Public health psychology and chronic disease intervention in Africa: translating theory into practice

Ama de-Graft AikinsUniversity of Cambridge

2nd Annual Workshop of the UK-Africa Academic Partnership on Chronic Disease, LSE, June 23rd 2008.

Overview� Africa’s neglected chronic disease epidemic: current

knowledge and recommendations

� Public health psychology (PHP): history and prospects for chronic disease intervention in Africa

� PHP and chronic disease intervention in Africa: a Ghanaian case study

� Implications of the Ghanaian case study for a PHP approach to chronic disease intervention in Africa

Africa’s NCD epidemic: some facts� Consensus on a chronic disease epidemic in SSA

(WHO, 2003, 2005; BMJ, 2005; Lancet, 2005)� The nutrition transition and NCDs in Africa (esp

hypertension and diabetes) (WHO/FAO, 2003)� 23% deaths due to chronic disease (WHO, 2005)

� CVD (10%); Cancer (4%); CRD(3%); Diabetes(1%); Other NCDs(5%)

� Projections dire: Deaths from chronic diseases will increase by 27%; deaths from diabetes will increase by 42% (WHO, 2005)

NCD Risk Factors

� Major causes of NCDs: obesity, high blood pressure, high cholesterol, alcohol and tobacco – either independently or in combination, are the major causes of NCDs.

� These risk factors are ‘lifestyle-related and amenable to prevention’ (WHO-AFRO: http://www.afro.who.int/).

� Strong scientific evidence: by changing to a healthier diet, increasing physical activityand stopping smoking, up to 80% of cases of coronary heart disease, 90% of type 2 diabetes cases, and one-third of cancers can be avoided (WHO, 2005).

Africa’s neglected epidemic: expert recommendations� Three-prong approach (e.g Unwin et al, 2001)

� Epidemiological surveillance� Primary prevention (preventing disease in healthy

populations)� Secondary prevention (preventing complications &

improving quality of life in affected communities)

� Overarching framework� Multi-institutional multifaceted (WHO, 2005)� Innovative & cost-effective (double burden of disease)

Challenges to public health & chronic disease intervention in Africa� Funding

� 80% of regional health budgets - usually 10% or less of the national budget (WHO, 2001a) - has been allocated to communicable disease for the last decade (Pobee, 1993; WHO-Afro, 2006).

� Policies� Few countries have non-communicable disease healthcare policies or plans

(Alwan et al, 2001)� Health Systems

� Weak – under-funded, overstretched, few specialists � Human resources (per 100,000 popn): Physicians (21); nurses (98); public

health professionals (7); cardiologists (0.4); oncologists (0.1) (Alwan et al 2001).

� Conceptual framework � Medical research dominates – emphasis epidemiological, clinical

(compliance).� Social science and the ‘faulty cultural knowledge’ thesis

� Clear implications for primary and secondary prevention� Health promotion still very much KAB (has

limited value in long-term behavioural change) and didactic (experts know best)

� Healthcare poor; few support systems

� Need for innovative approaches

� PHP a potential approach?

Public health psychology (Hepworth, 2004)

� A subfield in health psychology (UK, Australia, NZ)� a ‘strategic framework’ or matrix of existing theory,

methods and analyses aimed at addressing questions of significance to public health.

“health improvement requires strategies that encompass individual health knowledge, social relations (including medical relationships and communication), structural interventions such as legislation to ban smoking in public places and environmental factors such as pollution.”(Hepworth, 2004: 46)

� Aligned to current emphasis on a multi-level (ecological) approach to psychological phenomena“Psychologists have traditionally focused on cognition and behaviour as the figure, with environment often the distant amorphous ground (or context). A reversal of figure and ground is not suggested here; rather, cognitions and behaviour and the environment must receive equal and specific attention. (Winnet, 1995, p.348)

� Part of a critical turn in Psychology: community psychology (Prilleltensky et al, 2004, 2007), social psychology of health and participation (Campbell & Jovchelovitch, 2001)

� The onion model (Whitehead, 1995) or the multi-level model (e.g. Doise, 1986)Structural level

(culture, institutions)

Group level(community, workplace)

Inter-individual(dyadic relations: couples, parent-child)

Individual(perceptions, emotions,

cognitions, unique experiences)

Why public health psychology?1. Changing profile of global health and disease

…rise in preventable diseases such as coronary heart disease, stroke and forms of cancer and diabetes. These diseases, understood within the expanding field of preventive medicine, require a contribution from psychology to address modifiable risk factors such as behaviours related to diet and exercise (Hepworth, 2004)

2. Individual models of human behaviours do not easily translate to public health problems related to patterns of health and disease (e.g. geographical, socio-economic, gender, age and ethnic distributions)

Key componentsHepworth (2004)

1. Epistemology:Merging individual vs structural explanations of health

2. Theory: Developing multi-level theoretical approaches

3. Concepts:Understanding the (socio-cultural/ structural) context of individual health behaviours

4. Criticism: Developing a critical approach to health

� Will PHP work in Africa?

� Using Ghana as a case study: exploring potential of PHP on NCD primary and secondary prevention

Ghana� Population 19.5 million (2002)� 55% agricultural – 50% GDP

($8,869, 2004)� Unemployment 20% (↑?) � 44.8 < $1/day (1998/9)� Mineral/resource rich – cash

poor� Global debts $5billion – HIPC

status (debt relief granted)� SAPs negative impact on

public services (education, health, infrastructure)

� Healthcare compromised (4.5% GDP; Cash & Carry; NHIS)

Top 10 Inpatient Causes of Deaths in 32 Sentinel Hospitals(CHIM 2003)

WR CR GAR VR ER ASH BAR NR UER UWR Ghana

1 Malaria Malaria Malaria Stroke Malaria Malaria Sepsis Malaria Malaria Malaria Malaria

2 Anaemia Anaemia Stroke Malaria AnaemiaNeonatal condition

Malaria Anaemia Pneumonia Anaemia Anaemia

3 Pneumonia Pneumonia Anaemia Anaemia StrokeTyphoid Fever

Pneumonia Pneumonia Anaemia Pneumonia Pneumonia

4 Hepatitis Stroke Pneumonia Pneumonia Pneumonia Stroke Stroke Diarrhoea Meningitis Diarrhoea Stroke

5 HPTN HPTNCardiopath

yCardiopath

yHPTN Anaemia HIV/AIDS

Convulsions

TB HepatitisTyphoid Fever

6 Stroke Diarrhoea HPTN Sepsis Diarrhoea Hepatitis HepatitisTyphoid Fever

Typhoid Fever

Meningitis Diarrhoea

7 DiarrhoeaNeonatal condition

Typhoid Fever

TBCardiopath

yPneumonia Anaemia Meningitis Hepatitis

Typhoid Fever

HPTN

8Typhoid Fever

Typhoid Fever

Diarrhoea RTA Diabetes DiarrhoeaLiver

DiseaseNeonatal condition

StrokeConvulsion

sHepatitis

9Cardiopath

yRenal disease

LiverDisease

Cancer Sepsis TB Cancer HepatitisAbdominal

colicMalnutritio

nMeningitis

10 Injuries SepsisTyphoid Fever

Anaemia TBLiver

DiseaseCardiopath

yRTA

Liver Disease

HIV/AIDS Sepsis

Chronic non-communicable diseasesChronic non-communicable diseases (hypertension, stroke, diabetes) are set toovertake communicable diseases in terms of impact on morbidity and mortality across the country.

� Hypertension national prevalence (28.7%) (Amoah et al): � Reported facility cases of hypertension increased by 67 per cent from 58,677 in 1989

to 97,980 in 1998. � Since 1998 national OPD hypertension cases have increased 4-fold from about 60,000

in 1990 to 250,000 in 2005 (Bosu, 2007; MOH, 2001)� Diabetes prevalence↑ (0.2%, 1960s Ho (Dodu); 6.4% 2003 Accra (Amoah et

al))� Breast and prostate cancers on the increase: breast cancer cases have a 25%

survival rate (Clegg-Lamptey, 2007)

Note� If HIV prevalence (3.2% - 3.4%) constitutes an epidemic, then diabetes

(6.4%) and hypertension (28.7%) are epidemics

Primary Prevention: available knowledge

Since the 1970s studies in Accra have shown that poor communities in areas like Nima face dual risk of communicable and non-communicable diseases compared to wealthier communities(Agyei-Mensah, 2004; Pobee, 2007; Stephens et al, 1994).

Poverty (medical evidence: infectious diseases endemic in poor communities as risk factor for chronic disease)

More prevalent in urban settings where factors such as high car ownership and use and sedentary office jobs prevail (cf. GreaterAccra Annual Report 2006). But important intra-setting differences.

Physical Inactivity

Prevalence rates: from 0.9% in 1987-1988to 14% in 2003(Amoah, 2003; Berios et al, 1997; Britwum et al, 2005).

Higher obesity rates in southern vs northern regions; among women vs men, married individuals vs unmarried; older vsyoung individuals (Britwum et al, 2005).

Obesity

Current knowledge Risk factors

Secondary Prevention: available knowledge

-Social relationships (stigmatisation; ostracism)

Cancer (ibid, Daily Graphic, 2007)Family relationships(abandonment; tainted family identities)

Hypertension (de-Graft Aikins, 2004)Diet/food practices (psychological, nutritional, social, economic cost)

Cancer (ibid), asthma (Forson, 2007), hypertension, chronic/terminal childhood illnesses (Badasu, 2007)

Economic circumstance (work/income; drug/food costs)

Cancer and gender (ibid)Identity

Cancer (Clegg-Lamptey, 2007) sickle-cell disease, leukaemia (Ekem, 2007)

Body-self (psycho-emotional consequences)

Applies toDiabetes and Biographical Disruption (de-Graft Aikins, 2003, 2005)

Summary � Risk factors prevalent: esp obesity, physical

inactivity, emerging threat of infectious disease risk

� Poor quality of life of people living with chronic diseases

Responses: Policy � Poor: no policy or plan, but

� Establishment of Non-communicable disease programme (NCDP)with focus on public health

� The National Health Insurance Scheme (NHIS)

� Recently the Health Minister’s regenerative health initiative (strategic document focuses on Ghana’s NCD burden)

Responses: research� Early research medical (review

of Ghana Medical Journal, 1960s to present) � conditions of interest: diabetes,

CVD, sickle-cell disease, cancers, asthma

� More recently social science perspectives� Psychology (de-Graft Aikins,

2004)� Geography (Agyei-Mensah,

2004)� Sociology/demography

(Badasu, 2007, Tagoe, in prep)� Anthropology

Responses: practice � Patient organisations

� Diabetes (Ghana Diabetes Association), cancer (Reach for Recovery, DWIB Leukaemia Trust), sickle-cell disease (Sickle Cell Association of Ghana)

� Innovative models of care � the Korle-Bu Breast (Cancer) Clinic

� Surgeons; Radiation Oncologists; Clinical pharmacist; Clinical psychologist/ Breast cancer survivors

� Self-referral centre; Discussion of patients; Co-ordination/standardisation of management; Symposia; Guidelines for management; Research

� Dept of Psychiatry’s clinical psychologists and the proposed ‘Wellness Clinic’ (clin Psych students offering counselling at Korle-Bu)

� Media: training, dissemination � Politicians – e.g. lobbying for breast

cancer treatment on NHIS

Key insights, Key gaps� Lay knowledge:on expert

approaches poor, but rich complex of local/cultural knowledge on health and disease and communities who engage with health providers tend to understand better than expected (de-Graft Aikins, 2004)� Health workers knowledge poor (e.g

asthma, diabetes)

� Experiences:late presentation, poor self-care, poor support systems, women have greater burden

� Multi-institutional multi-faceted scene cohering: patient groups, health practitioners, researchers, media, politicians

� Health promotion: domain largely of NCDP; media print dominates, radio, particularly in rural areas less so)

� Least research in this area; support systems required for some conditions (asthma, hypertension)

� Key actors: bias toward expert led initiatives; in research arena, psychology insignificant presence; poor funding a common problem

Will PHP work in Ghana?� Theoretically, yes

� nature of recent responses and activities (both top down and bottom up) in the NCD arena.

� Basic building blocks present for multi-institutional multi-faceted approach � ‘strategic frameworks’

� To some extent the local psychology community lags behind an increasingly dynamic public health movement

� Practically, challenges exist� Number of psychologists working in the health arena and specifically

on NCDs very low (mental health focus): DoP at Korle-Bu� Curriculum mainstream, weak research culture - even community

psychologists are classroom based (Akotia & Barima, 2007)� Psychology and psychologists not recognised by the MOH and GHS

as healthcare providers � poor to no access to health policymakers

� Implications of Ghanaian case study for PHP and NCD prevention in Africa

(1) Gap between NCD Policy and practice

� There will be a gap between NCD policy and practice for the foreseeable future (Marks & de-Graft Aikins, 2007)� Competing interests - concrete material investment in

communicable disease (malaria, HIV/AIDS, TB) vsrhetorical investment in NCDs.

� Financial, human resource, conceptual barriers real

� The Ghanaian example: 16-year call for action.

� Innovative responses important and possible

(2) Innovative models exist in Africa� Innovative responses exist and constitute important models for cost-

effective primary and secondary prevention� The Ghanaian examples (in particular the Korle Bu Breast Cancer care

model)� Regional examples from HIV/AIDS (Kalipeni et al, 2004; Illife, 2006;

Campbell, 2003) & cancer care (Harding & Higginson, 2004)� All these have required pooling expertise, resources and commitment of lay

communities, pluralistic health professionals, multidisciplinary researchers, health policymakers and donors. As in LA:� Guareschi & Jovchelovitch’s (2004) ‘productive alliances’ between

different social actors with divergent knowledge, experiences, expertise and status.

� Krause’s (2002, 2003) action research work on diabetes, hypertension and inflammatory bowel disease

� PHP does have a role to play and can build on these models

(3) PHP model possible but challenges existInternal (strengthening disciplinary identity)� Critical mass of psychologists working in health and at

community level� SA and Nigeria; poor in other countries

� Pedagogical changes in African psychology � Three challenges: ‘culture’ (of wholesale borrowing from Euro-American

Psychology; ‘organisational’; ‘manpower & finance’ (Peltzer and Bless, 1989)

� Recognition of psychology (theory, practice) by health policymakers/administrators/ practitioners

Relational (‘strategic frameworks’)� Forging links/collaborations with other research/practice

communities

References� Alwan, A., Maclean, D. and Mandil, A. (2001). Assessment of National Capacity for

Noncommunicable Disease Prevention and Control.Geneva: WHO.� Amoah, A.G.B, Owusu, K.O., and Adjei, S (2002). Diabetes in Ghana: a community

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� WHO (2005a). Preventing Chronic Disease. A vital investment. Geneva: WHO.

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� WHO-Afro. http://www.afro.who.int/.

Thank you