PreprintPDF Available

The Epidemiological and Economic Burden of Diabetes in Ghana: A Scoping Review to Inform Health Technology Assessment

April 2023

April 2023

DOI:10.1101/2023.04.19.23288806

License
CC BY 4.0

Authors:

Joseph Kazibwe

Lund University

Mohamed Gad

Imperial College London

Ivy Amankwah

University of Ghana

Show all 10 authorsHide

Preprints and early-stage research may not have been peer reviewed yet.

Introduction Diabetes remains one of the four major causes of morbidity and mortality globally among non-communicable diseases (NCDs. It is predicted to increase in sub–Saharan Africa by over 50% by 2045. The aim of this study is to identify, map and estimate the burden of diabetes in Ghana, which is essential for optimising NCD country policy and understanding existing knowledge gaps to guide future research in this area. Methods We followed the Arksey and O’Malley framework for scoping reviews. We searched electronic databases including Medline, Embase, Web of Science, Scopus, Cochrane and African Index Medicus following a systematic search strategy. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews was followed when reporting the results. Results A total of 36 studies were found to fulfil the inclusion criteria. The reported prevalence of diabetes at national level in Ghana ranged between 2.80% – 3.95%. At the regional level, the Western region reported the highest prevalence of diabetes: 39.80%, followed by Ashanti region (25.20%) and Central region at 24.60%. The prevalence of diabetes was generally higher in women in comparison to men. Urban areas were found to have a higher prevalence of diabetes than rural areas. The mean annual financial cost of managing one diabetic case at the outpatient clinic was estimated at GHS 540.35 (2021 US $194.09). There was a paucity of evidence on the overall economic burden and the regional prevalence burden. Conclusion Ghana is faced with a considerable burden of diabetes which varies by region and setting (urban/rural). There is an urgent need for effective and efficient interventions to prevent the anticipated elevation in burden of disease through the utilisation of existing evidence and proven priority-setting tools like Health Technology Assessment (HTA).

Summary of studies that reported on the prevalence of complications/comorbidities for 383 diabetics in Ghana

…

Figures - available via license: Creative Commons Attribution 4.0 International

Content may be subject to copyright.

Available via license: CC BY 4.0

Content may be subject to copyright.

1The Epidemiological and Economic Burden of Diabetes in

2Ghana: A Scoping Review to Inform Health Technology

3Assessment

6Mohamed Gad1, Joseph Kazibwe1, Emmanuella Abassah-Konadu2, Ivy

7Amankwah2, Richmond Owusu3, Godwin Gulbi3, Sergio Torres-Rueda1, Brian

8Asare2, Anna Vassall1, Francis Ruiz1

14 Affiliations

16 1. Department of Global Health and Development, London School of Hygiene

17 and Tropical Medicine (LSHTM), London, United Kingdom

18 2. Pharmacy Directorate, Ministry of Health, Accra, Ghana

19 3. School of Public Health, University of Ghana, Accra, Ghana

22 - Joint first authors

24 Corresponding author:

26 Joseph Kazibwe

27 Global Health and Development

28 London School of Hygiene and Tropical Medicine

29 Joseph.kazibwe@lshtm.ac.uk

40 Keywords: Diabetes, Burden, Comorbidities, Ghana, Health Technology

41 Assessment

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted April 20, 2023. ; https://doi.org/10.1101/2023.04.19.23288806doi: medRxiv preprint

NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

51 Abstract

Introduction

53 Diabetes remains one of the four major causes of morbidity and mortality globally

54 among non-communicable diseases (NCDs. It is predicted to increase in sub–Saharan

55 Africa by over 50% by 2045. The aim of this study is to identify, map and estimate the

56 burden of diabetes in Ghana, which is essential for optimising NCD country policy and

57 understanding existing knowledge gaps to guide future research in this area.

Methods

60 We followed the Arksey and O’Malley framework for scoping reviews. We searched

61 electronic databases including Medline, Embase, Web of Science, Scopus, Cochrane

62 and African Index Medicus following a systematic search strategy. The Preferred

63 Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping

64 Reviews was followed when reporting the results.

Results

67 A total of 36 studies were found to fulfil the inclusion criteria. The reported prevalence

68 of diabetes at national level in Ghana ranged between 2.80% – 3.95%. At the regional

69 level, the Western region reported the highest prevalence of diabetes: 39.80%,

70 followed by Ashanti region (25.20%) and Central region at 24.60%. The prevalence of

71 diabetes was generally higher in women in comparison to men. Urban areas were

72 found to have a higher prevalence of diabetes than rural areas. The mean annual

73 financial cost of managing one diabetic case at the outpatient clinic was estimated at

. CC-BY 4.0 International licenseIt is made available under a

74 GHS 540.35 (2021 US $194.09). There was a paucity of evidence on the overall

75 economic burden and the regional prevalence burden.

Conclusion

78 Ghana is faced with a considerable burden of diabetes which varies by region and

79 setting (urban/rural). There is an urgent need for effective and efficient interventions

80 to prevent the anticipated elevation in burden of disease through the utilisation of

81 existing evidence and proven priority-setting tools like Health Technology Assessment

82 (HTA).

. CC-BY 4.0 International licenseIt is made available under a

87 Introduction

88 Diabetes is one of the top four non-communicable diseases (NCDs) in terms of

89 mortality globally1. Approximately 537 million people between the ages of 20-79 years

90 are living with diabetes globally of which over 75% live in low- and middle-income

91 countries (LMICs). Of those living with diabetes nearly half are unaware of their

92 diagnosis2. Diabetes exerts tremendous pressure on the resources available for

93 health; treatment and management of diabetes account for over 10% of the total health

94 expenditure among adults globally3. The prevalence of diabetes is expected to

95 increase globally to 783 million by 20452.

98 As of 2021, there were approximately 24 million people with diabetes in sub-Saharan

99 Africa (SSA) and the number is projected to increase by 134% by 2045. 3. The

100 prevalence of diabetes in the region stands at approximately 4.5% among those aged

101 between 20-79 years. In 2021 alone, over 306,000 people under 60-years of age died

102 due to diabetes in SSA3. It is estimated that each person with diabetes incurs

103 approximately USD 547 per year on healthcare (both patient and health system direct

104 costs) in SSA as of 2021.

105

106 Most cases of diabetes can be classified into two types: Type 1 diabetes (T1D) is most

107 common in children and results from the destruction of insulin-producing beta cells,

108 mostly by autoimmune mechanisms4. Type 2 diabetes (T2D) is a metabolic disorder

109 characterised by insulin resistance and relative insulin deficiency and, although it can

110 occur at any age, it is most common among adults5. T2D is linked to physical inactivity

. CC-BY 4.0 International licenseIt is made available under a

111 and an unhealthy diet, and accounts for approximately 90% of all diabetes cases

112 globally6.

113

114 While regional estimates are available to support policy making, there is a need to

115 understand the country-specific disease burdens (national and sub-national) to inform

116 target policy at a local level that yields effective and economically efficient impact.

117 Unfortunately, existing estimates of country-specific diabetes burden are sparse in low

118 and lower middle-income settings, especially in SSA. This makes it difficult to identity

119 and implement appropriate targeted interventions that are feasible and affordable by

120 a given country considering the existing financial constraints of the health budgets.

121 Countries in SSA are starting to adopt health technology assessment (HTA) as a

122 decision-making aid to identify and implement appropriate interventions while

123 maximizing value for money. Figure 1 illustrates the main steps involved in HTA

124 processes as adapted from Siegfried et al.7

125

126

127

128

Figure 1: The HTA process

129

130 HTA can be defined as a multidisciplinary process that uses explicit methods, often

131 involving cost-effectiveness analysis, to determine the value of a health technology at

132 different points in its lifecycle8. The HTA process typically starts with identifying

133 relevant alternatives linked to a policy need (defining the decision space). This is then

134 followed by the gathering and synthesis of various sources of evidence to arrive at an

135 understanding of the relative value for money of the alternatives (the analysis or

136 assessment step). There is then an appraisal of that evidence involving some form of

. CC-BY 4.0 International licenseIt is made available under a

137 deliberative process against decision criteria, leading to the development of

138 recommendations and the subsequent implementation of preferred options.

139 Information gathered from implementation can be used to inform a future HTA. An

140 important input into the conduct of HTA includes having credible estimates of disease

141 burden, which will be important in informing key parameters in any cost-effectiveness

142 model9.

143

144 Ghana has adopted the use of HTA to inform decision making within the health

145 sector10. This commitment to evidence-informed priority setting has included the

146 development and implementation of an HTA process guide, officially launched in

147 December 202211. The Ghana Ministry of Health has indicated an interest in using

148 HTA to inform decision making in diabetes management and prevention. Such an

149 approach requires up-to date information about the current epidemiological and

150 economic burden of diabetes in the country, which is currently unavailable12.

151

152 To address this need, our study aims to undertake a scoping review of the peer-

153 reviewed literature to identify, map and estimate the burden of diabetes in Ghana, in

154 terms of epidemiological distribution, health outcomes and economic consequences.

155 It is anticipated this work will support optimising current NCD country policy, especially

156 in relation to priority setting, as well inform the parameterisation of model-based

157 analyses and highlight existing knowledge gaps to guide future research in this area.

158

159

160

161 Methods

. CC-BY 4.0 International licenseIt is made available under a

162 Study design

163 We followed the Arksey and O’Malley framework for scoping reviews13. The

164 framework consists of five stages which were followed: (i) identifying the research

165 question; (ii) identifying relevant studies; (iii) selecting appropriate studies; (iv) charting

166 and collating the data, and (v) summarising and reporting the results. The detailed

167 search protocol is available in Appendix 1. A study protocol is available although not

168 registered. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses

169 Extension for Scoping Reviews (PRISMA-ScR) was followed when reporting the

170 results14. We examined the following aspects of burden: (1) epidemiological

171 distribution (incidence, prevalence, demographic distribution), (2) impact on health

172 outcomes (comorbidity or complications, health effects in disability adjusted life years

173 (DALYs), quality adjusted life years (QALYs), mortality among others), and (3)

174 economic consequences (cost of care, loss of productivity, or out of pocket

175 expenditure).

176

177 Eligibility criteria and study selection

178 A study was considered eligible for inclusion if it was published in a peer-reviewed

179 journal and reported burden of disease in Ghana reflecting at least one of the three

180 dimensions highlighted above. To ensure relevance, we only included studies

181 published after 2009. All study designs were considered for inclusion without

182 restrictions. There were also no restrictions on population, age or sex. Literature

183 reporting only the qualitative experience of diabetic patients, and those assessing the

184 relationship between socioeconomic status (SES), gender, and diabetes as a health

. CC-BY 4.0 International licenseIt is made available under a

185 outcome were excluded. Studies published in languages other than English were also

186 excluded.

187

188

189 Information Sources

190 We searched the following electronic databases: Medline, Embase, Web of Science,

191 Scopus, Cochrane and African Index Medicus. The databases were searched on 4th

192 April 2021 following a systematic search strategy and a second search was done on

193 11th April 2023 to find all new articles that were published since the previous search.

194

195 Search strategy

196 We used two broad key terms (‘Ghana’ and ‘diabetes’) as well as similar derivatives,

197 to identify the literature on the burden of disease. Search strings were tailored to the

198 different databases (appendix 1).

199

200 Selection process

201 The retrieved articles from the search were listed and uploaded to Covidence

202 software15 which was used to identify and remove duplicates, carry out the screening

203 process and full-text review. A standard process of screening articles by title and

204 abstract, followed by full-text reading was followed to assess eligibility to be included

205 in this study. These steps were conducted by two independent researchers (MG &

206 JK). Any discrepancies in the assessment decision were discussed and resolved by

207 reaching a consensus between the two researchers.

208

. CC-BY 4.0 International licenseIt is made available under a

209 Data charting

210 A data extraction sheet was used to extract relevant information from included studies

211 to allow us to map and highlight the main results and categorize findings in relation to

212 the research question. Information extracted included: author name, publication year,

213 form of diabetes burden being reported (such as prevalence, incidence, economic,

214 etc), study design, target population, geographical region, setting (urban or rural), and

215 main findings.

216

217 Our charting approach allowed us to interpret data from included studies according to

218 the forms of diabetes burden which we henceforth refer to as themes. The extracted

219 data was grouped under three themes (epidemiological, health outcomes, economic).

220 We used simple visualisation and basic descriptive analytical techniques to summarise

221 and report the scoping review findings.

222

223 Synthesis of results

224 We organised extracted data quantitatively following the themes. We produced tables

225 and charts in relation to the following: the distribution of studies geographically and

226 per type of burden, target groups; the research methods adopted, and health outcome

227 measures used.

228

229

230

231

232

233

234

235 Results

. CC-BY 4.0 International licenseIt is made available under a

236 The electronic database search yielded 1103 records after deduplication. Figure 2

237 below shows the PRISMA flowchart.

238

239

Figure 2: PRISMA flow chart

240

241

242

243 Study characteristics

244 A total of 36 studies fulfilled the inclusion criteria. Table 1 shows the characteristics of

245 the included studies. All studies were observational studies with a majority having a

246 cross-sectional design (n=30); there were four longitudinal studies16–19 and two case

247 control studies20,21. The longitudinal studies were based on either panel data or cohort

248 study data.

249

250 All studies included adults (persons aged 18 and above) as their target population.

251 Three studies focused on people above the age of 50 years22–24. Forms of burden

252 reported in the studies were prevalence (n=16), complications and comorbidity (n=17),

253 incidence (n=2)18,19, economic (n=1)25 and mortality (n=1)17. All studies either reported

254 on T2D or diabetes in general (without specifying the type).

255

256 Notably, most of the extracted studies were carried out in Ashanti region (n=14),

257 followed by Volta (n=4)26–29, Greater Accra (n=3)30–32, Central (n=1)33, Northern

258 (n=1)34 and Brong Ahafo (n=1)35. Four studies were carried out in more than one

259 region while five studies took a whole country perspective22–24,36,37. No study was

260 carried out that specifically focused on the following regions: Upper East, Upper West,

261 Western, and Eastern.

262

263

. CC-BY 4.0 International licenseIt is made available under a

264

Table 1: Table of study characteristics

Author

Public

ation

year

Study

design

Target

population

Form of

the Burden

Specific burden

Region

Gatimu et

al.22

2016

Cross-

sectional

Adults 50

years and

above

Prevalence

Prevalence of diabetes

and risk factors

National

Bawah et

al.26

2019

Cross-

sectional

Adults 30

years and

above

Prevalence

Prevalence of T2D and

pre-diabetes

Volta region

Kojo

Anderson38

2017

Cross-

sectional

Adults 18

years and

above

Prevalence

Prevalence of T2D

Western

Region, Central

Region

Vuvor et al30

2011

Cross-

sectional

Adults 36

years and

above

Prevalence

Prevalence of diabetes

and risk factors

Greater Accra

Chilunga et

al39

2019

Cross

sectional

Adults 25 -70

years with

BMI<25kg/m2

Prevalence

Prevalence of T2D

Ashanti region

Gato et al33

2017

Cross-

sectional

Adults 18

years and

above

Prevalence

Prevalence of diabetes

Central Region

Yorke et al23

2020

Cross-

sectional

Adults 50

years and

above

Prevalence

Prevalence of diabetes

National

Agyemang

et al40

2016

Cross

sectional

Adults 25 -70

years

Prevalence

Prevalence of T2D and

Obesity

Ashanti region

Tyrovolas et

al36

2015

Cross-

sectional

Adults 18

years and

above

Prevalence

Prevalence of diabetes

National

Annani-

Akollor et

al41

2019

Cross-

sectional

Adults 18

years and

above

Complicatio

Complications of T2D:

Macrovascular,

microvascular,

neuropathy,

nephropathy,

retinopathy, sexual

dysfunction, DKA,

hypoglycemia

Ashanti region

Hayfron-

Benjamin et

al37

2019

Cross-

sectional

Adults above

25 years with

T2D

Complicatio

Complications of T2D:

Macrovascular,

microvascular,

coronary artery

disease, nephropathy,

retinopathy, PAD,

stroke

National

Nsiah et al42

2015

Cross-

sectional

Adults 20 - 80

years with T2D

Complicatio

Prevalence of

comorbidities and risk

factors (Metabolic

Syndrome,

hypertension,

dyslipidemia)

Ashanti region

Mogre et al34

2014

Cross-

sectional

Adults 18

years and

above with

T2D

Comorbiditi

Prevalence of MetS

among diabetic

patients

Northern region

. CC-BY 4.0 International licenseIt is made available under a

Agyemang-

Yeboah et

al43

2019

Cross-

sectional

Patients with

diabetes

Comorbiditi

Prevalence of MetS

among diabetic

patients

Ashanti Region

Antwi-

Bafour et al20

2016

case-

control

Patients with

T2D

Comorbiditi

Prevalence of anaemia

among diabetics

Not mentioned

Akpalu et

al31

2018

Cross-

sectional

Adults 30 -65

years with T2D

Comorbiditi

Prevalence of

depression among T2D

patients

Greater Accra

Sarfo et al16

2018

Longitudi

nal

(Cohort)

Adults 18

years and

above

Comorbiditi

Prevalence of stroke

among diabetics

Eastern,

Ashanti,

Northern

Regions

Osei-

Yeboah et

al27

2017

Cross-

sectional

Patients with

T2D

Comorbiditi

Prevalence of MetS

among diabetic

patients

Volta region

Opare-Addo

et al44

2020

Cross-

sectional

Adults 18

years and

above

Comorbiditi

Prevalence of

hypertension among

diabetics

Ashanti region

Sarfo-

Kantanka et

al17

2016

Longitudi

nal

(panel)

Patients with

T2D admitted

to hospital

Mortality

Mortality trend for 31

years

Ashanti region

Lartey &

Aikins45

2018

Cross-

sectional

Patients with

diabetes

attending

Diabetic clinic

Comorbiditi

Prevalence of visual

impairment among

diabetics

Ashanti region

Nimako et

al32

2013

Cross-

sectional

Patients with

T2D attending

General

Hospital

Prevalence

and

comorbiditi

Prevalence of diabetes

and hypertension

Greater Accra

Region

Atosona &

Larbie46

2019

Cross-

sectional

Patients with

T2D at the

outpatient

clinic

Complicatio

Prevalence of diabetic

foot

Greater Accra,

Ashanti, and

Northern

regions

Sarfo-

Kantanka et

al18

2019

Longitudi

nal

(Cohort)

Patients with

T2D at the

diabetes clinic

Incidence

Incidence rate of

diabetes-related LLA

Ashanti region

Sarfo-

Kantanka et

al19

2018

Longitudi

nal

(panel)

Patients with

T2D at the

diabetes clinic

Incidence

Trend of incidence and

predictors of diabetic

foot

Ashanti region

Quaye et al25

2015

Cross-

sectional

Patients with

diabetes

Economic

Annual costs

Greater Accra,

Ashanti, Eastern

Regions

Tarekegne

et al24

2018

Cross-

sectional

Adults 50

years or above

Prevalence

Prevalence of DM

National

Cook-Huynh

et al47

2012

Cross-

sectional

Adults 18

years or above

Prevalence

Prevalence of DM

Ashanti region

Sarfo-

Kantanka et

al48

2014

Cross-

sectional

Adults 18

years or above

Prevalence

Prevalence of DM

Ashanti region

Agbogli et

al49

2017

Cross-

sectional

Adults 18

years or above

Prevalence

Prevalence of DM

Ashanti region

Quaicoe et

al21

2017

case-

control

Adults aged

18-64+ years

Prevalence

Prevalence of DM

Ashanti region

. CC-BY 4.0 International licenseIt is made available under a

Odame Anto

et al50

2021

Cross-

sectional

Adults aged 30

years or above

Complicatio

Prevalence of MetS

among diabetic

patients

Ashanti region

Abagre et

al35

2022

Cross-

sectional

Adults aged

30-79 years

old

Complicatio

Prevalence of MetS

among diabetic

patients

Brong-Ahafo

region

Abu et al51

2022

Cross-

sectional

Adults aged

38-85 years

old

Complicatio

Prevalence of dry eye

disease among T2D

patients

Central region

Tuglo et al28

2022

Cross-

sectional

Adults

Complicatio

Prevalence of diabetic

ulcers

Volta region

Ellahi et al29

2022

Cross-

sectional

Adults 18

years or above

Prevalence

Prevalence of DM

Volta region

265

266

267 Publication trend

268 The number of publications by year (figure 3) broadly shows an increasing trend

269 between 2009 and 2019 and a dip after 2019. Most articles were published in 2019

270 (n=7) before a decline in 2020.

271 Figure 3: Number of studies/publications per year

272

273 Forms of the burden of diabetes (themes) in Ghana

274 Our charting analysis mapped the studies across three main themes: epidemiological,

275 health outcomes, and economic. The epidemiological theme included prevalence of

276 diabetes (n=16) and incidence (n=2). The health outcomes theme (n=17) was

277 comprised of studies reporting on complications (n=6), comorbidities (n=10) and

278 mortality (n=1). Finally, the economic theme (n=1) included costs of diabetes services.

279 Some studies reported both the prevalence of diabetes and comorbidities (n=1).

280 Figure 4 demonstrates the percentage of included studies by theme.

281

282

Figure 4: Percentage of included studies by form of burden (theme)

283

284

. CC-BY 4.0 International licenseIt is made available under a

285 Frequency of theme by region

286 The Ashanti and Greater Accra regions were the most frequently targeted regions

287 across all studies, with reported studies covering all the three themes. We found data

288 on both prevalence and outcomes in the Volta and Central regions. The Western

289 region had only prevalence data reported while Brong-Ahafo and Northern regions

290 had studies that reported on health outcomes only. No data was found for the

291 remaining regions. Five studies were conducted using a nationally representative

292 sample. Figure 5 shows the frequency of themes by region from all included studies

293 (including single and multi-region studies).

294

295

296

297

298

Figure 5: Frequency of burden of disease themes reported by region

299

300

301

302

303

304 1) Epidemiological burden

305 The reported prevalence of diabetes at national level in Ghana ranged between

306 2.80%23,24 – 3.95%22. At sub-national levels, the Western region reported the highest

307 prevalence of diabetes: 39.80% among those 18 years and older38. The second

308 highest prevalence of diabetes (25.20%) was reported in Ashanti region48 followed by

309 24.60% in the Central region38.

310

311 In the national studies, the prevalence of diabetes was generally higher in women in

312 comparison to men22,24,36. Regionally, the prevalence of diabetes was also notably

. CC-BY 4.0 International licenseIt is made available under a

313 higher in females compared to males, with the exception of the Ashanti region26,30,48,49.

314 Urban areas had a higher prevalence than rural areas22–24,39,40.

315

316 Prevalence studies only covered five of the ten administrative regions: Ashanti (n=6),

317 Volta (n=3), Central (n=2), Greater Accra (n=2), and Western (n=1) regions. There

318 were four national-level studies. The majority of prevalence studies were focused on

319 adults aged 18 years old and above (n=7), followed by adults 50 years and above

320 (n=4). Table 2 shows the summary of studies that reported the prevalence of diabetes

321 in Ghana.

322

323

Table 2: Summary of findings of studies reporting the prevalence of diabetes in Ghana

Prevalence % (95% CI)

Author and

Year

Region

Age groups

Sample

size

Diagnostic

criteria

Overall

Male

Female

Urban

Rural

Tyrovolas et al.

201536

National

Adults 50 years

or above

52,946

Self-reported

3.9 (2.4

- 6.2)

Gatimu et al.

201622

National

Adults 50 years

or above

4,089

Self-reported

4.0 (3.4

- 4.6)

1.7

(1.3–

2.3)

2.2 (1.7

- 2.8)

6.2

(4.8 -

8.0)

2.3

(1.7-

3.3)

Tarekegne et al.

2018

National

Adults 50 years

or above

4,289

Self-reported

2.8

2.5

3.3

4.7

1.5

Yorke et al.

202023

National

Adults 50 years

or above

3,350

Self-reported

2.8 (2·0

- 3·9)

2.8

4.4

1.3

Cook-Huynh et

al. 201247

Ashanti

Adults 18 years

or above

326

WHO diagnostic

criteria

7.7

(5.0-

11.0)

Sarfo-Kantanka

et al. 201448

Ashanti

Adults 18 years

or above

1,292

WHO diagnostic

criteria (fasting

blood glucose

only)

25.2

25.7

24.4

Agyemang et al.

201640

Ashanti

Adults aged 25-

70 years old

820

WHO diagnostic

criteria

8.3

5.7

Agbogli et al

201749

Ashanti

Adults 18 years

or above

113

WHO diagnostic

criteria (fasting

blood glucose

only)

3.5

5.9

2.5

Chillunga et al.

201939

Ashanti

Adults aged 25-

70 years old

1,436

WHO diagnostic

criteria

5.7

8.8

3.6

Opare-Addo et

al. 202044

Ashanti

Adults 18 years

or above

684

Self-reported

5.4

Vuvor et al.

201130

Greater

Accra

Adults aged 36-

95 years old

597

Urinary dipsticks

and FBG

determinations

(level not

mentioned)

3.9

3.5

4.2

Bawah et al.

201926

Greater

Accra

130

HBA1C ≥ 6.5%

5.4

. CC-BY 4.0 International licenseIt is made available under a

Quaicoe et al

201721

Volta

Adults aged 18-

64+ years

226

American

Diabetes

Association

Criteria 2010

8.6

Bawah et al.

201926

Volta

Adults 30 years

or above

202

American

Diabetes

Association

criteria 2010

6.9

6.5

7.1

Ellahi et al.

202229

Volta

Adults 18 and

above

850

WHO diagnostic

criteria

4.4

Gato et al.

201733

Central

Adults 18-80

years

482

Self-reported

8.3

Anderson et al.

201738

Central

and

Western

Adults 18 years

or above

976

Fasting Blood

Glucose ≥

126mg/dl (7

mmol/L)

24.6 to

39.8

324 NR- Not reported

325

326

327

328 2) Common complications and comorbidity

329 Seven complications and/or comorbidities were identified in this review (figure 6).

330 Studies on complications and comorbidities were only found for six of the ten

331 administrative regions: Ashanti (n=9), Northern (n=2), Greater Accra (n=2), Volta

332 (n=2), Brong-Ahafo (n=1) and Central (n=1). In addition, a multi-region (sub-national)

333 study combining populations from Greater Accra, Ashanti, and Northern regions (n=1)

334 was identified along with a study that did not specify location (n=1). No study was

335 conducted at the national level for complications and comorbidities of diabetes.

336

337 The most common complication types reported in the included studies were metabolic

338 syndrome (n=6), followed by macrovascular and/or microvascular complications (n=4)

339 and diabetic foot and/or lower extremity amputation (n=4), hypertension (n=3),

340 anaemia (n=1), depression (n=1) and dry eye disease (n=1). Figure 6 shows the

341 number of studies per region by complication type.

342

. CC-BY 4.0 International licenseIt is made available under a

343

Figure 6: Number of studies per region by complication type

344

345 The prevalence of micro and macrovascular complications among people with

346 diabetes varied: coronary artery disease (CAD) ranged between 18.4%37 and 31.8%41,

347 peripheral arterial disease (PAD) between 11.2%37 and 19%17, neuropathy between

348 18.3%17 and 20.8%41, nephropathy between 12.5%41 and 44.70%17, and retinopathy

349 between 6.5%41 and 13.7%45.

350

351 Six studies assessed the prevalence of metabolic syndrome in diabetic patients in

352 Ghana in the regions of Ashanti, Northern, Volta and Brong-Ahafo. The highest

353 prevalence rate of metabolic syndrome was reported in the Ashanti region, with

354 prevalence ranging between 42%50 and 90%43. This was followed by Brong-Ahafo with

355 68.6%35, the Volta region with 43.8%27, and Northern region with 24%34. The

356 prevalence of hypertension among diabetic patients was assessed in three studies

357 that included populations of Ashanti, Northern, and Greater Accra regions. The highest

358 prevalence of hypertension as a complication/ comorbidity of diabetes was reported in

359 the Greater Accra region (36.60%). This was followed by the Northern region (21%),

360 and the Ashanti region (1.61%).

361

362 Diabetic foot disorders and lower extremity amputation were assessed in four studies.

363 Two longitudinal studies were conducted in Komfo Anokye Teaching Hospital in the

364 Ashanti region reporting a mean incidence of foot disorders and average incidence

365 rate of diabetes related amputations of 8.39% (5.27% males and 3.12% females)19 and

366 2.4 (95% CI:1.84–5.61) per 1000 follow-up years18 respectively among diabetes

367 patients. The third study was a cross-sectional study that randomly selected patients

. CC-BY 4.0 International licenseIt is made available under a

368 from the outpatient diabetes clinics of three tertiary hospitals from Greater Accra,

369 Ashanti, and Northern regions and reported a prevalence of 11% for diabetic foot

370 ulcers and 3% for lower extremity amputations. The fourth study was also cross

371 sectional in Volta region focusing on diabetic foot ulcers28.

372

373 One study assessed the prevalence of depression among diabetic patients at the

374 National Diabetes Management and Research Centre, Korle Bu Teaching Hospital in

375 Greater Accra region31. The study reported that 31% of diabetic patients suffered from

376 depression in 2018. Finally, a case-control study reported that 84.8 % of patients with

377 diabetes had haemoglobin concentrations that were significantly lower than the

378 general population. Table 3 provides a summary of findings stratified by complication

379 type and geographic region in Ghana.

380

381

382 Table 3: Summary of studies that reported on the prevalence of complications/comorbidities for

383 diabetics in Ghana

Metabolic syndrome

Region

Author

and

date

Target

populat

ion

Context

Sampl

e size

Diagnostic

criteria

Main results

Ashanti

Nsiah et

al.

201542

Adults

aged

20-86

years

old

T2D patients

attending the

Diabetic Centre of

the Komfo Anokye

Teaching

Hospital in Kumasi,

Ashanti region

150

NCEP/ATP

III

The overall percentage

prevalence of MetS was 58%.

Males had a lower percentage

prevalence of 22.99%,

compared to a higher

percentage prevalence of

77.01% for females.

Ashanti

Agyema

ng-

Yeboah

et al.

201943

Diabetic patients

attending the

Diabetic Clinic of

the Komfo Anokye

Teaching Hospital

(KATH) Kumasi,

Ashanti Region

405

NCEP/ATP

III

The prevalence of metabolic

syndrome observed among the

study population was 90.6%.

However, the MS condition

among female participants

(94.1%) was significantly

higher than that of their male

counterparts (76.5%) with

p<0.0001.

. CC-BY 4.0 International licenseIt is made available under a

Ashanti

Odame

Anto et

202150

Adults

30 years

above

Diabetic patients

attending the

Diabetic Clinic of

the Komfo Anokye

Teaching Hospital

(KATH) Kumasi,

Ashanti Region

241

NCEP/ATP

III

The prevalence of metabolic

syndrome observed among the

study population was 42.7%.

Among females, 52.8%

(75/142) had MetS

Norther

Mogres

et al.

201434

Patients diagnosed

with T2D receiving

care from an

outpatient clinic of

the Tamale

Teaching Hospital

200

IDF

Consensus

The prevalence of MetS was

24.0% (n=48). The prevalence

was higher in women (27.3%,

n= 42) compared to men

(13.0%, n=6). The commonest

occurring components of the

MetS included abdominal

obesity (77.0%) and elevated

FPG (77.0%) denoting

uncontrolled diabetes. The

prevalence of elevated BP was

found to be 44.0%(n=88) and

was higher in men (56.5%)

than in women (40.3%).

Volta

Osei-

Yeboah

et al.

201727

Adults

aged

25-86

years

old

Diabetic patients

attending diabetic

management clinic

at the Ho Municipal

Hospital in the

Volta Region

162

NCEP-ATP

III, the

WHO, and

the IDF

criteria

The overall prevalence of

metabolic syndrome among

the study population was

43.83%, 63.58%, and 69.14%

using the NCEP-ATP III, the

WHO, and the IDF criteria,

respectively. The most

predominant component

among the study population

was high blood pressure using

the NCEP-ATP III (108

(66.67%)) and WHO (102

(62.96)) criteria and abdominal

obesity (112 (69.14%)) for IDF

criteria. High blood pressure

was the most prevalent

component among the males

while abdominal obesity was

the principal component

among the females.

Brong-

Ahafo

Abagre

et al35

Adults

aged

30-79

years

old

Diabetic patients

enrolled at selected

diabetes clinics

(Dormaa

Presbyterian and

Berekum Holy

Family Hospitals)

430

NCEP-ATP

III, the

WHO

criteria

The prevalence of MS was

68.6% (95% CI: 64.0–72.8),

higher among women (76.3%,

95% CI: 70.6–81.2) than men

(58.0%, 95% CI: 35.0–49.4)

and in the 50–59-year age

group (32.1%)

Diabetic foot and or lower extremity amputations

Region

Author

and

date

Target

populat

ion

Context

Sampl

e size

Diagnostic

criteria

Main results

. CC-BY 4.0 International licenseIt is made available under a

Ashanti

Sarfo-

Kantank

a et al.

201819

Patients enrolled

with the diabetes

clinic of Komfo

Anokye Teaching

Hospital, a tertiary

hospital in Kumasi.

7,383

Diabetic

foot

disorders

include foot

ulcers,

PADs, and

gangrene

The mean incidence of foot

disorders was 8.39% (5.27%

males and 3.12% females). An

increase in the incidence of

diabetic foot ranging from

3.25% in 2005 to 12.57% in

2016, p < 0.001, was

determined.

Ashanti

Sarfo-

Kantank

a et al.

201918

Patients enrolled

with the diabetes

clinic of Komfo

Anokye Teaching

Hospital, a tertiary

hospital in Kumasi.

3,143

The global

lower

extremity

amputation

study

The average incidence rate of

diabetes-related amputation

was 2.4 (95% CI:1.84–5.61)

per 1000 follow-up years:

increasing from 0.6% (95%

CI:0.21–2.21) per 1000 follow-

up years in 2010 to 10.9%

(95% CI:6.22–12.44) per 1000

follow-up years in 2015.

Greater

Accra,

Ashanti,

and

Norther

Atosona

et al.

201946

Randomly selected

patients from the

outpatient diabetes

clinics of three

tertiary hospitals

namely: Korle Bu

Teaching Hospital,

Komfo Anokye

Teaching Hospital,

and Tamale

Teaching Hospital

100

Internationa

Consensus

on Diabetic

Foot

Among the patients, 11% had

diabetic foot ulcers whilst 3%

had lower extremity

amputations.

Volta

Tuglo et

al28

Diabetic patients

attending selected

diabetic clinics (Ho

Teaching Hospital,

Ho Municipal

Hospital, Hohoe

Municipal Hospital,

and Margret

Marquart Catholic

Hospital)

473

Not

mentioned

Foot ulcers were observed in

41(8.7%) diabetic patients

Hypertension

Region

Author

and

date

Target

populat

ion

Context

Sampl

e size

Diagnostic

criteria

Main results

Ashanti

Opare-

Addo et

al.

202044

Adults

18 years

above

Rural districts in the

Ashanti region of

Ghana (Amansie

West and Offinso

North, Asante Akim

South and Ahafo

Ano South)

684

The prevalence of

hypertension was 111

(16.23%). Diabetes was

prevalent in 37 (5.41%) of the

study participants; thus, the

prevalence of hypertension

and diabetes was 137

(20.02%). The prevalence of

diabetes and hypertension as

a comorbidity was 11 (1.61%).

. CC-BY 4.0 International licenseIt is made available under a

Greater

Accra

Nimako

et al.

201832

Adults

18 years

above

Patients attending

Tema General

Hospital (TGH) in

the Greater Accra

Region

1,527

The prevalence of

multimorbidity was 38.8%, and

around half (48.6%) of the

patients with multimorbidity

were aged between 18–59

years old. The most common

combination of conditions was

hypertension and diabetes

mellitus (36.6%), hypertension

and musculoskeletal

conditions (19.9%), and

hypertension and other

cardiovascular conditions

(11.4%).

Norther

Mogre

et al.

201434

Previously

diagnosed diabetes

mellitus patients

attending a diabetic

clinic at the Tamale

Teaching Hospital

100

In general, 7.0% of the

participants

were underweight and 32.0%

were overweight or obese.

21% of the studied participants

were hypertensive. Prevalence

of hyperglycaemia was higher

among patients aged ≤40

years (88.9% vs. 75.8%)

Micro and Macro vascular complications of DM

Region

Author

and

date

Target

populat

ion

Context

Sampl

e size

Diagnostic

criteria

Main results

Ashanti

Sarfo-

Kantank

a et al.

201617

Diabetes

admissions at

Komfo Anokye

Teaching Hospital

(KATH) in Kumasi

11,414

Two thousand three hundred

and ninety-two (21.0%)

diabetic admissions were due

to end-organ complications. Of

these, 503 (18.7%) had

peripheral vascular diseases,

377(14.0%) had coronary

artery diseases, peripheral

neuropathic ulcers (26.4%),

529 nephropathies (18.3%),

282 (10.5%) cerebrovascular

diseases. Again 1207(44.8%)

had nephropathy and

325(12.0) had peripheral

neuropathic ulcers.

Ashanti

Lartey

et al.

201845

Adults

18 years

above

Diabetic Center and

the Eye

Department of a

tertiary teaching

hospital in the

Ashanti region of

Ghana

208

Non-insulin-dependent

diabetics constituted 97.1%

whilst 2.9% were insulin-

dependent diabetics. The

prevalence of the outcome

measures was: Cataract

(23.7%) mild and moderate

retinopathy (13.7%) severe

proliferative retinopathy (1.8%)

maculopathy (6.8%). The

prevalence of low vision and

blindness was 18.4%.

Amongst diabetics, 59.1% had

no previous eye evaluation.

Impaired vision due to

cataracts was 24.0 %

. CC-BY 4.0 International licenseIt is made available under a

representing a 40% decline in

a decade.

Ashanti

Annani-

Akollor

et al.

201941

Adults

18 years

above

Ghanian T2DM

adults at Kmofo

Anokye Teaching

hospital (KATH)

1,600

The prevalence of

macrovascular and

microvascular complications of

T2DM was 31.8% and 35.3%

respectively. The prevalence

of neuropathy, nephropathy,

retinopathy, sexual

dysfunction, diabetic

ketoacidosis (DKA), and

hypoglycemia were 20.8%,

12.5%, 6.5%, 3.8%, 2.0%, and

0.8% respectively. The

prevalence of single, double,

and multiple complications are

59%, 16.3%, and 1.5%

Ashanti

Hayfron

Benjami

n et al.

201937

Adults

aged

25-70

years

old

Ghanaian adult

T2DM population

(206 in Ghana)

aged >25 years

650

Nephropath

y based on

report from

Joint

Committee

on Diabetic

Nephropath

y; PAD

based on

AHA 2012;

coronary

artery

disease

(CAD) was

assessed

using the

WHO Rose

angina

questionnai

re;

Retinopath

y, possible

myocardial

infarction,

angina, and

stroker

were based

questionnai

Microvascular and

macrovascular complications

rates were higher in non-

migrant Ghanaians than in

migrant Ghanaians

(nephropathy 32.0% vs.

19.8%; PAD 11.2% vs. 3.4%;

CAD 18.4% vs. 8.3%; and

stroke 14.5% vs. 5.6%), except

for self-reported retinopathy

(11.0% vs. 21.6%)

Other (Depression and Anaemia)

Region

Author

and

date

Target

populat

ion

Context

Sampl

e size

Diagnostic

criteria

Main results

. CC-BY 4.0 International licenseIt is made available under a

Greater

Accra

Akpalu

et al.

201831

Adults

aged

30-65

years

old

Patients recruited

at the National

Diabetes

Management and

Research Centre,

Korle Bu Teaching

Hospital, Accra,

Ghana

400

Patient

Health

Questionna

ire-9 (PHQ-

The prevalence of depression

was 31.3% among T2DM

patients. Female gender, being

unmarried, frequent intake of

alcohol, previous smoking

status and insulin use were

associated with increased

odds of depression, whereas

being educated above basic

school level was associated

with decreased odds of

depression.

Antwi-

Bafour

et al.

201620

50 control and 50

diabetic cases

100

Of the patients with diabetes,

84.8 % had a haemoglobin

concentration (incidence) that

was significantly less (males

11.16±1.83 and females

10.41±1.49) than the controls

(males 14.25±1.78 and

females 12.53±1.14).

Dry eye disease (DED)

Region

Author

and

date

Target

populat

ion

Context

Sampl

e size

Diagnostic

criteria

Main results

Central

Abu et

202251

Adults

aged

38-85

years

old

Diabetic patients

attending Cape

Coast Teaching

Hospital

311

Diabetes

was based

on the

American

Diabetes

association.

DED

Clinical

assessmen

t included

meibum

expressibilit

y and

quality,

Schirmer

test 1, tear

breakup

time

(TBUT),

ocular

surface

staining,

and blink

rates.

Prevalence of DED was 72.3%

384

385

386

. CC-BY 4.0 International licenseIt is made available under a

387 3) Economic burden

388 Only one study reported on the economic burden of diabetes, assessing the financial

389 cost of diabetes management (from a provider perspective) in cocoa clinics in

390 Greater Accra, Ashanti, and Eastern regions25. Bottom-up micro costing was used to

391 estimate the costs. The mean annual financial cost of managing one diabetic case at

392 the outpatient clinics was estimated at GHS 540.3 (2021 US $194.09). The costs

393 were broken down between service costs (22%) and direct medical costs (78%).

394 Drug costs accounted for 71% of the direct medical costs. The cost of hospitalization

395 per patient-day at clinics was estimated at GHS 32.78 (2021 US$ 11.78). The total

396 annual financial cost of diabetes management accounted for 8% of the total annual

397 expenditure of the clinics.

398

399 Discussion

400

401 This scoping review reveals that there is paucity of literature on the burden of diabetes

402 in Ghana. We divided the burden into three forms (themes): epidemiological burden

403 (prevalence and incidence of diabetes); health outcomes (mortality, diabetes

404 complications and comorbidity); and economic burden (cost of illness to the patients

405 and health system). Most of the existing Ghana centred literature focuses on the

406 prevalence of diabetes, including its complications and comorbidities. There is sparse

407 data on the economic burden of the disease in Ghana. This review did not find any

408 study that used generic health outcome measures such as DALYs or QALYs to

409 estimate the diabetes burden. The existing literature is skewed towards a few

410 particularly Ashanti, leaving some geographical regions of Ghana without any

411 reporting (including, for example, Upper East, and Upper West regions).

. CC-BY 4.0 International licenseIt is made available under a

412

413 Out of the identified studies, 36 studies focused on the prevalence of diabetes and

414 associated complications; only one study reported economic-related findings,

415 indicating a need for more costing studies, important also to support the development

416 of economic evaluations. All diabetes studies were either on T2D or referred to

417 diabetes generally without specifying the type. No studies explicitly targeting T1D were

418 found. Our findings suggest important gaps in the Ghanaian scientific literature, and

419 the need for further research to characterise the burden of diabetes in the country.

420

421 The national prevalence of diabetes in Ghana was reported in the studies to be

422 between 2.80% and 3.95%22–24. The reported national prevalence of diabetes (2.8-%

423 to 3.95%) is below the sub-Saharan Africa regional average of 4.5%3. However,

424 studies that reported on prevalence sub-nationally provided substantially higher

425 estimates; for example in Western, Ashanti, and Central regions, diabetes prevalence

426 was reported to be 39.8%38, 25.2%48 24.6%38 respectively. Despite Ghana having

427 seemingly lower levels of prevalence of diabetes at a national level in comparison to

428 the SSA average, there remains an urgent need to put in place interventions to

429 address these regional differences, and stem any further anticipated rise in disease

430 burden3. The within-country regional variations call for a more targeted approach when

431 implementing diabetes interventions.

432

433 Diabetes in Ghana was found to be more prevalent among women compared to

434 men22–24,30. This is in line with the recently reported prevalence in SSA by International

435 Diabetes Ferderation3 and other studies52,53. Systematic reviews have found that

436 women were more likely to have diabetes [odds ratio1.65 (95% CI 1.43, 1.91)], and

. CC-BY 4.0 International licenseIt is made available under a

437 less likely to have glycaemic control than men. It has been argued that relative

438 differences in physical activity between men and women may be a factor 52. There was

439 an urban-rural divide in the prevalence of diabetes in Ghana where urban areas were

440 reported to have a higher prevalence compared to the rural areas22–24,39,40. This finding

441 is consistent with other studies done in India (prevalence of 15.0% and 19.0% in rural

442 and urban areas respectively in the year 2015-2019)54, and Myanmar (prevalence of

443 7.1% and 12.1% in rural and urban areas respectively in year 2013/2014)55. This has

444 been attributed to differences in dietary habits and levels of physical activity between

445 urban and rural areas.

446

447 Hypertension and metabolic syndrome were among the most prevalent comorbidities

448 of diabetic patients in Ghana. Hypertension prevalence was highest in the Greater

449 Accra region (36.60% of diabetic patients)32. Metabolic syndrome is a cluster of

450 conditions that include combinations of hypertension, central obesity, insulin

451 resistance, or atherogenic dyslipidaemia56. The two main risk factors of metabolic

452 syndrome are the increase in consumption of high-calorie, low-fibre fast food and a

453 decrease in physical activity which may be linked to mechanized transportation and a

454 sedentary form of leisure time activities. These are the same established behavioural

455 risk factors for diabetes and obesity that are typically predominant in urban areas.

456 Without treatment, diabetes, high blood pressure, and obesity can damage blood

457 vessels, leading to micro and macrovascular complications, which can occur

458 concurrently. The highest prevalence of metabolic syndrome was reported in the

459 Ashanti region where it was reported to range from 59 to 90% among diabetic

460 patients42,43.

461

. CC-BY 4.0 International licenseIt is made available under a

462 Our results also align well with the Institute of Health Metrics and Evaluation (IHME)

463 assessment of the trend of disease burden in Ghana. Notably, in the year 2000,

464 diabetes was not within the top 10 disease groups in terms of burden of disease. By

465 2019 diabetes had moved up to eighth position and was linked to more than 2,157

466 DALYs per 100,000 people. Cardiovascular diseases, which are often complications

467 of diabetes and metabolic syndrome, were ranked first in 2019, causing an estimated

468 6,216 DALYs per 100,000 population57. This evidence points to the rapid rise of

469 diabetes, cardiovascular diseases and other NCDs, linked with common genetic,

470 metabolic, and behavioural risk factors. The ranking also suggests that there is a

471 gradual receding of communicable diseases in the last 2 decades compared to NCDs.

472 Combined, diabetes and cardiovascular diseases is linked to more than 8,300 DALYs

473 per 100,000 people in Ghana, representing a significant proportion (12.6%) of the total

474 disease burden in the country57.

475

476 Literature on the economic burden of diabetes in Ghana is very limited with only one

477 study reporting on the burden. This finding is in line with the study by Hollingworth et

478 al. (2020) that looked at available localised information to support HTA in Ghana noting

479 that there were few accessible data sources for costs and resource utilisation

480 generally9. Relatedly, we found a falling off in the number of studies published after

481 2019, although that may reflect the impact of the COVID-19 pandemic on research

482 and publication choices within the country and globally

483

484 Policy implications

485 Our review provides some evidence of the situation in Ghana, and associated

486 information gaps, consistent with studies focused on other African countries58. We find

. CC-BY 4.0 International licenseIt is made available under a

487 that Ghana is faced with a rising prevalence of diabetes and cardiovascular disorders

488 with potentially important regional differences in disease burden. To address this

489 challenge, there is a need to understand the contextual factors driving the rise and the

490 likely causes behind the existing regional variations in the reported burden.

491

492 Unlike communicable diseases, NCDs are usually chronic in nature and exhibit a

493 progressive disease course. A person may develop more than one NCD at a time,

494 fuelling disease progression even further59,60. NCDs constitute a long-term burden not

495 only to the patient and carers, but also to the healthcare system and the economy.

496 Currently, NCDs do not attract as much development assistance funds as

497 communicable diseases such as HIV, tuberculosis and malaria, and Ghana which is

498 currently classed as a middle-income country is no longer eligible for some

499 development assistance grants. Therefore, there is a need for Ghana, as well as

500 countries, to ensure that available domestic resources for health can be used as

501 efficiently as possible to address this growing burden. Typically, this involves

502 operationalising and institutionalising proven priority-setting processes.

503

504 HTA can be applied to both treatments for NCDs, such as insulin analogues for the

505 management of diabetes, and also to interventions that seek to reduce disease

506 prevalence and incidence in the first place. On the latter this could include identifying

507 cost-effective interventions to tackle the common NCD risk factors shared by diabetes

508 and other comorbidities such as cardiovascular diseases, obesity, or metabolic

509 syndrome to reduce the burden of diabetes in the country. This may require stronger

510 prevention approaches61 targeting high risk individuals or whole populations, which

511 aim to increase physical activity and promote a healthy diet while also monitoring

. CC-BY 4.0 International licenseIt is made available under a

512 obesity levels. This would be especially important in urban communities in Ghana

513 where the burden appears higher than the national average.

514

515 Institutionalising HTA for localised decision making requires that relevant data sources

516 are available, and that may mean developing a strategy to address key informational

517 gaps as part of building any HTA system. There was a scarcity of evidence on the

518 economic burden of diabetes in Ghana, and there were no estimates available of the

519 burden of disease for a number of regions. A key issue is the lack of diabetes incidence

520 data: as previously reported9, the Ghana Health and Demographic Surveillance

521 Systems (GHDSS) could potentially be a valuable source of such information, and the

522 Ministry of Health and other stakeholders could consider enhancing their operation in

523 this space, for diabetes as well as other NCDs. It may also mean better leveraging

524 already existing data sources, such as from the National Health Insurance Scheme9.

525

526 Limitations

527 The scoping review did not include an appraisal of the quality of included studies.

528 According to Arksey and O’Malley’s (2005) framework, the study quality is not

529 assessed during scoping reviews, but rather in systematic reviews that aim to address

530 specific questions relating to feasibility, appropriateness, meaningfulness or

531 effectiveness of a certain treatment or practice. The exploratory nature of our study

532 about the burden of diabetes made the scoping review methodology suitable.

533

534 The included studies used different diagnostic criteria for diabetes including WHI

535 criteria, American Diabetes Association and self-reporting. Self-reported diabetes

536 can be misleading because some of the people involved in the studies may not have

. CC-BY 4.0 International licenseIt is made available under a

537 received a diagnosis and thus report as not having the diabetes. This may have

538 underestimated the prevalence of diabetes in the country or region.

539

540 This study has used an older geographical classification system for the administrative

541 regions in Ghana. The sub-national regions of Ghana constitute the first level of

542 subnational government administration within the country. From 1987, Ghana had ten

543 officially established regional boundaries. In 2018, a referendum on the creation of six

544 new regions was held and the overall number were later increased to 16. We used the

545 older system of 10 regions based on the available literature which mostly reported

546 within that classification system. However, we expect that there would be no

547 substantial differences had the newer system been applied, since all new regional

548 divisions stem from the partitioning of regions where no studies were found (e.g, Brong

549 Ahafo and Northern regions).

550

551 Conclusion

552

553 Ghana is faced with a considerable burden of diabetes which varies by geographical

554 region and setting (rural/urban). It is urgent to tackle the growing challenge to mitigate

555 the likely enormous burden and cost of the disease. Despite the existing regional

556 variation of the burden of diabetes, there is a paucity of literature in some regions (for

557 example Eastern, Western, Upper East, Upper West, and Brong Ahafo). There is

558 therefore a need for further research to understand the burden (epidemiological, health

559 outcomes and economic) of diabetes in these regions in order to inform the NCD

560 prevention and management policies in the country.

561

. CC-BY 4.0 International licenseIt is made available under a

562

563

564 Declaration

565

566 Ethics approval and consent to participate

567 The study utilised secondary data/literature that is publicly available and did not use

568 any personal or private data.

569

570 Consent for publication

571 Not applicable

572

573 Availability of data and materials

574 The extracted data analysed during the current study is available from the

575 corresponding author upon reasonable request.

576

577 Competing interests

578 The authors declare that they have no competing interests

579

580 Funding

581 This study was supported by the International Decision Support Initiative, which is

582 funded by the Bill and Melinda Gates Foundation (OPP1202541).

583

584

585 Role of funder

586 The funder of the study had no role in study design, data collection, data analysis,

587 data interpretation, or writing of the report. Funders supported researcher time and

588 other resources (such as computer equipment) needed for completion of the study.

589

590

591 Authors contributions

592 Conceptualisation: – MG, JK, FR

593 Developing and carrying out search strategy: – MG

594 Screening of articles: – MG, JK

595 Data extraction, and quality assessment: – MG, JK

596 Validation: – STR

597 Data curation and analysis: – MG, JK

598 Funding acquisition: – FR

599 Methodology: – MG, JK,

600 Project administration: – MG, JK, IA, GG, RO, EAK

601 Supervision: – FR, AV

602 Writing – original draft: – MG, JK,

603 writing review & editing: – MG, JK, RO, EAK, GG, IA, FR, STR, AV

604

605 Acknowledgements

606 None

. CC-BY 4.0 International licenseIt is made available under a

607

608

609

610 References

611 1. World Health Organization. Noncommunicable diseases: Mortality. Published

612 2022. Accessed December 28, 2022.

613 https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/ncd-

614 mortality

615 2. International Diabetes Federation. Facts & figures. Published December 9,

616 2021. Accessed December 28, 2022. https://www.idf.org/aboutdiabetes/what-

617 is-diabetes/facts-figures.html

618 3. International Diabetes Federation. IDF Diabetes Atlas | Tenth Edition.; 2021.

619 Accessed December 29, 2022. https://diabetesatlas.org/

620 4. World Health Organization. ICD-11 for Mortality and Morbidity Statistics: 5A10

621 Type 1 diabetes mellitus. Published February 2022. Accessed December 28,

622 2022. https://icd.who.int/browse11/l-

623 m/en#http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1651053999

624 5. World Health Organization. ICD-11 for Mortality and Morbidity Statistics: 5A11

625 Type 2 diabetes mellitus. Published February 2022. Accessed December 28,

626 2022. https://icd.who.int/browse11/l-

627 m/en#/http%253a%252f%252fid.who.int%252ficd%252fentity%252f119724091

628 6. International Diabetes Federation. What is diabetes. Published July 7, 2022.

629 Accessed December 28, 2022. https://www.idf.org/aboutdiabetes/what-is-

630 diabetes.html

631 7. Siegfried N, Wilkinson T, Hofman K. Where from and where to for health

632 technology assessment in South Africa? A legal and policy landscape analysis.

633 South African Heal Rev . Published online 2017:41. Accessed March 1, 2023.

634 https://www.hst.org.za/publications/South African Health Reviews/4_Where

635 from and where to for health technology assessment in South Africa.pdf

636 8. O’Rourke B, Oortwijn W, Schuller T. The new definition of health technology

637 assessment: A milestone in international collaboration. Int J Technol Assess

638 Health Care. 2020;36(3):187-190. doi:10.1017/S0266462320000215

639 9. Hollingworth SA, Downey L, Ruiz FJ, et al. What do we need to know? Data

640 sources to support evidence-based decisions using health technology

641 assessment in Ghana. Heal Res Policy Syst. 2020;18(1):1-12.

642 doi:10.1186/S12961-020-00550-8/TABLES/2

643 10. Ghana Web. MOH launches Ghana’s strategy for Health Technology

644 Assessment document. Accessed January 18, 2023.

645 https://www.ghanaweb.com/GhanaHomePage/NewsArchive/MOH-launches-

646 Ghana-s-strategy-for-Health-Technology-Assessment-document-1324405

647 11. Ghana M of H. Ghana Health Technology Assessment Process Guide.; 2022.

648 12. Ministry of Health. Ghana National Policy on Non Communicable Diseases.

649 Published March 2022. Accessed January 28, 2023.

650 https://www.moh.gov.gh/wp-content/uploads/2022/05/Ghana-NCD-Policy-

651 2022.pdf

652 13. Arksey H, O’Malley L. Scoping studies: Towards a methodological framework.

653 Int J Soc Res Methodol Theory Pract. 2005;8(1):19-32.

654 doi:10.1080/1364557032000119616

655 14. Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews

. CC-BY 4.0 International licenseIt is made available under a

656 (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467.

657 doi:10.7326/M18-0850

658 15. Veritas Health Innovation. Covidence systematic review software. Accessed

659 December 31, 2021. https://www.covidence.org/

660 16. Sarfo FS, Mobula LM, Plange-Rhule J, Ansong D, Ofori-Adjei D. Incident

661 stroke among Ghanaians with hypertension and diabetes: A multicenter,

662 prospective cohort study. J Neurol Sci. 2018;395:17-24.

663 doi:10.1016/j.jns.2018.09.018

664 17. Sarfo-Kantanka O, Sarfo FS, Ansah EO, Eghan B, Ayisi-Boateng NK,

665 Acheamfour-Akowuah E. Secular trends in admissions and mortality rates from

666 diabetes mellitus in the central belt of Ghana: A 31-year review. PLoS One.

667 2016;11(11). doi:10.1371/journal.pone.0165905

668 18. Sarfo-Kantanka O, Sarfo FS, Kyei I, Agyemang C, Mbanya JC. Incidence and

669 determinants of diabetes-related lower limb amputations in Ghana, 2010-2015

670 - A retrospective cohort study. BMC Endocr Disord. 2019;19(1):1-8.

671 doi:10.1186/S12902-019-0353-8/TABLES/3

672 19. Sarfo-Kantanka O, Kyei I, Mbanya JC, Owusu-Ansah M. Diabetes-related foot

673 disorders among adult Ghanaians. Diabet FOOT \& ANKLE. 2018;9(1).

674 doi:10.1080/2000625X.2018.1511678

675 20. Antwi-Bafour S, Hammond S, Adjei JK, Kyeremeh R, Martin-Odoom A, Ekem

676 I. A case-control study of prevalence of anemia among patients with type 2

677 diabetes. J Med Case Rep. 2016;10(1):1-8. doi:10.1186/S13256-016-0889-

678 4/TABLES/6

679 21. Quaicoe P, Takramah W, Axame WK, et al. ASSOCIATED RISK FACTORS

680 OF TYPE 2 DIABETES MELLITUS AMONG ADULTS IN THE HOHOE

681 MUNICIPALITY OF GHANA. Int J ofMedical Res Pharm Sci. 2017;4(5):35-48.

682 doi:10.5281/ZENODO.581010

683 22. Gatimu SM, Milimo BW, Sebastian MS. Prevalence and determinants of

684 diabetes among older adults in Ghana. BMC Public Health. 2016;16(1):1-12.

685 doi:10.1186/s12889-016-3845-8

686 23. Yorke E, Tetteh J, Boima V, Yawson AE. High BMI: an important health risk

687 factor among older adults in Ghana. Public Health Nutr. 2021;24(14):4522-

688 4529. doi:10.1017/S1368980020003717

689 24. Tarekegne FE, Padyab M, Schroders J, Williams JS. Sociodemographic and

690 behavioral characteristics associated with self-reported diagnosed diabetes

691 mellitus in adults aged 50+ years in Ghana and South Africa: results from the

692 WHO-SAGE wave 1. BMJ OPEN DIABETES Res \& CARE. 2018;6(1).

693 doi:10.1136/bmjdrc-2017-000449

694 25. Quaye EA, Amporful EO, Akweongo P, Aikins MK. Analysis of the Financial

695 Cost of Diabetes Mellitus in Four Cocoa Clinics of Ghana. Value Heal Reg

696 issues. 2015;7:49-53. doi:10.1016/J.VHRI.2015.08.005

697 26. Bawah AT, Ngambire LT, Abaka-Yawson A, Anomah A, Kinanyok S, Tornyi H.

698 A community based prevalence of type 2 diabetes mellitus in the Ho

699 municipality of Ghana. J PUBLIC Heal. 2021;29(2):403-409.

700 doi:10.1007/s10389-019-01144-7

701 27. Osei-Yeboah J, Owiredu WKBA, Norgbe GK, et al. The Prevalence of

702 Metabolic Syndrome and Its Components among People with Type 2 Diabetes

703 in the Ho Municipality, Ghana: A Cross-Sectional Study. Int J Chronic Dis.

704 2017;2017:1-8. doi:10.1155/2017/8765804

. CC-BY 4.0 International licenseIt is made available under a

705 28. Tuglo LS, Nyande FK, Agordoh PD, et al. Knowledge and practice of diabetic

706 foot care and the prevalence of diabetic foot ulcers among diabetic patients of

707 selected hospitals in the Volta Region, Ghana. Int Wound J. 2022;19(3):601-

708 614. doi:10.1111/IWJ.13656

709 29. Ellahi B, Dikmen D, Seyhan-Erdoğan B, et al. Prevalence, risk factors, and

710 self-awareness for hypertension and diabetes: rural–urban and male–female

711 dimensions from a cross-sectional study in Ghana. Int J Diabetes Dev Ctries.

712 Published online November 29, 2022:1-15. doi:10.1007/S13410-022-01141-

713 9/TABLES/7

714 30. Vuvor F, Steiner-Asiedu M, Armar-Klemesu M, Armah S. Population-based

715 study of diabetic mellitus prevalence and its associated factors in adult

716 Ghanaians in the greater Accra region. Int J Diabetes Dev Ctries.

717 2011;31(3):149-153. doi:10.1007/s13410-011-0035-1

718 31. Akpalu J, Yorke E, Ainuson-Quampah J, Balogun W, Yeboah K. Depression

719 and glycaemic control among type 2 diabetes patients: a cross-sectional study

720 in a tertiary healthcare facility in Ghana. BMC Psychiatry. 2018;18.

721 doi:10.1186/s12888-018-1933-2

722 32. Nimako BA, Baiden F, Sackey SO, Binka F. Multimorbidity of chronic diseases

723 among adult patients presenting to an inner-city clinic in Ghana. Global Health.

724 2013;9. doi:10.1186/1744-8603-9-61

725 33. Gato WE, Acquah S, Apenteng BA, Opoku ST, Boakye BK. Diabetes in the

726 Cape Coast metropolis of Ghana: an assessment of risk factors, nutritional

727 practices and lifestyle changes. Int Health. 2017;9(5):310-316.

728 doi:10.1093/inthealth/ihx028

729 34. Mogre V, Salifu ZS, Abedandi R. Prevalence, components and associated

730 demographic and lifestyle factors of the metabolic syndrome in type 2 diabetes

731 mellitus. J Diabetes Metab Disord. 2014;13(1):80. doi:10.1186/2251-6581-13-

732 80

733 35. Abagre TA, Bandoh DA, Addo-Lartey AA. Determinants of metabolic syndrome

734 among patients attending diabetes clinics in two sub-urban hospitals: Bono

735 Region, Ghana. BMC Cardiovasc Disord. 2022;22(1):1-13.

736 doi:10.1186/S12872-022-02805-4/TABLES/4

737 36. Tyrovolas S, Koyanagi A, Garin N, et al. Diabetes mellitus and its association

738 with central obesity and disability among older adults: a global perspective.

739 Exp Gerontol. 2015;64:70-77. doi:10.1016/J.EXGER.2015.02.010

740 37. Hayfron-Benjamin C, van den Born B-J, der Zee AH, et al. Microvascular and

741 macrovascular complications in type 2 diabetes Ghanaian residents in Ghana

742 and Europe: The RODAM study. J Diabetes Complications. 2019;33(8):572-

743 578. doi:10.1016/j.jdiacomp.2019.04.016

744 38. Anderson AK. Prevalence of Anemia, Overweight/Obesity, and Undiagnosed

745 Hypertension and Diabetes among Residents of Selected Communities in

746 Ghana. Int J Chronic Dis. 2017;2017:1-7. doi:10.1155/2017/7836019

747 39. Chilunga FP, Henneman P, Meeks KAC, et al. Prevalence and determinants of

748 type 2 diabetes among lean African migrants and non-migrants: the RODAM

749 study. J Glob Health. 2019;9(2). doi:10.7189/jogh.09.020426

750 40. Agyemang C, Meeks K, Beune E, et al. Obesity and type 2 diabetes in sub-

751 Saharan Africans - Is the burden in today’s Africa similar to African migrants in

752 Europe? The RODAM study. BMC Med. 2016;14. doi:10.1186/s12916-016-

753 0709-0

. CC-BY 4.0 International licenseIt is made available under a

754 41. Annani-Akollor ME, Addai-Mensah O, Fondjo LA, et al. Predominant

755 Complications of Type 2 Diabetes in Kumasi: A 4-Year Retrospective Cross-

756 Sectional Study at a Teaching Hospital in Ghana. Medicina (Kaunas).

757 2019;55(5). doi:10.3390/MEDICINA55050125

758 42. Nsiah K, Shang VO, Boateng KA, Mensah F. Prevalence of metabolic

759 syndrome in type 2 diabetes mellitus patients. Int J Appl Basic Med Res.

760 2015;5(2):133. doi:10.4103/2229-516X.157170

761 43. Agyemang-Yeboah F, Eghan BAJ, Annani-Akollor ME, Togbe E, Donkor S,

762 Afranie BO. Evaluation of Metabolic Syndrome and Its Associated Risk Factors

763 in Type 2 Diabetes: A Descriptive Cross-Sectional Study at the Komfo Anokye

764 Teaching Hospital, Kumasi, Ghana. Biomed Res Int. 2019;2019.

765 doi:10.1155/2019/4562904

766 44. Opare-Addo MNA, Osei FA, Buabeng KO, et al. Healthcare services utilisation

767 among patients with hypertension and diabetes in rural Ghana. African J Prim

768 Heal Care Fam Med. 2020;12(1):8. doi:10.4102/PHCFM.V12I1.2114

769 45. Lartey SY, Aikins AK. Visual impairment amongst adult diabetics attending a

770 tertiary outpatient clinic. Ghana Med J. 2018;52(2):84.

771 doi:10.4314/GMJ.V52I2.4

772 46. Atosona A, Larbie C. Prevalence and Determinants of Diabetic Foot Ulcers

773 and Lower Extremity Amputations in Three Selected Tertiary Hospitals in

774 Ghana. J Diabetes Res. 2019;2019. doi:10.1155/2019/7132861

775 47. Cook-Huynh M, Ansong D, Steckelberg RC, et al. PREVALENCE OF

776 HYPERTENSION AND DIABETES MELLITUS IN ADULTS FROM A RURAL

777 COMMUNITY IN GHANA. Ethn \& Dis. 2012;22(3):347-352.

778 48. Sarfo-Kantank O, Owusu-Dabo E, Adomako-Boateng F, Eghan B, Dogbe J,

779 Bedu-Addo G. An assessment of prevalence and risk factors for hypertension

780 and diabetes during world diabetes day celebration in Kumasi, Ghana. East Afr

781 J Public Health. 2014;11(2):805-815. doi:10.4314/eajph.v11i2.

782 49. K AH, R A, E A-D, E M-ME. Prevalence and Risk Factors of Diabetes Mellitus

783 Among the Inhabitants of Kumasi Metropolis. Arch Clin Biomed Res. 1(4):224-

784 234. Accessed January 2, 2023. http://www.fotunejournals.com/prevalence-

785 and-risk-factors-of-diabetes-mellitus-among-the-inhabitants-of-kumasi-

786 metropolis.html

787 50. Anto EO, Frimpong J, Boadu WIO, et al. Prevalence of Cardiometabolic

788 Syndrome and its Association With Body Shape Index and A Body Roundness

789 Index Among Type 2 Diabetes Mellitus Patients: A Hospital-Based Cross-

790 Sectional Study in a Ghanaian Population. Front Clin Diabetes Healthc.

791 2022;2:33. doi:10.3389/FCDHC.2021.807201

792 51. Abu EK, Ofori AO, Boadi-Kusi SB, et al. Dry eye disease and meibomian gland

793 dysfunction among a clinical sample of type 2 diabetes patients in Ghana. Afr

794 Health Sci. 2022;22(1):293. doi:10.4314/AHS.V22I1.36

795 52. Sobers-Grannum N, Murphy MM, Nielsen A, et al. Female Gender Is a Social

796 Determinant of Diabetes in the Caribbean: A Systematic Review and Meta-

797 Analysis. PLoS One. 2015;10(5):e0126799.

798 doi:10.1371/JOURNAL.PONE.0126799

799 53. Zhang H, Ni J, Yu C, et al. Sex-based differences in diabetes prevalence and

800 risk factors: A population-based cross-sectional study among low-income

801 adults in China. Front Endocrinol (Lausanne). 2019;10(SEP):658.

802 doi:10.3389/FENDO.2019.00658/PDF

. CC-BY 4.0 International licenseIt is made available under a

803 54. Ranasinghe P, Jayawardena R, Gamage N, Sivanandam N, Misra A.

804 Prevalence and trends of the diabetes epidemic in urban and rural India: A

805 pooled systematic review and meta-analysis of 1.7 million adults. Ann

806 Epidemiol. 2021;58:128-148. doi:10.1016/J.ANNEPIDEM.2021.02.016

807 55. Aung WP, Htet AS, Bjertness E, Stigum H, Chongsuvivatwong V, Kjøllesdal

808 MKR. Urban–rural differences in the prevalence of diabetes mellitus among

809 25–74 year-old adults of the Yangon Region, Myanmar: two cross-sectional

810 studies. BMJ Open. 2018;8(3):e020406. doi:10.1136/BMJOPEN-2017-020406

811 56. Huang PL. A comprehensive definition for metabolic syndrome. DMM Dis

812 Model Mech. 2009;2(5-6):231-237. doi:10.1242/DMM.001180/-/DC1

813 57. IHME. VizHub - GBD Compare. Accessed January 4, 2023.

814 https://vizhub.healthdata.org/gbd-compare/

815 58. Zorron Pu L, de Moura EG, Bernardo WM, et al. Analysis the significant risk

816 factors on type 2 diabetes perspective of Bangladesh. PLoS ONE [Electronic

817 Resour. 2018;13(1):1. doi:https://dx.doi.org/10.1596/978-1-4648-0518-9

818 59. Alsaadon H, Afroz A, Karim A, et al. Hypertension and its related factors

819 among patients with type 2 diabetes mellitus – a multi-hospital study in

820 Bangladesh. BMC Public Health. 2022;22(1):1-10. doi:10.1186/S12889-022-

821 12509-1/TABLES/2

822 60. Tran PB, Kazibwe J, Nikolaidis GF, Linnosmaa I, Rijken M, van Olmen J.

823 Costs of multimorbidity: a systematic review and meta-analyses. BMC Med.

824 2022;20(1):1-15. doi:10.1186/S12916-022-02427-9/TABLES/1

825 61. Zhou X, Siegel KR, Ng BP, et al. Cost-effectiveness of Diabetes Prevention

826 Interventions Targeting High-risk Individuals and Whole Populations: A

827 Systematic Review. Diabetes Care. 2020;43(7):1593-1616.

828 doi:10.2337/DCI20-0018

829

830

831 Annex

832

833 Annex 1: Search strings

834

835 Web of Science search

836

837 Search link for Web of Science

838 https://www.webofscience.com/wos/woscc/summary/55ba5b67-9492-4899-a3dd-

839 8b2fe3588006-80f3249d/relevance/1

840

841 (TS=(Ghana)) AND TS=(Diabetes)

842

843 PubMed search string

844 (("ghana"[MeSH Terms] OR "ghana"[All Fields] OR "ghana s"[All Fields]) AND

845 ("diabete"[All Fields] OR "diabetes mellitus"[MeSH Terms] OR ("diabetes"[All Fields]

846 AND "mellitus"[All Fields]) OR "diabetes mellitus"[All Fields] OR "diabetes"[All Fields]

847 OR "diabetes insipidus"[MeSH Terms] OR ("diabetes"[All Fields] AND "insipidus"[All

848 Fields]) OR "diabetes insipidus"[All Fields] OR "diabetic"[All Fields] OR "diabetics"[All

849 Fields] OR "diabets"[All Fields])) AND (2021/4/4:2023/4/11[pdat])

850

851 Embase search string

. CC-BY 4.0 International licenseIt is made available under a

852 ('ghana'/exp OR ghana) AND ('diabetes mellitus'/exp OR 'diabetes mellitus')

853

854 Scopus search string

855 (TITLE-ABS-KEY ( ghana ) AND TITLE-ABS-KEY ( diabetes ) ) AND PUBYEAR >

856 2020 AND PUBYEAR < 2024

857

. CC-BY 4.0 International licenseIt is made available under a

ResearchGate has not been able to resolve any citations for this publication.

Knowledge and practice of diabetic foot care and the prevalence of diabetic foot ulcers among diabetic patients of selected hospitals in the Volta Region, Ghana

Article

Full-text available

Jun 2021
Int Wound J

Diabetic foot ulcers (DFUs) are a common but serious complication of diabetes mellitus (DM). The factors distressing the worth of diabetic foot care (DFC) are knowledge and practice. Foot ulcers are the main cause of amputation and death in people suffering from DM. This study assessed the knowledge and practice of DFC and the prevalence of DFUs and its associated factors among diabetic patients of selected hospitals in the Volta Region, Ghana. A multihospital-based cross-sectional study was conducted among 473 patients with DM who were recruited using the systematic sampling method. Data were collected using a validated, pretested, and structured questionnaire, while medical variables were obtained from patient folders and analysed using SPSS version 23. All statistically significant parameters in bivariate analysis were incorporated in the multivariate logistic regression analysis. The results showed that 63% of diabetic patients had good knowledge of DFC, while 49% competently practiced it. A negative correlation was found between knowledge and practice levels of DFC (r = -0.15, P = <.01). The prevalence of DFUs was 8.7% among the studied diabetic patients. Male diabetic patients were 3.4 times more likely to develop DFUs than female diabetic patients (crude odd ratio [cOR] = 3.35; 95% confidence interval [CI] = 1.75-6.43; P = <.001). Type 1 diabetic patients were five times more likely to develop DFUs than those who had type 2 diabetes (cOR = 5.00; 95% CI = 2.50-10.00; P = <.001). Diabetic patients who had a family history of diabetes were 4.7 times more likely to develop DFUs than those without family history (adjusted odd ratio [aOR] = 4.66; 95% CI = 1.55-13.89; P = .006). Those who had diabetes for 5 to 10 years were 3.3 times more likely to develop DFUs than those who had diabetes for less than 5 years (aOR = 3.28; 95% CI = 1.40-7.67; P = .006). Diabetic patients who had comorbidity were 3.4 times more likely to develop DFUs than those without comorbidity (cOR = 3.35; 95% CI = 1.74-6.45; P = <.001). The study found that there was good knowledge but poor practices of DFC among patients. Health care providers are expected to better educate patients and emphasise self-care practices to patients. Health care providers should also give more attention to patients with associated risk factors to avoid further complications and reduce the occurrence of DFUs.

High BMI: An important health risk factor among older adults in Ghana

Article

Full-text available

Oct 2020

Objective We examined BMI as a health risk factor for self-reported diabetes mellitus, angina, strokes and arthritis among older Ghanaians aged 50 years and above. Design We analysed the individual-level data from the World Health Organization Study on global AGEing and adult health Ghana Wave 2 (2014/2015). The influence of BMI on self-reported chronic conditions including diabetes, angina, stroke and arthritis was examined. Setting Households from all the administrative regions of Ghana. Participants Included 3350 adults aged 50 years and older. Results The prevalence of overweight and obesity among participants was 22·8 % (95 % CI 20·6, 25·2) and 13·2 %, respectively (95 % CI 11·5, 15·1). With respect to individual chronic conditions, arthritis emerged with the highest prevalence rate of 7·3 (95 % CI 5·3, 9·9), while the prevalence rate of diabetes, angina and stroke was 2·8 % (95 % CI 2·0, 3·9), 1·7 % (95 % CI 1·1, 2·6) and 1·3 % (95 % CI 1·0, 1·8), respectively. The risk of diabetes among overweight and obesity was over three and two times, respectively, higher compared with participants with normal weights. Overweight and obesity were significantly more than two and three times likely to experience angina, respectively, compared with participants with normal weight. Obesity significantly influences arthritis with approximately two times increased odds compared with normal weight participants. Conclusion Prevalence of obesity and overweight in Ghana is high and increasing, which poses a health risk at the individual and population levels. Inter-sectorial and multidisciplinary measures in line with the national non-communicable disease policies aimed at curbing this trend are imperative.

Healthcare services utilisation among patients with hypertension and diabetes in rural Ghana

Article

Full-text available

Jul 2020

Background: Non-communicable diseases (NCDs) remain a global burden and is projected to increase due to aging, rapid urbanization and unhealthy lifestyles. The study was conducted to determine the prevalence of hypertension and diabetes in rural districts in the Ashanti region of Ghana and to determine factors that influence utilization of health care services. Setting: Offinso North, Amansie West, Ahafo Ano South, and Asante Akim South. Methods: A population based prospective cross-sectional study comprising of adults aged 18 years and above was carried out from January 2016 to March 2016. A multistage sampling method was employed to select four rural districts in the Ashanti region of Ghana. A structured questionnaire was used to collect primary data from respondents. Results: A total of 684 participants were recruited in the study. The prevalence of hypertension and diabetes was found to be 16.23% and 5.41% respectively. The prevalence of diabetes and hypertension comorbidity was 1.61%. The public hospital was the most preferred choice of facility (52.56%) for patients with NCDs. Educational level significantly decreased the likelihood of seeking healthcare in OTCMS and Health Centre to Hospitals (RRR = 0.1, 95% CI = 0.011–0.917, p = 0.042) and (RRR = 0.4, 95% CI = 0.198-0.679, p = 0.001) respectively. Conclusion: The prevalence of self -reported hypertension and diabetes observed in this study was relatively lower for hypertension and higher for diabetes as compared to other studies in Ghana. The public hospital is the most preferred choice of health facilities for patients with hypertension and diabetes in the rural districts.

Prevalence and determinants of type 2 diabetes among lean African migrants and non-migrants: The RODAM study

Article

Full-text available

Oct 2019

Background: Exposure to adverse conditions earlier in life-course can predispose to type 2 diabetes in adulthood, irrespective of body mass index (BMI). However, the burden of type 2 diabetes in lean Africans is not well understood despite higher exposure to adverse early life conditions. Mirroring ongoing epidemiological transition, we assessed the burden and determinants of type 2 diabetes in a homogenous group of lean Ghanaians residing in rural and urban Ghana, and as migrants in Europe. Methods: Baseline data from 2179 RODAM study participants with BMI<25kg/m2 (25-70 years) were analyzed. Prevalence and determinants of type 2 diabetes were estimated using logistic regression analysis. Adjustments were made for socio-demographic and lifestyle factors, use of anti-diabetic medication and optimal blood glucose control. Results: Prevalence of type 2 diabetes in rural, urban and migrant lean participants were 3.5%, 8.9% and 7.5% respectively, representing 55.4%, 35.6%, 13.2% of all participants with type 2 diabetes. Compared with lean rural participants, the odds of type 2 diabetes were higher in lean urban participants (adjusted OR = 8.81, 95% CI = 6.56-11.06), followed by migrants (5.27, 95% CI = 3.51-6.91). Irrespective of site, determinants of type 2 diabetes in lean participants include; presence of hypertension, physical inactivity, hypercholesterolemia and age (>45 years). Conclusions: Our study shows a high prevalence of type 2 diabetes among lean African populations in different geographical settings. Future studies are needed in-order to examine how contextual differences are related to the pathophysiology of type 2 diabetes in lean individuals.

Predominant Complications of Type 2 Diabetes in Kumasi: A 4-Year Retrospective Cross-Sectional Study at a Teaching Hospital in Ghana

Article

Full-text available

May 2019
MED LITH

Background and objectives: Diabetes mellitus type 2 (T2DM) has been associated with several microvascular and macrovascular complications. However, studies regarding the predominant complications of T2DM in Ghana have not been conducted. This study evaluated the prevalence and predominant complications of T2DM and assessed the sociodemographic factors associated with the development of diabetes-related complications in Kumasi, Ghana. Materials and Methods: This was a retrospective cross-sectional study conducted at Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. A total of 1600 Ghanaian T2DM adults were included in this study. Patients' clinical data from 2012 to 2016 were retrieved from the hospital's archive. Results: The prevalence of macrovascular and microvascular complications of T2DM was 31.8% and 35.3% respectively. The prevalence of neuropathy, nephropathy, retinopathy, sexual dysfunction, diabetic keto-acidosis (DKA), and hypoglycemia were 20.8%, 12.5%, 6.5%, 3.8%, 2.0%, and 0.8% respectively. Sexual dysfunction was significantly associated with the male gender compared to females. Being employed: Informal (aOR = 0.479, p < 0.0001), and Formal (aOR = 0.475, p = 0.0008) was associated with lower age-and sex-adjusted odds of developing T2DM-related complications while having T2DM for 5-10 years (aOR = 1.550, p = 0.0009) and more than 10 years (aOR = 2.755, p < 0.0001) was associated with increased odds of developing complications. Conclusions: Microvascular complication is the most predominant among T2DM in Kumasi, Ghana. The most prevalent T2DM-related microvascular complication in Kumasi, Ghana is neuropathy. Sexual dysfunction is associated with male compared to female T2DM patients. Being employed reduces the chance of developing T2DM-related complications while increasing DM duration increases the risk of complications.

Evaluation of Metabolic Syndrome and Its Associated Risk Factors in Type 2 Diabetes: A Descriptive Cross-Sectional Study at the Komfo Anokye Teaching Hospital, Kumasi, Ghana

Article

Full-text available

May 2019
BMRI

Background. Metabolic syndrome (MS) is a collection of cardiovascular risk factors comprising insulin resistance, dyslipidemia, obesity, and hypertension, which may cause further complications in diabetes. Although metabolic syndrome (MS) is increasing in incidence in diabetics and leading to significant cardiovascular diseases and mortality, there is dearth of data in Ghana. This study investigated metabolic syndrome, its prevalence, and its associated risk factors in type 2 diabetes at the Komfo Anokye Teaching Hospital, Kumasi, Ghana. Methods . The study involved 405 diabetic patients attending the Diabetic Clinic of the Komfo Anokye Teaching Hospital (KATH) Kumasi, in the Ashanti Region of Ghana. A well-structured questionnaire was used to obtain demographic background such as their age and gender. Anthropometric measurements were obtained using the Body Composition Monitor (Omron ® 500, Germany) which generated digital results on a screen and also by manual methods. Fasting venous blood was collected for the measurement of biochemical parameters comprising fasting plasma glucose (FPG), glycated haemoglobin (HbA1c), high density lipoprotein cholesterol (HDL-c), and triglyceride (TG). Metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III). Results. Out of the total of 405 participants, 81 were males and 324 were females, and the estimated mean age was 58.5 ± 9.9 years. The female patients exhibited higher mean waist circumference (WC) and mean hip circumference (HC) as well as an approximately higher body mass index than males (28.3 ± 5.1, 26.5 ± 4.2 for the female and male respectively). Overall, the prevalence of metabolic syndrome observed among the study population was 90.6%. Conclusions. The prevalence of metabolic syndrome observed among the study population was 90.6%, with a higher percentage in females than males. High triglyceride levels and high waist circumference were the main risk factors for MS in the diabetic population.

Prevalence and Determinants of Diabetic Foot Ulcers and Lower Extremity Amputations in Three Selected Tertiary Hospitals in Ghana

Article

Full-text available

Feb 2019

Background: The occurrence and complications of diabetes are increasing worldwide. This study examined the prevalence and determinants of diabetic foot ulcers and lower extremity amputations in three selected tertiary hospitals in Ghana. Methods: A cross-sectional multicenter study involving 100 subjects was carried out. Subjects were selected through simple random sampling from three selected tertiary hospitals in Ghana. A structured questionnaire was used to document information on sociodemographic, medical history, lifestyle, and physical characteristics of subjects. Foot ulcers and lower extremity amputations were also investigated. Total cholesterol, triglycerides, low-density lipoproteins, high-density lipoproteins, serum urea, serum creatinine, and estimated glomerular filtration rate of subjects were assessed. Data analysis was done using SPSS version 22. Results: The study revealed that 31% and 69% were males and females, respectively, with a mean age of 53.8 ± 13.8 years. Among the patients, 11% had diabetic foot ulcers whilst 3% had lower extremity amputations. In the multivariate binary logistic regression analysis, previous history of foot ulcers (OR = 40.4, 95% CI = 5.5-299.9) and foot deformities (OR = 14.4, 95% CI = 1.3-161.2) were identified as independent predictors of diabetic foot ulcers. Foot deformity (p = 0.043) and serum urea (p = 0.002) were associated with diabetic lower extremity amputations in the univariate analysis. Conclusion: This study showed that the prevalences of diabetic foot ulcers and lower extremity amputations are high among diabetes patients. Foot deformities and previous history of foot ulcers are determinants of diabetic foot ulcers. Foot deformity and serum urea are associated with diabetic lower extremity amputations.

Cost-effectiveness of Diabetes Prevention Interventions Targeting High-risk Individuals and Whole Populations: A Systematic Review

Article

Jul 2020
DIABETES CARE

Objective: We conducted a systematic review of studies evaluating the cost-effectiveness (CE) of interventions to prevent type 2 diabetes (T2D) among high-risk individuals and whole populations. Research design and methods: Interventions targeting high-risk individuals are those that identify people at high risk of developing T2D and then treat them with either lifestyle or metformin interventions. Population-based prevention strategies are those that focus on the whole population regardless of the level of risk, creating public health impact through policy implementation, campaigns, and other environmental strategies. We systematically searched seven electronic databases for studies published in English between 2008 and 2017. We grouped lifestyle interventions targeting high-risk individuals by delivery method and personnel type. We used the median incremental cost-effectiveness ratio (ICER), measured in cost per quality-adjusted life year (QALY) or cost saved to measure the CE of interventions. We used the $50,000/QALY threshold to determine whether an intervention was cost-effective or not. ICERs are reported in 2017 U.S. dollars. Results: Our review included 39 studies: 28 on interventions targeting high-risk individuals and 11 targeting whole populations. Both lifestyle and metformin interventions in high-risk individuals were cost-effective from a health care system or a societal perspective, with median ICERs of $12,510/QALY and $17,089/QALY, respectively, compared with no intervention. Among lifestyle interventions, those that followed a Diabetes Prevention Program (DPP) curriculum had a median ICER of $6,212/QALY, while those that did not follow a DPP curriculum had a median ICER of $13,228/QALY. Compared with lifestyle interventions delivered one-on-one or by a health professional, those offered in a group setting or provided by a combination of health professionals and lay health workers had lower ICERs. Among population-based interventions, taxing sugar-sweetened beverages was cost-saving from both the health care system and governmental perspectives. Evaluations of other population-based interventions-including fruit and vegetable subsidies, community-based education programs, and modifications to the built environment-showed inconsistent results. Conclusions: Most of the T2D prevention interventions included in our review were found to be either cost-effective or cost-saving. Our findings may help decision makers set priorities and allocate resources for T2D prevention in real-world settings.

The new definition of health technology assessment: A milestone in international collaboration

Article

May 2020

Background An international joint task group co-led by the International Network of Agencies for Health Technology Assessment (INAHTA) and Health Technology Assessment International (HTAi) has developed a new and internationally accepted definition of HTA. Methods The task group, consisting of representatives of leading HTA networks, societies and global organizations, developed guiding principles for the process and followed an established consultation plan with the broader HTA community to develop the definition. Results The consensus achieved by the international joint task group brings the collective weight of the participating networks, societies, and organizations behind the new definition. Conclusion The new definition of HTA is an historic achievement and it is offered to the current and emerging HTA world as a cornerstone reference for today and into the future.

Microvascular and macrovascular complications in type 2 diabetes Ghanaian residents in Ghana and Europe: The RODAM study

Article

May 2019
J DIABETES COMPLICAT

Aims: To compare microvascular and macrovascular complication rates among Ghanaians with type 2 diabetes (T2D) living in Ghana and in three European cities (Amsterdam, London and Berlin). Methods: Data from the multicenter Research on Obesity and Diabetes among African Migrants (RODAM) study were analyzed. 650 Ghanaian participants with T2D (206 non-migrant and 444 migrants) were included. Logistic regression analyses were used to determine the association between migrant status and microvascular (nephropathy and retinopathy) and macrovascular (coronary artery disease (CAD), peripheral artery disease (PAD) and stroke) complications with adjustment for age, gender, socioeconomic status, alcohol, smoking, physical activity, hypertension, BMI, total-cholesterol, and HbA1c. Results: Microvascular and macrovascular complications rates were higher in non-migrant Ghanaians than in migrant Ghanaians (nephropathy 32.0% vs. 19.8%; PAD 11.2% vs. 3.4%; CAD 18.4% vs. 8.3%; and stroke 14.5% vs. 5.6%), except for self-reported retinopathy (11.0% vs. 21.6%). Except nephropathy and stroke, the differences persisted after adjustment for the above-mentioned covariates: PAD (OR 7.48; 95% CI, 2.16-25.90); CAD (2.32; 1.09-4.93); and retinopathy (0.23; 0.07-0.75). Conclusions: Except retinopathy, the rates of microvascular and macrovascular complications were higher in non-migrant than in migrant Ghanaians with T2D. Conventional cardiovascular risk factors did not explain the differences except for nephropathy and stroke.

The Epidemiological and Economic Burden of Diabetes in Ghana: A Scoping Review to Inform Health Technology Assessment

Abstract and Figures

Recommended publications

The epidemiological and economic burden of diabetes in Ghana: A scoping review to inform health tech...

A systematic review of risk factors of type 2 diabetes mellitus in the Ashanti region of Ghana

Prevalence and risk factors for diabetes mellitus among adults in Ghana: a systematic review and met...

Prevalence study of type 2 diabetes mellitus in the Ashanti region of Ghana: a systematic review of...