Background
Iodine-deficiency disorders (IDDs) are some of the public health problems that confront 118 countries worldwide, and approximately 1.5 billion people are at risk of preventable IDDs [
1‐
3]. The vulnerable groups particularly at risk include pregnant women, infants and children. In some cases, the developing foetus is affected in the womb [
3‐
5]. Iodine is required to synthesize thyroid hormones which control the body's metabolic rate, and its deficiency results in problems such as abortions, stillbirths, congenital abnormalities, cretinism, goitre and impaired mental function, squinting and mutism [
6‐
10].
In Ghana, it is estimated that 120,000 children born each year are at risk of intellectual impairment because of iodine deficiency. Approximately 15,600 (13%) of these babies are severely impaired and are unable to develop properly, which results in an average of 22 million dollars loss in productivity each year in Ghana. Most of these affected children are also held back by reduced intelligence and mental dullness which are enormous negative educational implications of iodine deficiency [
11].
It has been recommended that most developing countries battling with IDD can address the problem in a cost effective way by adding iodine to universally consumed products such as common salt, as done in most industrialized countries [
12‐
16].
In Ghana, the first baseline survey on the state of IDDs in 27 districts was conducted between 1991 and 1994, and the findings revealed a varying degree of endemicity ranging from mild to severe Total Goitre Rates (TGR) [
17,
18]. On the basis of a baseline survey conducted in 1994, it was found out that IDD was serious in 33% of the 110 surveyed districts [
19]. In most of the surveys conducted, the method employed to measure the thyroid volume of subjects was thyroid palpation.
A survey conducted in 2001 revealed that the median urinary iodine level was 77 mcg/L with a range of 28 mcg/L to183 mcg/L [
20]. Another study conducted among school children revealed that the median urinary iodine concentration was 67.9 ug/L [
21]. Similarly, a study conducted in two districts in the Upper East region in 2007 showed that while there was a drop in overall total goitre rates in the two districts, the median urine iodine levels were below the satisfactory threshold of 100 ug/L. The median urine iodine levels were 51.6 ug/L and 62.56 ug/L in Jirapa and Bongo respectively. The study also found out that only 38.5% and 36.3% of households in Jirapa and Bongo districts respectively were using iodized salt adequately [
22].
A market survey conducted in the Western Region in 2007 revealed that the level of patronage of iodized salt was 95.7%. However, this figure dropped to 52% in 2010 [
23]. In addition, the market survey showed that 58% of salt sold in markets was iodized, yet below 20 ppm, compared with the mandated iodization level of between 25 and 45 ppm [
20,
23]. Consequently, it was concluded that the National Salt Iodization Committee and the United Nations' target of 90 per cent plus of Universal Salt Iodization has not been achieved.
A re-analysis of the 1994 baseline data conducted in 2007 indicated that 51.8% rather than 33.3% of Ghana's 1,194 districts were afflicted with IDD, deserving public health attention [
19]. Another study conducted in 1998 in the northern parts of Ghana revealed that 68.8% of 1061 subjects had goitre. The subjects were examined for goitre by the palpation method, and every tenth subject examined provided urine for urinary iodine determination. The median urinary iodine level for the subjects was 1.6 micrograms/dl. Seventy two percent (72%) of the subjects had urinary iodine level less than 2 micrograms/dl, 24% had urinary iodine levels in the range 2-5 micrograms/dl and the remainder had urine iodine in the range 5-10 micrograms/dl. The researchers suggested that further studies should be conducted to determine the cause(s) of the IDD endemic [
24]. The ignorance of people regarding the importance and sources of iodine to the body could be a contributory factor to this public health problem.
Fortification of salt with iodine has been the most widespread, long-term and effective preventive measure against IDDs since 1920 [
25]. To improve consumption of iodized salt, the Universal Salt Iodization (USI) programme was launched in Ghana in 1995. However, in Ghana it has been estimated that approximately 50% of households use iodized salt exclusively [
26,
27]. Surveys conducted by the Ghana Health Service to assess consumption levels of iodized salts in households revealed that, only 49.1%, 41.5%, 74.1% and 50.8% of households in the country consumed iodized salt solely in 2002, 2003, 2005 and 2006 respectively [
28]. The survey conducted in 2006 revealed that only 32.4% of household salt samples were adequately iodized [
28]. In addition, only 74% of households consumed iodized salt in Ghana as at 2008, below the national target of 90% which was to have been attained by the end of 2005 and sustained by 2011 [
29].
The Medium Term Health Strategy for Ghana towards 'Vision 2020' revised in August 2000, still maintained and emphasized that levels of IDDs were high, especially in the northern part of the country and some parts of the Western Region [
30]. It has also been indicated that though the IDD control programme is in place, there are doubts with regard to how the general populace especially in rural communities utilize iodized salt [
31].
In the Western Region, surveys carried out to assess household utilization of iodized salt showed that, 53.2%, 67.5% and 78.1% of households consumed iodized salt in 2003, 2005 and 2007 respectively. It was also revealed that, 51.7% of households consumed iodized salt in Bia district (formerly Juaboso-Bia) in 2003, which rose to 76.7% and 77.4% in 2005 and 2007 respectively [
32]. The last survey conducted in 2007 showed that 78.1% of households consumed iodized salt in the region, with Bia, the district with the lowest reported iodized salt consumption rate in the Western Region, recording 77.4%, (in a range of 77.4% to 80.8%) [
32]. Findings of the 2007 survey further revealed that the goitre rate stood at 18.8% which, according to the study, was quite high [
32].
Apart from a survey which was conducted in 2007 to assess household utilization of iodized salt, no other survey has been conducted in the district. Hence the need to undertake this survey to provide current information regarding the utilization of iodized salt in Bia District.
The main objectives of the study, then, were to assess the perceptions, knowledge and practices of people in respect of the use of iodized salt, and to ascertain the current consumption rate of iodized salt in the district. The survey also assessed the iodine concentrations of salt consumed in households in the district.
The findings of this study would be useful to District Health Management Teams (DHMT) which plan promotional and educational programmes on the utilization of iodized salt in Ghana, and to other countries grappling with the problem of IDDs, mainly because of the low utilization of iodized salt.
Discussion
In Ghana, as in most developing countries, iodization of salt is the major strategy that has been employed to help avert the public health effect of iodine deficiency disorders (IDDs).
Findings regarding the intake of iodized salt in the present study suggest that there has been a remarkable improvement in knowledge about iodized salt compared with the findings of a study conducted by the University of Ghana in collaboration with the Ministry of Health, Ghana, from 1991-1993 on IDDs in Ghana that 98% of the respondents had no knowledge about iodized salt [
18]. This improvement has occurred as a result of the Food and Drugs Board amendment Act, Act 523 of 1996 on universal salt iodization and the propagation of health education by the Ministry of Health and the Ghana Health Service creating awareness about the importance of iodized salt. The increase in the knowledge levels over the years suggests that, if awareness creation and educational activities are sustained mainly in the local dialects, it is likely that all Ghanaians would become aware of iodized salt and its importance to human health and wellbeing.
A significant proportion of the respondents (39.9%) indicated that their major source of information about iodized salt was the radio, which could be attributed to the high number of radio stations in the country, especially the three stations in the Bia District. A similar study conducted among rural households also revealed that over 95% of the study participants knew about iodized salt and IDDs mostly through educational programmes broadcast on radios and televisions [
3]. Forty two respondents, representing 16.6% indicated that the television and health workers were their main sources of information regarding iodized salt. This low percentage could also be attributed to the fact that majority of the people in Bia are settler farmers who live on their cocoa farms and as such are not likely to have access to public health educational messages propagated through the electronic media or by health workers in the communities. These findings suggest that even though the use of the electronic media is one effective way to improve and sustain peoples' use of iodized salt, settler cocoa farmers, a considerable section of the population in the district, are likely to be left out and may not have access to these educational programmes.
The findings regarding why the intake of iodized salt is important show an improvement over the findings of a similar study conducted by Asibey-Berko (1995) [
18] in 30 selected districts from all the ten regions of Ghana within a period of three years (1992-1995) in which it was reported that 1.1% and 0.4% of the respondents indicated that iodized salt prevents goitre and improves the overall health of the individual respectively. It can be inferred that as a result of increased knowledge regarding the importance of using iodized salt and the effects of its deficiency in the diet of an individual, there has also been an increase in the consumption rate of iodized salt as indicated in Figure
1 and Table
3. The knowledge levels of respondents can be described as above average, reflected in the responses of 72% of the respondents who indicated that every salt does not contain iodine. Similarly, the majority of the respondents knew that inadequate intake of iodized salt resulted in the development of goitre. On the other hand, 60% of the respondents indicated that the taste of iodized salt is different from that of common salt, corroborating the report of a similar study conducted in Mongolia, that more than half of the study participants indicated that the taste of iodized salt was not the same as that of common salt. However, in a double-blind study using the same respondents, it was revealed that they could not distinguish the taste differences between iodized and uniodized salt [
3]. This misconception regarding the differences between the taste of common salt and iodized salt should be corrected through educational messages, particularly because it can act as a barrier and prevent people from using iodized salt.
Some non-users and occasional users (respondents who used both common salt and iodized salt) reported that common salt was cheaper compared with iodized salt, which influenced their decision in choosing common salt. This finding is supported by a similar study which also reported that the majority of occasional users and non-users of iodized salt indicated that the price of iodized salt was slightly higher than that of common salt [
3]. As asserted by Yamada et al. (1998) [
3], generally, iodized salt costs more than common salt because of the additional processing cost involved in fortifying common salt with iodine.
A high proportion (57%) of the respondents knew that the iodine content of iodized salt reduces when it is not stored in enclosed containers, by virtue of its volatile characteristic. The findings of a study conducted by Sebotse et al. (2009) [
7], indicated that when iodized salt was not stored in closed plastic bags, sealed waterproof materials or closed containers, iodine losses occurred leading to a reduction in the iodine content of the salt before it is consumed.
The finding that 75.6% of respondents consumed iodized salt indicates a slight reduction in the intake of iodized salt compared with the Western Regional Annual Health Sector Report [
32] based on that year's household survey which revealed that approximately 77% of the people living in Bia district consumed iodized salt. The present finding suggests that the initial effort by health workers and other collaborators in the dissemination of information to sensitize and create awareness about the importance of consuming iodized salt might be declining. Similarly, it is likely that programmes broadcast through radio stations are also declining. The implication of these findings is that if health education activities are not stepped- up, this downward trend will continue. Other reasons that have been given for the failure of most developing countries to achieve 90% utilization of iodized salt include political factors and logistical problems in the production and distribution of iodized salt [
3,
35‐
37].
Conclusions
The knowledge on iodized salt of people in charge of preparing household meals in the district is relatively high, as most (90.4%) of them knew about iodized salt. However, their knowledge levels were not translated into or reflected in their practices as only 64.6% of households exclusively used iodized salt for cooking and 75.6% of the samples of salt tested had an iodine content of ≥ 25 PPM. A commendable practice of a good proportion (62.6%) of the respondents was the storage of salt in enclosed containers or water proof materials to prevent iodine losses. The research also revealed that, continual and effective use of the electronic media for broadcasting health education programmes in addition to house-to- house visits by public health workers to target populations with no access to the electronic media will help to sustain and improve on the utilization of iodized salt in the district.
Recommendations and suggestions for further study
On the basis of the findings of the study, recommendations made include the following: In the propagation of educational messages, great effort should be made to correct misconceptions regarding the differences between the tastes of iodized and common salt.
As part of technical surveillance and laboratory services to ensure quality assurance, Environmental Health Workers in the country should be trained by the DHMT on how to conduct iodine tests, and they should be supplied with the rapid test kits to enable them monitor whether salt sold in marketplaces are adequately fortified with iodine, as part of their routine food inspection activities in the district.
Environmental health workers should be empowered by law to prosecute or take legal action against salt sellers found selling salt that is not iodized and also manufacturers who do not comply with the universal salt iodization Act. The Food and Drugs Board should enforce laws that will require all salt produced to bear brand names and contact addresses of manufacturers in order to easily identify uniodized products.
To address the issue of the inability of some consumers to distinguish between iodized salt and uniodized salt, a logo could be inscribed on all recommended brands of iodized salt by the Ghana Standards Board and the Food and Drugs Board to enable consumers, particularly people without any formal education, to identify approved iodized salt brands on the market.
Lastly, regarding the settler cocoa farmers who do not have access to information broadcast through the mass media, perhaps interpersonal communication by disease control officers, public health nurses and other health workers will be a more effective means to disseminate health information to them, as this was reported to be effective in a similar study conducted in Peru [
38].
A suggestion for further study is the need to assess the iodine status of school children and pregnant women in particular, which should include the determination of Urinary Iodine Concentration (UIC) levels as recommended by the WHO. This is because these two groups are described as the most vulnerable groups confronted by iodine deficiency disorders.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
The authors' responsibilities were as follows: CB supervised the study, participated in the design of the research instrument, reviewed related literature, and participated in discussing findings and making recommendations on the basis of the findings of the study. She finalized the manuscript for submission. BB concieved the idea of this study, participated in the design of the study, and had the major responsibility of coordinating the data collection (interviews and testing of iodine levels of salt) in households, analysis of the data, and presentation of results. He also actively participated in the write-up of the study. Both authors have read and approved the final manuscript.