A Qualitative Study of the Perceived Rise of Food Allergy and Associated Risk Factors in the Greater Accra Region, Ghana George A

Atiim et al. Global Health Research and Policy (2017) 2:20 Global Health DOI 10.1186/s41256-017-0040-0 Research and Policy RESEARCH Open Access “If we are waiting for the numbers alone, we will miss the point”: a qualitative study of the perceived rise of food allergy and associated risk factors in the Greater Accra Region, Ghana George A. Atiim1*, Susan J. Elliott1 and Ann E. Clarke2 Abstract Background: Globally, food allergy [FA] is considered a growing health epidemic. While much of what is known comes from developed countries, there is growing interest in the epidemiology of FA in developing regions such as sub-Saharan Africa. Indeed, researchers are beginning to document the incidence and prevalence of FA and sensitization. The results outlined in this paper stem from an exploratory qualitative study examining the emergence of the health risk of FA in Ghana, a country undergoing epidemiologic changes. Methods: Between June and August, 2015, we conducted thirty-seven (37) semi-structured in-depth interviews. This comprised seventeen (17) healthcare workers across 12 public and private hospitals and twenty (20) individuals with FA and families with allergic children. All interviews were recorded and transcribed verbatim. Transcripts were analyzed to develop thematic areas that characterize perceptions and experiences around FA. Results: Three key broad themes arise from this study. First, FA is an emerging health risk, whose incidence is perceived to be increasing. Second, participants expressed mixed perceptions about the public health burden of FA. Third, participants identified individual and societal factors that may be influencing FA risks and susceptibility. Conclusion: Our research suggests FA is a growing but unrecognized public health concern. There is the need for health policies and researchers to consider the full extent of ongoing epidemiologic changes for the health of populations in developing regions. Keywords: Food allergy, Chronic illness, Epidemiologic transition, Qualitative, Ghana Background and disease occurrence [3]. While the specific pathways Allergic diseases including asthma, rhinitis, eczema and remain unclear, researchers suggest a direct relationship food allergy (FA) are a growing global public health chal- between infections and the rise in allergic disease, espe- lenge [1]. Globally, between 30 to 40% of the world’s cially in western societies [4, 5]. For example, a notable population have at least one allergic condition [1, 2] cre- review revealed that between 1950 and 2000, as rates of ating serious psychosocial and economic impacts for in- infectious disease declined, the incidence of allergies and dividuals at risk, their families, and healthcare systems. autoimmune disease [e.g. multiple sclerosis, type 1 dia- The interaction between one’s genetics and environmen- betes] increased [5]. Other studies and reviews highlight tal factors are thought to increase one’s susceptibility linkages between exposure to micro organic environ- ments [e.g. living on farms], heightened risk of develop- * Correspondence: [email protected] ing allergies [e.g. asthma, hay fever] and atopic 1Department of Geography and Environmental Management, Faculty of sensitization compared to those living on nonfarm lands Environment, University of Waterloo, Waterloo, Ontario, Canada or urban places [6–8]. Allergies, therefore appear to Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Atiim et al. Global Health Research and Policy (2017) 2:20 Page 2 of 12 follow a gradient along socio-economic status (SES), and SES bias in rates of FA and sensitization [27]. Taken geographic locality (e.g. rural vs urban) and measures of together, these studies suggest FA is becoming an im- national incomes. The assumption is that individuals portant health issue in urban SSA locations. Conse- with high SES, an urban lifestyle, and residency in high quently, there is need for research to understand the income countries have increased risk of acquiring aller- changing allergy landscape. gies and vice versa. Allergies occur and are experienced differently in vari- In North America and many parts of Western Europe ous settings. Spatial differences in prevalence is likely that have moved through the epidemiologic transition, mediated by factors such as (but not limited to) variation an epidemic of food allergy [FA] has emerged following in access to medical care, culture and language [28]. For similar increases in asthma and allergic rhinitis. Studies example, studies show FA is an unfamiliar health risk reveal 7.5% of children and adults in Canada [9], 8% in among immigrants in Canada [29]. We argue that pla- the United States [10], and 10% in Australia [11] self- cing FA within the sociocultural and political environ- report a FA. These rates come with many health and ment can provide insights toward understanding the social consequences. For example, FA impose a consid- experiences and practices around FA in developing re- erable psychosocial and financial burdens on individuals gions. Understanding FA in the context in which they and their families [12, 13]. Moreover, FA detrimentally arise will help develop context-dependent responses that shapes one’s quality of life [14] and forces people to con- address the unique needs of the allergic population. stantly negotiate physical safety and social wellbeing While available studies that characterize FA incidence [15]. In the most extreme cases, FA can trigger anaphyl- and prevalence in the African context use quantitative axis, a serious life-threatening condition [16, 17]. To approaches and markers (e.g. IgE antibodies), they ex- date, the only mechanism to manage an anaphylactic al- plain very little about the unique ways in which FA is ex- lergy is complete avoidance of allergens and use of an perienced. For example, little is known about local epinephrine autoinjector when a severe reaction occurs. perceptions of FA risk, diagnostic decision-making, While much of what is known about (food) allergic management, or the subsequent socioeconomic impact disease comes from developed countries, there is grow- of FA. Qualitative methods are an effective way to de- ing interest in regions such as sub-Saharan Africa (SSA). scribe these health experiences, beliefs, and practices as Especially, given evidence that prevalence of allergic well as illustrating how processes at multiple levels [30] symptoms (e.g. asthma, allergic rhinitis and atopic ec- shape health experiences and outcomes. However, only zema) have increased in SSA and represent central chal- recently are researchers engaging with qualitative lenges for child and adolescent health [18], there is methods to explore FA experiences related to psycho- growing suspicion that FA will soon be a challenge. Re- social responses, management, and coping strategies searchers are beginning to ask if countries in Africa will [31–33]. These studies highlight the importance of un- follow the experience of western countries as they derstanding how social context affect FA and allergy re- complete their health transitions [19–21]. lated behaviours. In the absence of population and hospitalization based In Ghana, the extent of FA is unknown and research studies (see 21, 22, 23 for exceptions), a body of small- to identify and understand the FA front is limited. To sample studies are beginning to document the incidence focus attention on this health risk, we draw on in-depth and prevalence of FA and sensitization in SSA. In unse- interviews with healthcare workers and the allergic lected populations, challenge proven FA was 2.5% in population to understand the scope of FA risk in Ghana. South Africa [22]. In the same context, other studies re- Specifically, we ask how do healthcare workers and aller- port high rates of FA – between 18% and 40% [23, 24] gic populations perceive FA and its associated health and food sensitization - 5% and 66% [24, 25]. In Ghana, risks? In so doing, we highlight FA as an emerging pub- self-reported FA and sensitization is estimated at 11% lic health problem and contribute to the scarce literature and 5% of schoolchildren respectively [26]. It is import- on (food) allergic disease in SSA. ant to note that sensitization – that is a positive response to an immunoglobulin E (IgE) antibody to the offending Embodied epidemiology of food allergy food - does not always imply FA. The latter is evaluated This study employs a lens from ecosocial theory [34], a partly on the basis of reproducing allergic symptoms relational approach to health that characterizes health [e.g. hives, eczema, shortness of breath, anaphylaxis] risk within social and political structures. Ecosocial per- upon exposure to an allergen and a confirmation of spectives to health have been applied in studies that ad- sensitization to the specific food. In the few recent ex- dress questions around cholera vulnerabilities [35], race, tant studies and reviews on FA in Africa, the high discrimination, and health disparities [36, 37], maternal sensitization rates are increasingly suggestive of clinical health experiences and pregnancy outcomes [38], and symptoms of FA [21]. In addition, they reveal an urban the water-health nexus [39]. Atiim et al. Global Health Research and Policy (2017) 2:20 Page 3 of 12 This paper particularly emphasizes the two core con- the responsibility of everyone (e.g researchers, experts, structs of ecosocial theory, namely embodiment and ac- patients) in exploring our relationship with food, disease, countability and agency in order to understand the and the creation of FA knowledge [41].

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