www.udsspace.uds.edu.gh UNIVERSITY FOR DEVELOPMENT STUDIES ASSESSING THE UNIVERSAL SALT IODISATION PROGRAM AMONG SALT PRODUCERS AND TRADERS IN TEN SALT PRODUCING DISTRICTS OF GHANA BY ABDUL KAHAD AMADU (BSc. Community Nutrition) (UDS/CHD/0060/12) A DISSERTATION SUBMITTED TO THE DEPARTMENT OF PUBLIC HEALTH, SCHOOL OF ALLIED HEALTH SCIENCES, UNIVERSITY FOR DEVELOPMENT STUDIES IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF PHILOSOPHY DEGREE IN COMMUNITY HEALTH AND DEVELOPMENT February, 2019 1 www.udsspace.uds.edu.gh DECLARATION I hereby declare that, this thesis is as a result of my own efforts and that it has never been submitted anywhere either in part or whole for the award of any degree. …………………………… ………………………… ABDUL-KAHAD AMADU DATE (STUDENT/AUTHOR) I hereby declare that the preparation and presentation of the dissertation was supervised in accordance with the guidelines on supervision of thesis laid down by the University for Development Studies. …………………………… ………………………… DR. VIDA NYAGRE YAKONG DATE (SUPERVISOR) i www.udsspace.uds.edu.gh ABSTRACT In 1996, Ghana enacted the Universal Salt Iodization law under the Food and Drug (Amended) Act 523 to achieve 90% household consumption of iodized salt as recommended by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF). Despite existence of regulation on mandatory iodization of salt for human consumption, implementation of strategies, policies and numerous educational programs, less than half of Ghanaian households are consuming adequately iodized salt. The aim of this study is to assess the knowledge and practices of salt producers and traders on universal salt iodization in ten major salt producing districts. The study was descriptive cross-sectional and the Lot Quality Assurance Sampling (LQAS) methodology was used. The sample size nineteen (19) was selected from each salt producing district which represents the minimum sample size that provided an alpha and beta error of ≤ 10% acceptable for making management decisions at least 92% of the time. Forty five percent (45%) of salt traders were aware of the Universal Salt Iodization (USI) law in the study catchment area. Traders in Awutu Senya, Ningo Prampram and Ada East districts were less aware of the Universal Salt Iodization law. Eighty five percent (85%) salt sample from producers tested above 15ppm and about 51% of the salt samples from traders tested above 15ppm. Traders in Ketu, Gomoa West and Ada East had most of their salt below 15ppm. Salt artisans and most medium scale producers of salt still lack adequate knowledge of salt iodization techniques and are also limited by the lack of access to salt iodization machine and salt iodization input (potassium iodate). Quality control and ensuring that all salt produced is iodize to 50ppm at production site is still a challenge in the ten salt producing districts. Quality controls and enforcement of the USI law through the salt value chain is necessary to achieving USI including Social and Behavioral Change Communication (SBCC) programs to increase knowledge on the benefits iodized salt and awareness of the USI law. ii www.udsspace.uds.edu.gh ACKNOWLEDGEMENT My most profound appreciation and thanks goes to my supervisor for this master piece, Dr. Vida Nyagre Yakong through whom I am able to successfully carry out this study. Mr. Akwasi Boakye Yiadom, I would not have come this far without your patience and guidance during the study, thank you. Special thanks also go to the United Nations Children’s Fund (UNICEF) for making it possible for me to carry out this study. I am using this opportunity to say a big thank you to Ms Esi Amoaful (Ghana Health Service Head Office, Head of the Nutrition Department) for being my motivator and my strength. I am also thanking the volunteers and data collectors in each of the 10 salt-producing districts who supported this study, the driver uncle Winfred of Ghana Health Service, Head Office for his support throughout the study. I am very grateful to all the Market Traders and Salt Producers who made this study possible, thank you so much and God richly bless you. Finally, I wish to thank the Graduate school of the University for Development Studies for the knowledge bestowed on me as a student. iii www.udsspace.uds.edu.gh DEDICATION This work is dedicated to my parents and family iv www.udsspace.uds.edu.gh TABLE OF CONTENTS DECLARATION ................................................................................................................. i ABSTRACT........................................................................................................................ ii ACKNOWLEDGEMENT ................................................................................................. iii DEDICATION................................................................................................................... iv TABLE OF CONTENTS.................................................................................................... v LIST OF TABLES........................................................................................................... viii LIST OF FIGURES ........................................................................................................... ix LIST OF ABBREVIATIONS............................................................................................. x CHAPTER ONE ................................................................................................................. 1 INTRODUCTION .............................................................................................................. 1 1.0 Background ........................................................................................................................1 1.2 Problem Statement.............................................................................................................6 1.3 Justification ........................................................................................................................9 1.4 General Objective ............................................................................................................10 1.5 Specific Objectives ..........................................................................................................10 1.6 Research Questions.........................................................................................................11 1.7 Conceptual Framework....................................................................................................11 1.8 Overview of Thesis..........................................................................................................13 1.9 Definition of terms...........................................................................................................14 CHAPTER TWO .............................................................................................................. 16 LITERATURE REVIEW ................................................................................................. 16 2.0 Introduction ......................................................................................................................16 2.1 Background of Iodine and Iodine Deficiency ................................................................16 2.2 Global Iodine Deficiency and Universal Salt Iodization...............................................20 2.3 Universal Salt Iodization and Iodine Deficiency in Ghana...........................................23 2.4 Salt Production in Ghana.................................................................................................24 2.5 Iodization of Salt in Ghana..............................................................................................29 2.6 Awareness of the USI Law..............................................................................................36 2.7 Knowledge of iodized salt and its benefits.....................................................................39 2.8 Availability of Adequate Iodized Salt on the Market....................................................42 2.9 Sale of Refine and Un-Refined Salt by Traders.............................................................44 2.10 Stability of Iodine and Proper Display of Salt at Point Of Sales................................47 2.11 Misconceptions about the Use of Iodized Salt.............................................................50 v www.udsspace.uds.edu.gh 2.12 Current Trend in Ghanaian Household Consuming Adequately Iodized Salt ...........52 2.13 Behavioral Change Communication Theories .............................................................54 2.14 Summary ........................................................................................................................57 CHAPTER THREE .......................................................................................................... 60 METHODOLOGY ........................................................................................................... 60 3.0 Introduction ......................................................................................................................60 3.1 Study Design ....................................................................................................................60 3.2 Study Setting ....................................................................................................................60 3.3 Study Population..............................................................................................................74