Non-Communicable Diseases in Afghanistan and Ghana

Non-communicable diseases are a challenge to public health worldwide. Decades ago, the consensus was that non-communicable diseases were the problem of developed and wealthy nations. However, recent studies indicate that developing countries are on the edge of emerging increases in non-communicable diseases due to various factors such as the consumption of unhealthy food, lack of physical activities, poor access to primary healthcare services, and loosened policies on tobacco use. Non-communicable diseases cause increased mortality and have significant financial impact due to treatment costs. The conditions also decrease the capacity and productivity of the human workforce in the community who cannot adequately contribute when under treatment in the late stages of the disease. Multiple societal and economic factors contribute to poor outcomes from non-communicable diseases including increasing globalization and urbanization. The two countries reviewed, Afghanistan and Ghana, have worsened population health due to aforementioned factors. In low and middle-income countries such as Afghanistan and Ghana, the unparalleled progression of globalization and urbanization and lifestyle factors have contributed to fast track the prevalence and progression of non-communicable diseases. This literature review aims to overview the impact of non-communicable diseases in Afghanistan and Ghana and suggest potential strategies to improve overall population health outcomes.

represented in Table1. Besides curative measures for NCDs, we can use specific measures at the community and individual levels to prevent or decrease the incidence of NCDs in society (Budreviciute et al., 2020). The recognition of both the effective interventions and potential barriers will assist in informing policymaking efforts to affect change.

Barriers and Influences on Success of Health Promotion:
Numerous studies have illustrated that in terms of decreasing NCDs rates, merely depending on advanced and well-equipped facilities is not the answer. We must implement comprehensive strategies integrated with other sectors in the community to decrease NCDs in the community. For example, promoting a healthy lifestyle and improving health literacy are critically significant initiatives in preventing NCDs.Promoting these initiatives needs a multidisciplinary collaboration among different sectors. Only depending on health centers to propagate this important information to every family can be challenging and unsuccessful.

Impact of Environmental Factors at Community Level:
Environmental factors, especially air pollution, can also cause the risks of NCDs to increase. Air pollution is undervalued as a health risk factor. The Lancet Commission on pollution and health has indicated that outdoor air pollution has led to a 9 million deaths globally annually (Landrigan et al., 2018).

Impact of Health Literacy at Community Level:
Health literacy indicates that individuals have the cognitive and social skills to comprehend and appropriately use the information to promote and support the continuation of optimal health status in society (Nutbeam, 1998

Noncommunicable Diseases in Afghanistan:
The health system in Afghanistan has progressively improved in the last two decades, and access to healthcare coverage and services has been enhanced across the country. In 2018 approximately 3135 healthcare centers in different services were operating, providing healthcare services to approximately 87% of Afghans within two hours (WHO, 2021b). Afghanistan has suffered primarily from a shortage of health care professionals due to the migration of Afghan cadres and healthcare professionals such as doctors, nurses, and midwives to other countries during wartime. In 2006, 7.26 doctors, nurses, and midwives delivered care per 10,000 population in Afghanistan, significantly below the threshold of 23 healthcare professionals to provide essential primary care per 10,000 people (WHO, 2016). Based on the available resources in the country, this number was predicted to increase to 9.12 providers and nurses and midwives per 10,000 population in five years (WHO, 2021c). In Afghanistan, in recent decades, the scope of diseases has changed from primarily communicable diseases to now include NCDs, creating a double burden of care for healthcare systems. Currently, NCDs accounts for approximately 44% of premature mortality in Afghanistan, with 51% in men and 49% in women (Institute for Health Metrics and Evaluation, 2017). In Afghanistan, NCDs are a significant cause of death and contributed to disability-adjusted life years which is defined by the World Health Organization (2021) when an individual loses -the sum of years life due to premature mortality‖ (WHO, 2021d, para. 1). Other factors for the increase in NCDs in Afghanistan include socioeconomic factors, lifestyle, access to healthcare, and funding for public health campaigns.

Socioeconomic Factors in Community Health in Afghanistan:
Socioeconomic imbalance and inadequate availability and accessibility to preventive and primary health care are the core elements for the addition of NCD complications in developing countries like Afghanistan (Sommer et al., 2015). Furthermore, inadequate information on risk factors for NCD in Afghanistan has been a critical challenge that hinders policymakers from developing policies and regulations to intervene and prevent and decrease NCDs (Saeed et al., 2020). A cross-sectional study in five significant provinces of Afghanistan indicated that 1/10 adults used tobacco in different forms, and the level of excessive physical activity was low (Saeed et al., 2020). In big cities, rapid urbanization has caused areas to be densely populated, and the government has paid no attention to make open areas for people to do aerobic exercises. Also, the study indicated that obesity was prevalent more in females than males (Saeed et al., 2020). In Afghan culture, females are more prone to obesity because culturally, it is not common for Afghan women to go outside to jog or do other exercises that can prevent obesity. In some areas, obesity is believed to be the sign of health and beauty that impedes women from losing weight. On the other hand, most Afghan families do not have access to healthy food such as fruits and vegetables due to socioeconomic status that can lead to NCDs (Saeed et al., 2020).

Non-Communicable Diseases in Ghana:
Like other developing countries, in Ghana, the incidence of NCDs and specifically respiratory illness has risen. The leading causes of death have changed from communicable diseases to noncommunicable diseases-causes of death due to hypertension, diabetes, and stroke are predominant in the country (Owusu et al.,2021). Approximately 86,000 people die from NCDs annually in Ghana with 55% of the population less . Ghana has instituted more than 50 resolutions for preventing and managing chronic diseases since 1984, which comprises risk factors such as tobacco control, healthy diet, lack of physical activity, nutritional deficiency, and alcohol consumption (Bosu, 2012). Also, Ghana has implemented strategies to improve community-based primary health care, access to healthcare services, and increase the number of healthcare providers. Still rural populations in Ghana experience inequity in access to healthcare services that have negatively impacted health outcomes (Assembly, 2014). Despite limited resources and infrastructure, Ghana's government has formed a proportionately well-organized and unique health insurance system that has made medical care more effective (Drislane et al., 2014). The demand for clinicians and healthcare facilities is higher in rural areas of Ghana than the big cities such as Accra. Ghana's rural areas are densely populated, and more challenging to retain healthcare providers (Drislane et al., 2014). Also, the uneven placement of the healthcare workforce between urban and rural areas and the lack of well-trained healthcare providers in rural areas has contributed to significant issues in delivering effective care to people (Willis-Shattuck et al., 2008). As the call for more providers in rural areas increases Ghana can apply the WHO's recommendations that are intended to motivate healthcare professionals by providing resources to increase their retention (Rourke, 2010).

Lifestyle and Other Factors in Ghana:
In Ghana, the unhealthy alteration in lifestyle and behaviors, old age, suboptimal health literacy, the unparalleled upsurge of disorganized urbanization, and failing health system infrastructures have contributed to the burden of NCDs, mortality and morbidity, and increasing risk factors (Agyei-Mensah & Aikins, 2010). A community-based prevalence survey indicated that 70% of the Ghana population did not know that they have hypertension and diabetes (Bosu, 2012). Poor health literacy contributes to delays in seeking ontime care and causes early complications such as hypertension, with one of the major complications being stroke. In Ghana, the incidence of hypertension is 15%, with most cerebral vascular disease-related deaths occurring prematurely between the ages of 40 and 60 (Sanuade et al., 2014).

The Impact of Poverty on Non-communicable Diseases in Afghanistan and Ghana:
NCDs have a direct correlation with poverty. Higher incidences of NCD are projected to prevent and delay poverty depletion initiatives in low-income countries like Afghanistan and Ghana, primarily through increased expenses related to health care. Vulnerable populations more easily contract diseases with unhealthy lifestyles such as smoking, poor nutrition, and insufficient access to proper nutrition and appropriate healthcare services (WHO, 2021a). A recent study by European Society of Cardiology (2014) indicated that of the low to middle-income countries of the members of the World Health Organization (WHO), merely 47% had strategies to cope with NCDs. It is crucially important to promote and prioritize the role of healthy lifestyles at an individual, family, and community level to make a substantial impact and change in the prevention and treatment of NCDs globally. It is essential to initiate healthy lifestyle programs under the auspices of healthcare settings (hospitals and clinics). A healthy lifestyle initiative requires a comprehensive approach among stakeholders. An -all hands-on deck‖ model will be an essential approach to promoting a healthy lifestyle campaign, identifying stakeholders and their roles, and promoting initiatives aimed at the prevention of NCDs (Arena et al., 2015). Models focusing on the management and prevention of NCDs and mitigation of risk factors can influence the rates of NCDs and decrease NCD-related deaths. Nearly 77% of all NCDs deaths occur in low-and middle-income countries such as Afghanistan, Ghana, (WHO, 2021). Collaboration of stakeholders is essential to amplify healthy lifestyle education efforts. The institution of health lifestyle campaigns that reach a broader audience must first start within the healthcare setting and spread using established population health and public health systems already in place. Thus, it is crucial for stakeholders to consistently communicate and collaborate to effectively implement healthy lifestyle initiatives, especially in low-income populations or developing countries such as Afghanistan and Ghana (Arena et al., 2015). The roles and examples of potential stakeholders are represented on Table 2.

Community Level Strategies:
The local government in Afghanistan and Ghana must prioritize the management of NCDs in their public health policies to decrease the incidence and the impact on local populations. Other sectors in the community must collaborate with Public Health to implement comprehensive and coordinated strategies to prevent and reduce NCDs. For example, when public health advises against indoor smoking, other local authorities should assist Public Health to improve compliance in their employees and customers or clients (Arora et al., 2011). Application of these policies and initiatives in Afghanistan in Ghana would be essential. For example, decreasing tobacco use rapidly reduces NCDs and expenses related to healthcare within one year (Fischteberg & Glants, 2000). People living in poverty often cannot afford nutritious food, which is a risk factor for NCDs. Often after being diagnosed with one of those diseases, people living at or below the poverty level must spend more money on treatment and have even less money left over to put toward a healthy diet (Arora et al., 2011). With the assistance of stakeholder's organizations, the local governments in Afghanistan and Ghana ought to develop strategies to decrease poverty and increase programs of aid for access to healthy whole foods sources, health education related to proper nutrition, and services to provide financial assistance for the purchase of nutritious food items.

Discussion:
Ghana has strategies to control and manage NCDs that focus on primary prevention, such as tobacco cessation, promoting a healthy diet, physical activity, and immunization (Bosu, 2012). Moreover, they have strategies to detect noncommunicable diseases and provide primary healthcare services. These strategies include primary prevention and early detection guidelines targeting people who are currently nonsymptomatic but who have risk factors for NCDs. In addition, Ghana has programs in place to address symptomatic individuals to provide healthcare to improve outcomes (Republic of Ghana, 2012). Furthermore, Ghana's health sector has strengthened its health system by increasing health workforce capacity, providing essential medication access, ensuring financial allocation for sustainability of programs, and supporting ongoing surveillance of noncommunicable diseases and their risk factors (Republic of Ghana, 2012). By implementing these strategies, Ghana has been able to decrease NCDs deaths from 3 deaths per 1000 admissions in 2017 to 2.5 deaths per 1000 hospital admissions in 2018 (Owusu et al.,2021). On the other hand, in Afghanistan, even though NCDs present a double burden, on economies, health system, and general health, including a significant financial drain on local governments and donor organizations, NCDs are not on their priority list. Limited studies exist to demonstrate efforts of the Afghan public health system to prevent and decrease the burden of NCDs in the Afghan population. An example of this nonpriority approach in Afghanistan reveals that local authorities have made insufficient progress on tobacco cessation since signing the Framework Convention on Tobacco Control in 2004, but surveillance of NCDs has been critically limited. In addition, the Afghan basic health package medication allotment does not include NCDs prevention or treatment drugs (World Bank, 2011). These insufficient strategies in Afghanistan have led to current mortality for NCDs approximately 44% of premature mortality, with 51% in men and 49% in women (Institute for Health Metrics and Evaluation, 2017) compared with the risk of premature mortality is 21% from NCDs in Ghana in 2016 (WHO, 2018).

Recommendations:
Both countries of Ghana and Afghanistan can utilize the WHO (2011) recommendations to assist in preventing and controlling NCDs. These include:

Conclusion:
For low and middle-income countries such as Ghana and Afghanistan, management and control of NCDs are essential to have a healthy population to contribute to economic development through improved productivity and longevity. Control and management of NCDs require a multi-disciplinary and comprehensive approach with the integration and collaboration of other sectors in the society to apply the strategies of public health at the individual and community levels. Strategies to modify lifestyle, smoking cessation, and early detection and management of NCDs via access to effective primary healthcare services, improved lifestyle, mitigation of globalization and urbanization impacts, and population education will improve longevity and quality of life in Afghanistan and Ghana. Future studies of population health within these and other developing countries must include a comprehensive approach to early identification of risk factors for NCDs address environmental, socioeconomic, and lifestyle factors, and institute ongoing surveillance initiatives to evaluate the effectiveness of policies and programs. (2015). Impact evaluation of a health promotion-focused organisational development strategy on a health service's capacity to deliver comprehensive primary health care. Australian journal of primary health, 21(4), 444-449. European Heart Health Charter. http://www. heartcharter.org.