at men in getting them to live healthier lifestyles. There is also the need to pay more attention to urban areas. While is important to promote healthy lifestyles in urban areas, there is also a need to target barriers in the urban environment that does not support the adoption of healthy lifestyles. These findings provide the leverage for further assessment of the regenerative health and nutrition health initiative on healthy lifestyle behaviours and its influence on morbidity and mortality. Additional research should attempt to explain the changes in healthy lifestyle behaviour among men and women in opposite directions. Exploring methods of targeting messages of healthy lifestyle behaviour choices and ways of making such options financially possible will foster the adoption of the regenerative health and nutrition program in other countries in the Global South.