Food Science and Nutrition Studies ISSN 2573-1661 (Print) ISSN 2573-167X (Online) Vol. 2, No. 1, 2018 www.scholink.org/ojs/index.php/fsns 1 Original Paper Knowledge and Determinants of Fruit and Vegetable Consumption among Adults in Hohoe Municipality, Ghana Thomas K. Awuni1*, Gideon Kye-Duodu2, Charles Duodu3, Francis B. Zotor4 & Basma Ellahi5 1 Ghana Health Service, Municipal Health Directorate, Elmina, Ghana 2 Department of Epidemiology and Biostatistics, University of Health and Allied Sciences, Ho, Ghana 3 Ghana Health Service, Volta Regional Health Directorate, Ho, Ghana 4 Department of Family and Community Health, University of Health and Allied Sciences, Ho, Ghana 5 Faculty of Health and Social Care, University of Chester, Chester, UK * Thomas Kwasi Awuni, Ghana Health Service, Municipal Health Directorate, 852-8102, Elmina, Ghana Received: October 28, 2017 Accepted: November 7, 2017 Online Published: December 4, 2017 doi:10.22158/fsns.v2n1p1 URL: http://dx.doi.org/10.22158/fsns.v2n1p1 Abstract The World Health Organization (WHO) recommends that a person consumes at least 400g of Fruit and Vegetable (FV) daily to prevent chronic disease risk. We assessed knowledge of current WHO guidelines and other determinants of FV intake among adults (≥ 18 years, n = 397) in Hohoe Municipality, Ghana. Face-to-face interviews using a questionnaire adopted from WHO Risk Factor Surveillance System were undertaken. Knowledge of FV daily servings and determinants of intake were evaluated by descriptive statistics and binary logistic regression. There was a 99.2% response rate with approximately 9% of participants correctly stating the WHO daily recommended amount (P = .296). Most (54%) of respondents’ FV intake was affected by unavailability of desired choice (P = .050). Odds of inadequate consumption for persons aware of adequate intake amount was 1.97 (95% CI: 0.64, 6.05, P = .234) higher than persons without awareness. Participants with problems accessing their desired choice of FV had 0.59 odds (95% CI: 0.36, 0.95, P = .030) of consuming inadequate amount compared to those with easy access. Adequate FV intake depends on availability of consumer prefered choice regardless of knowledge of recommendations. Individual home based FV cultivation is relevant for availability of preferred choice and adequate consumption for NCDs risk reductions among Ghanaians. Keywords Non-Communicable Diseases, awareness, Africa, recommendations www.scholink.org/ojs/index.php/fsns Food Science and Nutrition Studies Vol. 2, No. 1, 2018 2 Published by SCHOLINK INC. 1. Introduction Inadequate Fruit and Vegetable (FV) consumption is ranked high among behavioural risk factors associated with increasing incidence of global Non-Communicable Diseases (NCDs) such as cardiovascular disease, ischaemic heart disease, stroke, and cancers (WHO, 2016; Oyebode, Gordon-Dseagu, & Walke, 2014; Vaidya, Oli, Aryal, Karki, & Krettek, 2013; Boeing et al., 2012; Hall, Moore, Harper, & Lynch 2009). Other research has also linked the phenomenon to disabilities and mortalities worldwide (WHO, 2016; Hall et al., 2009). Notably, in 2000, almost 27 million Disability Adjusted Life Years (DALYs) reported worldwide was associated with poor FV consumption (Hall et al., 2009). More regrettably, in 2013, low FV intake accounted for an estimated 5.2 million global deaths (WHO, 2016). Studies have shown positive associations between increased FV intake and NCDs risk prevention (WHO, 2016; Oyebode et al., 2014; Boeing et al., 2012). Consumers of FV hardly become obese and are less likely to develop chronic diseases (WHO, 2016; Oyebode et al., 2014; Boeing et al., 2012). This evidence underpins the World Health Organization (WHO) guidance on individual consumption of ≥ 400g daily (≥ 5 servings of 80 g each) of varieties of FV as reported (Hall et al., 2009; Agudo, 2014). The guideline aims to achieve and maintain adequate FV intake globally for NCDs prevention and has since been translated into diverse national health promotion campaigns in different geographical areas (Agudo, 2004). Notably, in Ghana, the Ministry of Health (MoH) promoted FV intake as “medicine” as part of the regenerative health campaign strategy to enhance healthy eating and for averting increasing risk of NCDs among residents (MoH, 2008). Despite this, the MoH campaign seems to be silent on WHO recommendations. There is a lack of data on awareness of the WHO guidance for maintaining adequate intake in previous studies (Amo-Adjei & Kumi-Kyereme, 2015; Nti, Hagan, Bagina, & Seglah, 2011; Hall et al., 2009). In particular, Hall et al.’s global study and similar studies on FV intake in Ghana only focused on consumption (Amo-Adjei & Kumi-Kyereme, 2015; Nti et al., 2011; Hall et al., 2009). More importantly, subsequent assessments of interventions on FV consumption showed negligible successes and warrants further research (Amo-Adjei & Kumi-Kyereme, 2015; Nti et al., 2011; Tagoe & Dake, 2011; Pomerleau, Karen, Cécile, & Mckee, 2005). We therefore aimed to assess knowledge on the WHO guideline of daily FV intake and determinants of consumption among adults in the Hohoe Municipality, Ghana, to provide evidence for future interventions. 2. Materials and Methods 2.1 Study Population and Design A cross-sectional study was undertaken in three locations (urban, peri-urban and rural) in the Hohoe Municipality, Volta region of Ghana using a multistage sampling method. The Municipality is located in the northern part of Volta region, and shares its border with the Eastern part of the Republic of Togo. Most of the residents are farmers who cultivate cash crops and vegetables and also rear livestock. www.scholink.org/ojs/index.php/fsns Food Science and Nutrition Studies Vol. 2, No. 1, 2018 3 Published by SCHOLINK INC. Farming activity is more popular among the rural dwellers whilst trading and other industrial activities are undertaken by most of the urban inhabitants. A total sample size (n) of 397 adults (18 years and above) was estimated using low FV intake population prevalence (p = 38%), margin of error (e = 5%), confidence level desired (Zα/2 = 1.96), 95% confidence interval (CI) and published formula n = (Zα/2) 2 P (1-P) ÷ е2 (Hall et al., 2009; Snedecor & Cochran, 1989). Selected adults are eligible since in Ghana they represent a constitutionally acceptable and self-informed decision-making body whose decisions can invariably impact households eating habits. Adolescents below 18 years and those whose mental judgement could influence responses including proxy respondents were excluded in this study. 2.1.1 Sampling Techniques Eligible respondents were selected with probability proportionate to sample size in each location: urban (232), sub-urban (117) and rural (48). This ensures that the information gathered represent rural/urban dynamics. Researchers grouped the municipality into three strata and one community was randomly selected from each stratum using lottery method where individual units were interviewed. In the chosen community, the investigators located the centre, spun a pen on the ground and followed the direction in which the head of the pen indicated to select the first house where a household was interviewed at random. This method (spin-the-pen) for selecting respondents has been discussed elsewhere (Grais, Angela, & Jean-Paul, 2007). Subsequently, the investigators visited the next house whose entrance was facing them in that manner until the number of respondents was interviewed. The procedure was repeated throughout in each selected stratum. 2.1.2 Ethical Approval Individual written informed consent was obtained from all participants. The study was approved by Ghana Health Service Ethical Review Committee (GHS-ERC, ID: 02/04/15). 2.1.3 Data Collection A face-to-face interview was undertaken between May and June 2015 by trained research assistants using the pre-tested semi-structured questionnaire adapted from WHO STEP wise approach to surveillance of Non-Communicable Diseases (NCDs) FV module (WHO, 2015; WHO, 2008). The tool is reported to be valid and data gathered reflects the usual consumption reflecting positively on respondents’ habitual rather than actual intake (Agudo, 2004). The questionnaire was translated from English to the local language (Ewe and Akan) by an independent bilingual researcher or translator prior to field implementation for ease of understanding by the subjects and used as appropriate. It was back translated by members of the research team following (WHO, n.d). Researchers also used a pictorial show card that presented samples of locally available FV and their amounts, excluding juices, in line with WHO standard amounts (modified from Hall et al., 2009; WHO, 2008). Field pre-testing of the show card was undertaken prior to data collection. The show card supported the interview processes for standard estimation of serving size and number of servings as reported elsewhere (Hall et al., 2009; WHO, 2008; Agudo, 2004). This ensured participants understood www.scholink.org/ojs/index.php/fsns Food Science and Nutrition Studies Vol. 2, No. 1, 2018 4 Published by SCHOLINK INC. how each count was calculated in relation to the responding question and enhanced the content validity of the survey tool. The study examined data on sex, age, marital status, education, occupation and monthly income, and source of information. Knowledge of experts’ daily recommendation was measured by asking participants the following questions: 1. In your opinion, are you eating enough FV to be healthy? Limited to a yes or no response. 2. What is the WHO minimum recommended FV servings day/person? Responses selected from 1, 2, 3, 4 and ≥ 5 servings respectively. Other determinants of FV intake were analysed by perceived barriers/facilitators including access to materials to cultivate, (land, seeds and equipment) quality, availability of preferred choice, initiatives and FV information source. 2.1.4 Statistical Analysis Data was coded, entered and analysed using the Statistical Package for Social Sciences (SPSS) version 20, 2011 (IBM Inc.). Of the 397 questionnaires, a total of 394 respondents’ completed questionnaires were analysed representing a 99.2% useable response rate due to 0.8% missing data. Participants’ knowledge of adequate FV consumption was classified based on their response to WHO defined criterion (Hall et al., 2009; Agudo, 2004). Dependent variables included FV intake grouped into inadequate serving (< 5 servings) and adequate intake (≥ 5 servings) whereas independent variables were respondents’ background characteristics, knowledge and factors of FV consumption. Statistical analysis performed included descriptive and binary logistic regression to establish odds ratio of factors influencing consumption among adequate (≥ 5 servings coded “0”) and inadequate (˂ 5 servings coded “1”) respondents. A chi-square test was used to test for statistical difference for categorical variables and p-value 0.05 was considered significant. 3. Results The demographic characteristics for the respondents are provided in Table 1. Respondents mean age was 35.6 years (standard deviation [SD] ± 12.6y). Urban participants represented the majority (58.4%) and almost 52% were within low income group with 33.5% of them being traders. Junior High/Middle School and Tertiary graduates respectively dominated respondents’ educational background. Although, the respondents’ marital status, income and educational levels show no statistical significance with FV intake, there was a statistical significant relationship between their location, their occupation and FV consumption. www.scholink.org/ojs/index.php/fsns Food Science and Nutrition Studies Vol. 2, No. 1, 2018 5 Published by SCHOLINK INC. Table 1. Background Characteristic Stratified with Subjects’ Fruit and Vegetable Intake Variables Fruit and vegetable daily consumption P-value < 5, n = 108(27.4%) ≥ 5, n = 286(72.6%) Total n = 394(%) Age (years) Mean age 35.6(SD 12.6) 18-29 55 (50.9) 114 (39.9) 169 (42.9) .287 30-39 25 (23.1) 70 (24.5) 95 (24.1) 40-49 17 (15.7) 54 (18.9) 71 (18.0) 50-59 7 (6.5) 31 (10.8) 38 (9.6) 60 plus 4 (3.7) 17 (5.9) 21 (5.3) Gender of respondents .820 Male 45 (41.7) 124 (43.4) 169 (42.9) Female 63 (58.3) 162 (56.6) 225 (57.1) Marital status of respondents .748 Single 34(31.5) 77(26.9) 111(28.2) Married/co-habiting 66(61.1) 185(64.7) 251(63.7) Divorced 2(1.9) 9(3.1) 11(2.8) Widowed/Widower 6(5.6) 15(5.2) 21(5.3) Respondents Community of residents .001 Urban 80 (74.1) 150 (52.4) 230 (58.4) Sub-urban 23 (21.3) 93 (32.5) 116 (29.4) Rural 5 (4.6) 43 (15.0) 48 (12.2) Educational level of respondents .593 None 6 (5.6) 18 (6.3) 24 (6.1) Primary 20 (18.5) 38 (13.3) 58 (14.7) Junior High School 39 (36.1) 122 (42.7) 161(40.9) Senior High School 23 (21.3) 52 (18.2) 75 (19.0) Tertiary 20 (18.5) 56 (19.6) 76 (19.3) Occupation of respondents .044 Artisan 28 (25.9) 64 (22.4) 92 (23.4) Farming 6 (5.6) 34 (11.9) 40 (10.2) Government/private employee 16 (14.8) 62 (21.7) 78 (19.8) Trading 37 (34.3) 95 (33.2) 132 (33.5) Unemployed 21 (19.4) 31 (10.8) 52 (13.2) Income status of respondents .800 Low 145 (50.7) 58 (53.7) 203 (51.5) Average 127 (44.4) 44 (40.7) 171(43.4) High 14 (4.9) 6 (5.6) 20 (5.1) SD: Standard Deviation, n: sample size; % Per cent; < Less than; ≥ Greater than or equal to. www.scholink.org/ojs/index.php/fsns Food Science and Nutrition Studies Vol. 2, No. 1, 2018 6 Published by SCHOLINK INC. Table 2 shows there is no significant association between knowledge of recommended daily quantity of FV and its consumption. Although the majority (80.2%) of respondents affirmed they consumed adequate FV to remain healthy (P = .667), this did not reflect their knowledge as only 8.9% could indicate correctly the WHO recommendation (P = .296). About 43% and 39% of the respondents had access to land and seed/equipment respectively for their own FV cultivation. Majority (more than 80%) of both adequate and inadequate consumption participants indicated they could easily obtain good quality FV (P = .288). However, a significant association existed between availability of the kind of FV and what kind a participant’s desire to eat at a particular time (season of the year). Of 54.3% participants who were challenged with their desired choice of FV, 46.3% consumed below WHO predefined standard (P = .050). In relation to where knowledge is obtained from the highest proportion (78%) of participants reported they were informed about FV intake via radio (P = .903), compared to television (45.6%) (P = 1.00) and 37.3% by health workers (P = 1.00) though there was no statistically significant association (Bonferroni correction due to multiple comparison). Table 2. Knowledge and Factors of Fruit and Vegetable Consumption among Respondents Variables Daily Amount of fruit and vegetable consumed P-value < 5, n = 108(27.4%) ≥ 5, n = 86(72.6%) Total n = 394 In your opinion, are you eating enough fruit and vegetable to be healthy? .667 Yes 84 (77.8) 232 (81.1) 316 (80.2) No 13 (12.0) 26 (9.1) 39 (9.9) Don’t know 11 (10.2) 28 (9.8) 39 (9.9) What is the WHO daily recommended minimum amount of fruit and vegetable per person? .296 1 serving 15(13.9) 33(11.5) 48(12.2) 2-4 servings 16(14.8) 36(12.6) 52(13.2) ≥ 5 servings 5 (4.6) 30(10.4) 35 (8.9) Do not know 72(66.7) 187(65.4) 259(65.7) Do you think eating a diet high in fruit and vegetable can decrease chances of developing NCDs? Yes 77 (71.3) 206 (72.0) 283 (71.8) .626 No 19 (17.6) 41 (14.3) 60 (15.2) Don’t know. 39 (13.6) 12 (11.1) 51 (12.9) Is it easy for you to get good quality fruit and vegetable? .288 Yes 87(80.6) 243(85.0) 330(83.8) No 21(19.4) 43(15.0) 64(16.2) Do you have problem getting your choice of fruit and vegetable to consume? .050 Yes 50(46.3) 164(57.3) 214(54.3) No 58(53.7) 122(42.7) 180(45.7) Do you have access to an area to grow your own fruit and vegetable? .066 www.scholink.org/ojs/index.php/fsns Food Science and Nutrition Studies Vol. 2, No. 1, 2018 7 Published by SCHOLINK INC. Yes 38 (35.2) 130(45.5) 168(42.6) No 70 (64.8) 156(54.5) 226(57.4) Can you easily obtain seeds/equipment you need to grow your own fruit and vegetable in your area? .079 Yes 33(30.6) 120(42.0) 153(38.8) No 5(4.6) 13(4.5) 18(4.6) Not Applicable 70(64.8) 153(53.5) 223(56.6) Are there initiatives promoting fruit and vegetable intake? .617 Yes 75(69.4) 207(72.4) 282(71.6) No 33(30.6) 79(27.6) 112(28.4) Where do you get information on fruit and vegetable intake? Radio 50(84.7) 138(75.8) 188 (78.0) .903 Television 24(40.6 86(47.3) 110(45.6) 1.000 Newspaper 1(1.69) 7(3.8) 8(3.3) 1.000 Leaflet 1(1.6) 7(3.8) 8(3.3) 1.000 Poster 2(3.4) 15(37.9) 17(7.1) 1.000 Health workers 21(35.5) 69(37.9) 90(37.3) 1.000 % Per cent; < Less than; ≥ Greater than or equal to; n: sample size. Table 3 illustrates possible influence of availability on FV consumption using binary logistic regression analysis. The Odds Ratio (OR) of consuming inadequate serving of FV was 0.59 (95% CI: 0.36, 0.95, P = .030) among participants with problem getting a desired choice of FV compared with persons without problem of choice. This result was statistically significant. The OR of having inadequate servings for persons who are aware of what an adequate serving is, was 1.97 (95% CI: 0.64, 6.05, P = .234). This is higher than persons with no awareness, although the result is not statistically significant. Table 3. Logistics Regression Analysis of Knowledge and Determinants of Fruit and Vegetable Intake < 5 Fruit and Vegetable Servings β S.E. P-Value Odds Ratio 95% CI Lower Upper Is it easy for you to get good quality fruit and vegetable? -.431 0.313 .168 0.650 0.352 1.199 Do you have area to grow fruit and vegetable? -.384 0.238 .107 0.681 0.427 1.087 Do you get your desired choice of fruit and vegetable? -.531 0.245 .030 0.588 0.364 0.950 Can fruit and vegetable intake prevent NCDs? -.003 0.260 .990 0.997 0.599 1.658 Do you know the recommended amount fruit and vegetable to be consumed daily? .680 0.572 .234 1.974 0.644 6.054 Are there initiatives promoting fruit and vegetable intake? .035 0.263 .893 1.036 0.619 1.734 < Less than; β: Regression Coefficient; S.E: Standard Error of the Mean, CI: Confidence Interval. www.scholink.org/ojs/index.php/fsns Food Science and Nutrition Studies Vol. 2, No. 1, 2018 8 Published by SCHOLINK INC. 4. Discussion We established that less than 10% of the respondents are correctly aware of WHO predefined daily minimum intake amount of FV (P = .296). This finding did not correspond with the majority who indicated they consumed adequate amounts to remain healthy (P = .667). The odds ratio of having inadequate servings to persons aware of adequate servings was rather higher (OR > 1) than among persons without awareness. Therefore, awareness about WHO predefined criterion had no positive influence on quantity of FV consumption. Indeed, the low level of knowledge found in this study corroborates a previous study in Ghana (Aitken et al., 2014). In contrast, a review that extensively discussed adequate FV intake and chronic diseases risk reduction benefits fell short of finding out whether people know what adequate consumptions are (Boeing et al., 2012). Of note, Hall and colleagues reported intake below standard globally, including Ghana (Hall et al., 2009). Studies conducted in three zones of Ghana involving the study region also documented poor intake (Amo-Adjei & Kumi-Kyereme, 2015; Nti et al., 2011). However, these studies did not adequately address subjects’ knowledge of health experts’ recommended amount that could possibly trigger individual adequate consumption and this is a clear limitation to assessing population FV consumption (Agudo, 2004). Certainly, measuring population FV consumption in relation to the quantity consumed to derived health benefits strongly reinforces public health strategies of which our study supports (Agudo, 2004). In this study, we affirm that media advertisement serves as one of such platform to facilitate increased FV intake, notwithstanding the result of our study showing no statistical significance. Radio and television were two main ways found in this study to have informed segment of Ghanaian population about the nutritional benefits of FV as had been reported (Nti et al., 2011). Adequate health education on healthy lifestyle benefits supposedly influences healthy behaviour changes among African American women (Delores, Harville, Efunbumi, & Martin, 2015). A well-informed people likely adopted healthy lifestyles and equally applied such information obtained based on the source (Delores, 2015). Also, several other reviews of wide ranges of worldwide intervention and local policies on FV intake implemented provide evidence to suggest that intensification of healthy life campaigns may be a determinant of improvement in FV intake, though data revealed just modest increase on the amount consumed (Amo-Adjei et al., 2015; Tagoe et al., 2011; Pomerleau et al., 2005). Interestingly though, awareness of the WHO recommendation reflected poorly on quantity consumed, evidence from this study suggest that lack of desired choice of FV and location negatively influenced subjects’ consumption. Our result shows association between participants’ consumption at a particular time (season of the year) and availability of choice and their locations. Indeed, the greater proportion of the respondents who could easily obtain good quality FV even consumed poorly as a result of not finding what they desired for and this increased disproportionally from among rural to urban respondents (P = .288). In our study, we also established that the odds ratio of consuming inadequate serving for persons who had challenges accessing their desired choice of FV was lower compared with persons without problem of desired choice. Possibly, the respondents limited access to land and www.scholink.org/ojs/index.php/fsns Food Science and Nutrition Studies Vol. 2, No. 1, 2018 9 Published by SCHOLINK INC. materials for cultivating their own FV threatened availability and thus consumption. The decision to consume FV has strong linkages with numerous factors ranging from personal to the environment (Amo-Adjei et al., 2015; Ting, Wojciech, Sarpong, Manjeet, & Anna, 2014; Marie, Minot, & Lisa, 2004; Pollard, Kirk, & Cade, 2002). Previous studies elucidated individual preference, accessibility and availability (quality and quantity), sensory appeal (taste or texture) and location, all of which our result substantiates (Ting et al., 2014; Marie et al., 2004; Pollard et al., 2002). Indeed, we confirmed that those who consumed adequate FV actually got their best choice that they wanted regardless of what health experts have indicated to be the appropriate amount. Moreover, although we did not examine ethnicity and cultural preference, which has strong influence, it has been reported in other studies (Di Noia, Monica, Cullen, Pérez-Escamilla, Gray, & Sikorskii, 2015; Marie et al., 2004). Our finding therefore advances the understanding of drivers of FV intake and recognition of WHO guideline and practices. This study employed quantitative terms to defining FV intake and used same to explain respondents’ views about experts’ advice on consumption. This method has been proven valid for evaluating population FV consumption (Agudo, 2004). The WHO System for NCDs Risk-Factor Surveillance FV intake assessment model is validated, flexible and easily applicable and reports reliable estimate of usual consumption and therefore our finding from recruiting respondents from three strata enhanced views from diverse background is justified for population comparisons (WHO, 2008; Agudo 2004). However, the study had limitations. FV intake knowledge was measured by self-reporting relying on respondent recall, thus there existed a natural tendency of recall bias, random error and social desirability (Oyebode et al., 2014; Agudo 2004). Additionally, cultural preferences were not assessed and determining the amount of servings pictorially from show card of which the questionnaire did not measure FV juices could lead to imprecise estimation of intake (Agudo, 2004). The strength of the study includes the use of field investigators who were trained using appropriate protocols (Hall et al., 2009; WHO, 2008). They also explained the portion size and how it is counted from the show card to the participants before the interview enhancing understanding of reliability of information gathered. 5. Conclusion We established poor knowledge on daily FV consumption based on the WHO guideline and furthermore the few knowledgeable participants tended to consume below the recommended levels. Importantly, the absence of desired choice of FV impacted negatively on consumption. Adequate FV intake depends on consumer preference and availability regardless of health experts’ advice. This suggests individual home based FV cultivation is relevant for availability of preferred choice and adequate consumption to mitigate risk of NCDs among Ghanaians. www.scholink.org/ojs/index.php/fsns Food Science and Nutrition Studies Vol. 2, No. 1, 2018 10 Published by SCHOLINK INC. Acknowledgements Trained Research Assistants who assisted with data collection led by Carl Agbitor (Nutritionist, Ghana Health Service), for data collection, and the participants who took part in the study. Wisdom Takrama of the Department of Epidemiology and Biostatistics, University of Health and Allied Sciences, Ho, Ghana who assisted with data analysis. References Agudo, A. (2004). Measuring intake of Fruit and Vegetables. Background Paper for the Joint FAO/WHO Workshop on Fruit and Vegetables for Health. Kobe, Japan. Aitken, A. et al. (2014). Street Food Vendors in Ghana: Fruit and Vegetable Knowledge and Influences on Vending Practice. 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