University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC REALm COLLEGE OF REALm SCIENCES UNIVERSITY OF GHANA BIOMASS FUEL USE AND RESPIRATORY REALm AMONG GA-KENXEYMAKERS AT CHORKOR, A SUBURB OF ACCRA IN THE GREATER ACCRA REGION, GHANA BY TWUM BARIMA YAW (10598442) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEOON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF SCIENCE IN OCCUPATIONAL MEDICINE DEGREE JULY, 2017 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Yaw Barima Twum hereby declare that apart from references to other people's works which have been duly acknowledged, this proposal is as a result of my own independent work and has not been submitted for the award of any degree in any institution . ..........~ ............... . TWUMBARIMAYAW DATE (STIJDENT) - .......~ . ................... . ... . \~.I.~.\ ...\ s. ...... . DR JOHN ARKO-MENSAH DATE (SUPERVISOR) ...................................... .. .................................. . PROFESSOR JULIUS FOBIL DATE (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my amazing parents (ps. Kwabena Twum and Mrs Akosua Henewaa Twum), my family and all the hardworking Ga-kenkey makers who feed us with their delicious meals. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am very indebted to the Almighty God for His amazing grace, good health and wellbeing throughout this programme. I would like to reflect on the people who have supported and helped me so much during this period. I am sincerely grateful to my academic supervisors, Dr. John Arko-Menash and Professor Julius Fobil for their support, kindness and guidance. I am also grateful to West Africa- Michigan Collaborative Health Alliance for Reshaping Training, Education and Research in Global Environmental and Occupational Health (WEST AFRICA-MICHIGAN CHAPTER II) for the grant awarded me. My heartfelt gratitude goes to Dr. Afua Amoabeng-Nti for vouching for me as well as Miss Lawrencia and Miss Slyvia for their timely counsel. I am also grateful to Miss Aboagyewaah Oppong-Damoah, Mr Stephen Asare, Miss Nana Akua Debrah, Mr Sampson Afrifa and the community volunteers that supported me during the ~ata collection. I also acknowledge the support I received from Dr. William Ankobiah and staff of Bemuah Royal Hospital. I really appreciate the support I received from Dr Quansah Reginald, Dr Mawuli Dzodzomenyo and the entire staff of the department of Biological, Environmental and Occupational Health. To the MSc. Occupational HygienelMedicine class of2017, Deborah Serwaah Baafi, Mrs Hannah Amankwah, Patricia Serwaah Afrifa and every contributor to this work, I'm immensely grateful. iv University of Ghana http://ugspace.ug.edu.gh ABSTRACT BackgroaDd: The use of biomass fuel for cooking leads to the production of air pollutants which could be deleterious to human health. Some studies have reported decreased pulmonary function and prevalence of certain respiratory symptoms among biomass fuel users. However, no study has been conducted to investigate the relationship between Ga-kenkey making, an activity heavily reliant on use of biomass fuel and respiratory health of Ga-kenkey makers. Objective: The primary objective of this study was to assess the relationship between biomass fuel use and respiratory health among Ga-kenkey makers in Accra. Methods: A cross-sectional analytical study was conducted from May to July, 2017 among 52 purposively selected Ga-kenkey makers at Chorkor, a suburb of Accra. Semi-structured questionnaire and spirometry were used to collect data from study participants. Mean values and standard deviations of participants, cross tabulations and Chi-square analysis were computed to find relationship between hours spent using biomass fuel and pulmonary symptoms. The associations between duration of work and pulmonary indices were assessed using multivariate linear regression analysis. Statistical analysis was done in STATA software version 14. ResaID: The mean age±SD of Ga-kenkey makers was 41.87± 11.11 years. The most commonly self- reported respiratory symptoms included itchy and watery eyes, 40 (76.92%); itchy ears and throat, 32 (61.54%); prolonged or repeated sneezing 30 (57.69%) and colds, 29 (55.77%). The study recorded reduced pulmonary indices. The mean±SD pulmonary indices were FVC (2.45L±0.58L); FEV) (1.65US%0.48Us) and FVCIFEVI (68.12s·1 ±14.09 S·I). There was no significant association between the duration of work and the pulmonary indices. v University of Ghana http://ugspace.ug.edu.gh Coad.sioas: In conclusion, this study demonstrated no significant statistical relationship between duration of work as a Ga-kenkey maker and lung function parameters among the study participants. Keywords: Biomass fuel, Spirometry, Respiratory symptoms, Pulmonary function, Ga-kenkey makers vi University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ......................................................................................................................................... .ii DEDICATION ............................................................................................................................................. iii ACKNOWLEDGEMENT ........................................................................................................................... iv ABSTRACT .................................................................................................................................................. v TABLE OF CONTENTS ............................................................................................................................ vii LIST OF TABLES ........................................................................................................................................ x 1.0 INTRODUCTION .................................................................................................................................. 1 1.1 Background ......................................................................................................................................... 1 1.2 Statement of Problem .......................................................................................................................... 3 1.3 Conceptual framework ........................................................................................................................ 4 1.4 General Objective ................................................................................................................................ 7 1.4.1 Specific objectives ........................................................................................................................ 7 1.5 JUSTIFICATION ................................................................................................................................... 7 2.0 LITERATURE REVIEW ....................................................................................................................... 9 2. I BMF use and respiratory effect ........................................................................................................... 9 2.3 Health conditions associated with BMF smoke exposure ................................................................. ll 2.3.1 Interstitial lung disease ............................................................................................................... 11 2.3.2 Chronic obstructive pulmonary disease (COPD) ....................................................................... 12 2.3.3 Tuberculosis (TB) ....................................................................................................................... 13 2.3.4 Lung cancer ................................................................................................................................ 13 2.4.1 Small solid particles .................................................................................................................... 14 2.4.2 Carbon monoxide (CO) .............................................................................................................. 14 2.4.3 Polyorganic and polyaromatic hydrocarbons (PAH) .................................................................. IS 3.0 METHODOLOGY ............................................................................................................................... 16 3.1 Overview ........................................................................................................................................... 16 3.2 Study Area ......................................................................................................................................... 16 3.3 Study Design ..................................................................................................................................... 17 Dependent Variables- ................................................................................................................................ 17 vii University of Ghana http://ugspace.ug.edu.gh 1~~;~;~~:~~~~=:~::~~:~~~:~:~~~~::::~:::::::::::::::~:::::::::::~::~::~:::::~::::~:::::::::::::~::::~:~~:::::~~~:~~~~ f1 3.7.2 Exclusion criteria: ................................................................................................................. 19 3.8 Recruitment! Sampling Method ........................................................................................................ 20 3.9 Spirometer ......................................................................................................................................... 21 3.10 Data collection Tools ...................................................................................................................... 21 3.11 Questionnaire .................................................................................................................................. 21 3.12 Clinical Examination ....................................................................................................................... 22 3.13 Anthropometric Measurement ......................................................................................................... 22 3.14 Lung fUnction measurement (Spirometry) ...................................................................................... 22 3.15 Quality Control ................................................................................................................................ 23 3.16 Data Management ........................................................................................................................... 23 3.16.1 Data Processing ........................................................................................................................ 23 3.17 Statistical Analysis .......................................................................................................................... 23 3.18 Ethical Issues ................................................................................................................................... 24 4.0 RESULTS ............................................................................................................................................. 25 4.2 Chronic Respiratory Illnesses in Ga- Kenkey makers ....................................................................... 28 4.3 Prevalence of Respiratory Symptoms ............................................................................................... 28 Respiratory Symptoms ................................................................................................................................ 30 4.5 Relationship between years of making Ga-Kenley and Respiratory Symptoms .............................. 30 Symptoms ................................................................................................................................................... 31 4.7 Mean values of Pulmonary Function of Participants ........................................................................ 32 5.0 DISCUSSION ....................................................................................................................................... 36 5.1 Summary of Main Findings ............................................................................................................... 36 5.2 Methodological validity .................................................................................................................... 36 5.3 Exposure to biomass fuel and respiratory symptoms ........................................................................ 37 6.0 CONCLUSION AND RECOMMENDATIONS ................................................................................. 39 6.1 Conclusion ......................................................................................................................................... 39 6.2 Recommendation ............................................................................................................................... 39 viii University of Ghana http://ugspace.ug.edu.gh REFERENCES ...................................••••••.•................................................••••............................................ 40 7.0 APPENDICES ........................................................................................•....................................•••....•. 47 SPIROMETRY DATA ENTRY SECTION ............................................................................................... 49 Appendix 2: Consent Fonn ......................................................................................................................... 51 Confidentiality Data security ...................................................................................................................... 51 ix University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4.1: Socio-demographic characteristics of Ga-Kenkey makers .........................2 5-26 Table 4.2: Respiratory health among Ga-Kenkey makers ......................•.....•...........2 8 Table 4.3: Smnmary of mean values of pulmonary function measures ........................3 2 Table 4.4: Correlation between age, duration of working and pulmonary indices ......•..... 33 Table 4.5: Relationship between duration of work and pUlmonary indices .....................3 4 Table 4.6: Association between duration of work and FVC (L) •................................ 34 LIST OF FIGURES Figure 1.1: Conceptual framework ..............................................................................................6 Figure 3.1: Map of study area. .................................................................................................... 16 Figure 3.2: Ga- kenkey maker at work ...................................................................2 0 Figure 4.1: Type of Fuel used by participants ..........................................................2 7 Figure 4.2: Prevalence of Respiratory Symptoms among Ga-kenkey makers ......................2 9 Figure 4.3: Relationship between hours spent using BMF and Respiratory Symptoms ..........3 0 Figure 4.4: Relationship between years of working with BMF and Respiratory Symptoms .....3 1 Figure 4.5: Relationship between type of cooking space and Respiratory Symptoms .............3 2 University of Ghana http://ugspace.ug.edu.gh UST OF ABBREVIATIONS BMF Biomass fuel SSA Sub-Saharan Africa WHO World Health Organization DALYs Disability-adjusted life years COPD Chronic obstructive pulmonary disease TB Tuberculosis CO Carbon Monoxide FVC Forced Vital Capacity FEV) Forced Expiratory Volume in one second SOl Sulfur dioxide NO Nitrogen Oxide PAHs Polycyclic aromatic hydrocarbons Pb Lead Cu Copper PM Particulate matter PF Pulmonary function xi University of Ghana http://ugspace.ug.edu.gh 1.0 INTRODUCTION 1.1 BackgrouDd Globally, about 33% of the world's populace use Biomass Fuel (BMF) for cooking, heating and lighting although its usage is associated with causing air pollution in households. The Global Burden of Disease Study done in 20 I 0 estimated that nearly 3.5 million deaths recorded worldwide were as a result ofBMF exposure (Lim et aI., 2012). Biomass fuel use pose multiple environmental concerns, first due to deforestation as well as air emissions for instance methane, nitrogen dioxide and carbon dioxide (Ramanathan et aI., 2007; Rehfuess, Mehta, & Prilss-UstUn, 2006). A great proportion of people living in sub-Saharan Africa (SSA) relies on BMF and this proportion is predicted to rise from 2.6 billion by 2015 to 2.7 billion by 2030 as a result of populace surge and lack of policies regarding its use (World Energy Outlook. 2016). In SSA, women arc typically responsible for household chores such as cooking, collecting water and firewood among others. The majority of these women depend on BMF as their source of energy for preparation of meals and are subsequently exposed to its inhalational and dermal effect. In Ghana, about 2.2 million households depend on fIrewood as their principal source of cooking fuel, with a further I million households using charcoal (K.wakwa, Wiafe, & Alhassan, 2013). This indicates that approximately 86% of the total household population are reliant on biomass fuels (Arthur, Baidoo, & Antwi, 2011). Ghana is recognized as the largest user of charcoal in West Africa. 66% of the energy expenditure of Ghana is from fuel wood (Hansen, Lund, & Treue, 2009). University of Ghana http://ugspace.ug.edu.gh Charcoal accounts for approximately 69% of fuel wood used in all urban households in Ghana. According to Owusu Boadi & Kuitunen (2006), 57% of all charcoal produced in Ghana is used in Accra and Kumasi, the two biggest urban areas in Ghana. The exposure to indoor air pollution from BMF use is associated with loss of 502,000 disability adjusted life years (OAL Ys) every year (Annab, Odoi. & Luginaab, 2015). The WHO (2012) analysis reported indoor air pollution is accountable for 16,600 deaths per year in Ghana. An excessively high number of such losses involve women and children. Solid BMF include fIrewood, dried animal dung and agriCUltural residues such as straw and sticks, have low combustion efficiency. Incomplete combustion give rise to release of smoke formed by fIne particulate matter, which fIlls the kitchen or living area and is inhaled by the person involved in it use. It has been reported that an average of 4.5 hours ofe xposure to smoke from wood is equivalent to smoking about 20 packets of cigarettes each day (Smith, Aggarwal, & Dave, 2010). In industrialized countries, chronic obstructive pulmonary disease (COPD) is connected with cigarette smoking, while in the developing world, biomass combustion is an essential risk factor for COPD, especially in rural areas (Sood et aI., 2012). Biomass combustion results in the production of air pollutants such as particulate matter (PM2S and PM,o), carbon monoxide (CO), nitrogen oxides (NO), polycyclic aromatic hydrocarbons (PAHs), metals like lead (Pb) and copper (Cu) and other toxic organic compounds (Clark et aJ., 2013). These air pollutants when inhaled are able to traverse the alveolar-<:apillary barrier and infIltrate deep into the lungs causing deleterious effect on the respiratory system (Tesfaigzi et aJ., 2002). A meta-analysis carried out on 25 reviews reported associations between domestic use ofs olid BMF and diverse respiratory conditions University of Ghana http://ugspace.ug.edu.gh in rural populations (po, FitzGerald, & Carlsten, 2011). People living in developing countries are facing growing risks of respiratory diseases due to exposure to smoke and dust in different occupational and industrial sectors. In Ghana, there is a popular food called Ga- Kenkey, which is basically prepared from fennented com meal. Production of Ga- kenkey in Ghana involves the use of fIrewood and charcoal or inefficient traditional cook stoves in cooking for several hours openly. The cooking process is usually done in a poorly ventilated semi enclosed cooking space, which could generate high levels of air pollutants in the environment. For example, Smith, Aggarwal, & Dave (2010) found that peak kitchen emissions ofPM2.s from combustion of biomass fuels can reach up to 10,00030,000 l1g/m3 which far exceeds the WHO 24-hr average exposure level of25 l1g/m3 by orders ofm agnitude (WHO, 2014). Particulate matter can stay suspended in the atmosphere over long periods of time (Branis, Safranek, & Hytychova, 2009), and pose a direct risk to those near the burning process, who do not use any personal protective equipment. No study has so far enumerated the effects of BMF smoke exposure on the respiratory health ofGa-lcenlcey makers. 1.2 StatemeDt of Problem Biomass fuels (BMFs) are used largely for cooking and heating homes, but have been documented to have adverse health effects (Mekonnen & K6hlin, 2008). Burning of BMF lead to discharge of smoke formed by free radicals hydrocarbons, carbon monoxide, oxygenated and chlorinated organics, fme particulate matter and other harmful substances which occupies the kitchen or living area (Duncan G. Fullerton, Bruce, & Gordon, 2008; Naeher et aI., 2007). These fme particulate matter, carbon monoxide and other harmful 3 University of Ghana http://ugspace.ug.edu.gh substances can be inhaled by the person involved in using the use of BMF as well as other people in the household. Studies done have associated biomass smoke hazard to increased risk of chronic obstructive pulmonary disease (COPD), asthma, lung cancer, tuberculosis, cardiac outcomes, low weight babies and prenatal mortality (Dionisio et al., 2010; Fullerton, Bruce, & Gordon, 2008b). BMF use for cooking is also associated with respiratory symptoms which include cough, wheezing, chest pain, breathlessness and rhinitis (Desalu, Adekoya, & Ampitan, 2010). Ga-kenkey, which is a popular stable food in Ga communities in Ghana, as well as several other communities in Southern Ghana rely the use of mostly firewood and charcoal in its preparations. The Ga-kenkey making process involves a minimum of four (4) days in its preparation and more than three hours of continuous cooking (Saalia, Asante, & Kyeretwie, 2013). Kenkey makers often stay in the vicinity of the cooking process to ensure from time to time that there is adequate heat penetration to achieve the desired texture. The cooking process is usually done in poorly ventilated areas which could significantly increase inhalationaJ and dermal exposure to BMF smoke. In Ghana, no studies have been done to assess the link between BMF smoke exposure and its impact on respiratory health. 1.3 CODceptual framework The conceptual framework demonstrates respiratory health is affected by demographic factors and environmental factors associated with exposure to BMF smoke. Exposure may be influenced by route of exposure, the kitchen characteristics that is whether the cooking is done indoor or outdoor, history of respiratory condition as well as duration of exposure. Due to increased time involved in cooking, women and children are disproportionally exposed to heath damaging chemical compounds (Torres-Duque et al., 2008). Variables 4 University of Ghana http://ugspace.ug.edu.gh such as age, level of education and smoking status also influence the choice of BMF. A person's socioeconomic status also significantly influences the choice ofBMF use. Agent! in the BMF smoke such as particulate matter, polycyclic aromatic hydrocarbons etc. whicl1 fmd their way into the lungs may initiate allergic or inflammatory reactions leading to respiratory health symptoms. Some studies have examined acute respiratory symptoms such as cough, phlegm, wheeze, and dyspnea as early indicators of airway inflammation and asthma in women exposed to biomass fuel (Diaz et aI., 2007). Recurrent exposure to the BMF smoke is associated with impaired lung function (Kurmi et aI., 2013). 5 University of Ghana http://ugspace.ug.edu.gh Figure 1.1: Conceptual Framework of BMF use and respiratory symptoms 6 University of Ghana http://ugspace.ug.edu.gh 1.4 GeuenJ Objective • To assess exposure to biomass fuel smoke and respiratory health among Ga-kenkey makers at ChorKor, a suburb of Accra 1.4.1 Specific objectives • To determine the prevalence of respiratory symptoms among Ga-kenkey makers • To determine lung function among Ga-kenkey makers by spirometry • To determine whether there is an association between BMF use and respiratory symptoms among Ga-kenkeY makers To determine the relationship between BMF use and respiratory function among Ga- kenkey makers 1.5 JUSTIJi1CATION This study aims at determining the prevalence of respiratory symptoms among Ga-Kenkey makers and the type of effect of BMF smoke exposure on lung function. This research has been necessitated as there is no data on the respiratory effects ofBMF smoke exposure on traditional food processors. Ga-kenkey making provides meal for the community and plays an important socioeconomic role in terms of employment potential. The use of fIrewood and charcoal for the cooking process undergo incomplete combustion which the products are inhaled by the women causing respiratory adverse effect. Air pollution from BMF smoke is of global public health importance for which policy intervention is urgently required to curtail its harmful effects to human health and the 7 University of Ghana http://ugspace.ug.edu.gh environment (Duncan G. FuJlerton et aI., 2008). The cumulative lifetime exposure to hazardous pollutants in BMF could lead to high direct cost in health care and environmental cost to plant life and animal life. Whilst the Government could help these workers with provision of cleaner fuel, there is the need to quantifY the burden of diseases due to BMF smoke emission and to monitor environmental pollutants. Undertaking this academic exercise is significant and a ftrSt step in assessing the impact ofBMF exposure on respiratory health, and could provide important basis for policy formulation and regulation on use of open air burning of BMF. Also, further research could help establish a reliable biomarker of exposure to biomass smoke that could help the early diagnosis of respiratory conditions. 8 University of Ghana http://ugspace.ug.edu.gh 1.0 LITERATURE REVIEW Workplace exposure to unsafe air coupled with general environmental air pollution among other fonns of smoke exposure has been identified as contributing factors to the global burden of respiratory health issues. According to Shrestha & Shrestha, (2005) the estimated PMlo level in kitchens in Nepal using biomass fuel were three times higher than in kitchens using cleaner fuels such as kerosene, liquefied petroleum gas (LPG) among other known cleaner fuels. Although the underlying mechanism is unknown, pulmonary dysfunction among biomass users have been associated with particulate pollution. A cross-sectional review done in Mexico City, compared cooking with gas and use ofBMF. The use ofBMF was related with increased reporting ofphJegm (27 vs. 9%) and reduced FEVIIFVC (79.9 vs. 82.8%). The FEV1 indices were 81 ml reduced and cough was more common (odds ratio, 1. 7; 95% confidence interval, 1.~2.8) in women from homes with higher PMIO levels (Regalado et aI., 2006). 1.1 BMF use ud respiratory effed BMF smoke emanating from cooking with it has been associated with causing indoor air pollution which causes significant respiratory health risks. Several studies have been done to linked exposure to BMF and pulmonary symptoms associated with it use. The respiratory symptoms include cough, excessive phlegm production, itching eyes, cold, wheezing, sore throat and shortness of breath. A study done in Turkey which assessed the clinical and functional parameters in female subjects with biomass smoke exposure among fifty-five patients reported dyspnea (75%), phlegm (55%), cough (80010), and wheezing (35%) as the common respiratory symptoms (YurtJu et aI., 2012). 9 University of Ghana http://ugspace.ug.edu.gh Several studies done have presented findings indicating an increased cases of respiratory ill health amongst adults with exposure to biomass smoke with predicted risk ratios between 1.2 and 7.9 ($ood et at., 2012). Another study done in Nepal comparing the impact of biomass smoke exposure on pulmonary symptoms in adult urban and rural Nepalese populations reported 17.8% breathlessness, approximately three times more for wheeze, and chronic bronchitis symptoms as the prevalent respiratory symptoms (Naeher et aI., 2007). A study done in Malawi reported people using wood as their principal domestic fuel had significantly more compromised lung function as compared with those using charcoal (Fullerton et aI., 20 II). A study done by Vliet, (2016) in Kintampo to assess respiratory symptoms and risk factors in pregnant women cooking with biomass fuels reported the prevalence of phlegm being the highest of all the respiratory symptoms (9.6%, 95% CI 7.6, 11.6), while cough more than 5 days was reported by 6.2% of the pregnant women (95% CI: 4.5, 7.8), wheeze by 4.8% (95% CI: 3.3,6.2), dyspnea was reported by 4.6% (95% CI: 3.2,6.1), and 1.7%(95% CI:0.07, 2.5) ofw omen reported seeking health care forrespiratory infection in the past four weeks before the study was conducted. 1.1 Mee.aaisma by which solid fuel smoke affects respiratory outcomes. There are limited data on the process by which solid fuel smoke alters the lung. Solid fuel exposure lead to macrophage dysfunction, increased proteolytic activity of matrix metalloproteinases (MMP), which lead to greater gene expression of MMP, pulmonary surfactant deactivation, reduced bacterial clearance from the respiratory tract and reduced mucociliary clearance have all been reported (Sood, 2012a). 10 University of Ghana http://ugspace.ug.edu.gh CODP subjects exposed to wood smoke demonstrate an upregulation of arginase activity in their platelets and erythrocytes, which is linked with greater oxidative stress (Assad. Balmes, Mehta, Cheema, & Sood, 20 IS). The elevated levels of oxidative stress related to wood smoke exposure further mediates increased apoptosis in human cells such as pulmonary artery endothel ial cells (Liu et al.. 2016). In addition, BMF smoke also produces inflammatory and DNA damage and oxidative stress response gene expression in cultured human cells (Sood, 20 12a). Exposure to wood smoke of healthy human volunteers is followed by a rise in serum and urine concentrations of Clara cell protein (Barregard et aI., 2008). Patients with chronic exposure to BMF smoke presents with inflamed bronchial epithelium, diffuse parenchymal anthracotic deposits, as well as inflammatory and fibrous thickening of the alveolar septa as their main pathological fmdings (Leslie, 2009). 2.3 Health conditions associated with BMF smoke exposure 2.3.1 IntentitialluDg disease BMF smoke is linked to an interstitial lung disease referred to as 'hut lung'. Chronic high- level of exposure to BMF smoke is associated with 'Hut lung' which is identified by carbon deposition, dust macules, and mixed dust fibrosis. The main symptoms and signs include dyspnea, cough, cyanosis and inspiratory crackles on auscultation. When pUlmonary function is assessed it usually shows obstruction or mixed obstruction- restriction pattern. Results from bronchoscopy done also reveals grossly noticeable anthracotic plaques, typically seen at the bifurcations ofJobar bronchi (Sood, 2012b). Histopathol· .. f OglC exammation 0 transbronchial biopsy specimens shows thickened basement membranes with diffuse d ·t· f fi epoSI Ion 0 me anthracotic particles (Sood, 20 12b). Open lung 11 University of Ghana http://ugspace.ug.edu.gh biopsy specimens confinn the presence of diffuse anthracosis and areas of interstitial fibrosis. The regimen of this condition is not known but improvement with systemic corticosteroids followed by inhaled corticosteroids has been recorded (Churg et aI., 2004) 2.3.2 Chronic obstructive POImODary disease (COPD) COPD is associated with cigarette smoking in developed countries and exposure to solid fuel smoke is a main contributing cause in developing countries. WHO (2016) estimates about 700,000 out of the 2.7 million global deaths due to COPD could be attributable to indoor air pollution from solid fuels, mostly in females. Other factors related with the development of COPO include lower socioeconomic status, low income and lower education. The pathogenesis of COPD among nonsmokers exposed to BMFs remain unknown, some toxicological studies have linked burning of biomass produces chemicals with high oxidative potential. This leads oxidative stress and DNA impairment in those exposed to biomass smoke. Lung growth retardation is linked to exposure to biomass smoke from an early age. In a study done in Nepal compared lung function between a biomass smoke exposed populace and an unexposed group, the absolute values for numerous indices of lung function were significantly reduced in the biomass smoke-exposed group (Kunni, Devereux, et aI., 2012). Airflow obstruction in the biomass smoke exposed group was almost twice the unexposed group (20% versus 11%) (Kurmi, Lam, & Ayres, 2012). 12 University of Ghana http://ugspace.ug.edu.gh 2.3.3 Tuben:u_is (TB) Though more epidemiological and laboratory data are required to support the hypothesis that BMF smoke leads to an increased incidence of TB, evidence is emerging that the incidence ofm is increased amongst BMF-exposed women. Per studies done by Mishra, Retherford, & Smith, (1999) and Perez-Padilla, Perez Guzman, Baez-SaIdatla, & Torres-Cruz, (2001) in Mexico and India respectively, implied that BMF smoke exposure plays a causal role in the development of TB. These conclusions have not been extensively explored in many studies, however the overall evidence from few studies support the hypothesis that exposure to pollutants from fIre from BMF increases the risk ofTB infection and disease (Lin, Ezzati, & Murray, 2007). 1.3.4 LUDg cucer The International Agency for Research on Cancer (lARC) recently termed biomass smoke a 'probable carcinogen' (Group 28) to humans (Straif et al., 2006). Data from China infer that domestic coal smoke is a significant risk factor for the development oflung cancer (Du et al., 1996; Zhao, Wang, Aunan, Martin Seip, & Hao, 2006). In studies from India and Mexico, data for non-smoking women exposed to BMP smoke for a number of years propose that long-term exposure to BMP smoke from cooking may add to the development of adenocarcinoma of the lung (HemandezGardufto, Brauer, Perez-Neria, & Vedal, 2004; Sood et aI., 2012). High levels polycyclic aromatic hydrocarbons (PAHs) and particulate matter with a diameter of2.5 J.UD or less which are emissions from combustion ofs olid fuels have been shown to have been associated with high rates oflung cancer (Jung et at., 2010). 13 University of Ghana http://ugspace.ug.edu.gh 2.4 The tODC emissions include: 2.4.1 Small solid particles Classification of particulate matter (PM) is based on its aerodynamic diameter(AD), which depends on the size of the particle, mass and shape. Studies where actual biomass smoke exposures have been measured reported exposures as PMIO and PM2.5, replicating the likelihood that greater toxicity exist in the smaller size fraction. PM can be evaluated by means of either gravimetric techniques or by photometric devices. Some studies have shown 24-hour indoor concentrations of PMIO produced from solid fuels in diverse settings to be in the range of 300-3,000 /lg·m-3, with peaks reaching as high as 20,000 l!8'm-l during cooking (WHO, 2014). Particles with a diameter smaller than PM10, can penneate deeply into the lungs and appear to have the highest potential for damaging respiratory health (Terzano, Di Stefano, Conti, Graziani, & Petroianni, 2010). l.U Carbo. monoxide (CO) An estimated 38 g, 17 g, 5 g, and 2 glmeal of carbon monoxide is discharged during household cooking using dung, crop residues, wood, and kerosene, respectively (Smith et aI., 2016). The levels of carbon monoxide will be determined extensively on the moisture content and the efficiency of fuel combustion. When CO is inhaled, it binds with hemoglobin in the blood fonning carboxyhemoglobin. High levels of carboxyhemoglobin leads to poor oxygenation of the cells in the body. 14 University of Ghana http://ugspace.ug.edu.gh The acute health effects of CO exposure comprise dizziness, headaches, nausea, and feeling weak. A relationship between chronic exposure to carbon monoxide from cigarette smoke and coronary disease and fetal development has been noted (Penney & Howley, 1991). 1.4.3 Polyorgaaie aDd polyaromatie 'ydroearboDS (pA H) Polyaromatic hydrocarbons include a large class of compounds released during the incomplete combustion of organic matter. Benzopyrene is noted to be the most carcinogenic in this group of compounds associated with cancer (Ba et aI., 2015). P AHs are stimulated by the hepatic microsomal enzyme system to carcinogenic forms that bind covalently to DNA (prasad, Singh, Garg, & Giridhar, 2012). A study by the National Institute of Occupational Health showed that the indoor levels ofPAH (total) in air during use of dung, wood, coal, kerosene, and LPG were 3.56, 2.01,0.55,0.23, and 0.13 Ilg/m3, respectively (prasad, Singh, Garg, & Giridhar, 2012). These P AHs include fluorine, pyrene, chrysene, benzoanthracene, benzoperylene, and indenopyrene. It does differ significantly (p < 0.05) for cooks using open outdoor kitchens as emissions are dispersed more outdoors (Prasad et aI., 2012). Therefore, cooks using an open outdoor kitchen have less exposure than cooks using an enclosed kitchen. 15 University of Ghana http://ugspace.ug.edu.gh 3.0 METHODOLOGY 3.1 Overview This section presents the methods used in the study. It gives descriptions of the study area, study design. study procedures, data collection tools as, data analysis as well as ethical considerations. 3.2 Study Area Chorkor is a fishing community and situated in the Accra Metropolitan Assembly in the Greater Accra Region of Ghana. According to the 20 I 0 population census, Chorkor has a population of 344.627 and an average growth rate of 6.0% per annum. It is a Ga community with the largest ethnic group in the area being the Ga-Dangme. A major source of employment for the inhabitants of Chorkor is fishing along the coast of Accra. Chorkor covers a total land area of 173 km2• It shares boundary with the Gulf of Guinea, to the south, which stretches from Gbegbeyese to La. To the east. the assembly shares boundary with the Ledzokuku-Krowor Assembly. The Ga East and G,W' e" ~ on 'he Northern and Western fron';", ~l~;< (A::~::5r . "'~., \ ,~ I . '\ -""" ~f.~,~ ~_ ~ .;. .. '.~ ._ __ IiIAiL, . . ~:. .. ~>: .....·1 1 « 'nt Figure 3.1: Map of the study area 16 University of Ghana http://ugspace.ug.edu.gh 3.3 Study Design An analytical cross-sectional study was carried out from May to July 20]7 to assess the respiratory health among Ga-kenke,y makers at Chorkor in the Accra Metropolis. This was carried out by conducting an interview with a semi-structured questionnaire to collect data on participant's sociodemographic characteristics, factors that influence their choice of biomass fuel, characteristics of the cooking environment and respiratory symptoms they experience as part of their work. An interpreter was employed to facilitate translation of the questionnaire which was be in English to the local Ga language. This was followed by conducting a lung function test by a professional (Medical Doctor) using a spirometer. 3.4 Variables of iDterest DepeDdeDt Variables- Measures of Pulmonary function (e.g. FEV!, FVC and FEVIIFVC) Respiratory symptoms including cough, phlegm production, cold, sore throat, breathlessness, chest pain. wheezing. itchy ear, eyes and throat, chest tightness and difficulty in breathing. IDdepeDdeDt Variables - -Individual Factors: Age, sex, weight, height, educational level, smoking status, duration of exposure, work experience and past medical history of respiratory disease. 17 University of Ghana http://ugspace.ug.edu.gh The covariates include age, educational level, home exposures example use of same source of BMF for cooking, use of mosquito coils and kerosene lamps and respiratory condition such as asthma. 3.5 Study Procedures Ethical clearance was obtained from Ghana Health Service Ethics Review Board to undertake the study for questionnaire administration and clinical examination. The pre-designed questionnaire was pretested among Ga- Kenkey makers at Madina. The research was explained, clearly, to all participants. The pretested questionnaires were administered by both the researcher and trained research assistants in the language the participant best understood, after their consent is obtained. The questions to be answered was on respiratory health, kitchen characteristics, duration of work and the other exposures to smoke. The Principal Researcher who is a clinician carried out a clinical examination of the participants. Their pUlmonary indices were measured using a portable spirometer. The participant performed the spirometry maneuver for at least three intervals to meet reproducibility criteria and the best effort was used for the analysis. 3.6 Study POpaiatiOD The study population was the entire women who make Ga- kenkey at Chorkor, a suburb of Accra in the Greater Accra Region, Ghana. 18 University of Ghana http://ugspace.ug.edu.gh 3.7 Eligibility Criteria As many women as available who fit the inclusion criteria and gave their consent were purposively sampled to be part of the study. 3.7.1 IaclDsion criteria: • Adult (18 years Or older). • Occupation was Ga- Kenkey making for a period of at least 6 months 3.7.2 Exclusion criteria: • Not willing or able to understand or comply with study procedures • Only a Ga-A:enkey seller • Use of clean fuel • No previous and current history of smoking • No medical history of pulmonary tuberculosis, flail chest and obvious skeletal abnormalities of the chest Males were not included in the study since Ga-A:enkey was a predominantly female occupation 19 University of Ghana http://ugspace.ug.edu.gh Figure 3.2: Ga-kenkey maker at work 3.8 Reeruitmentl Sampling Method The Principal Investigator together with the study team first approached the Ga- Kenkey makers through informal exchange of pleasantry prior to the data collection period. They introduced themselves and asked for Ga-Kenkey leaders and community volunteer. With the assistance ofthe community volunteer, translators and local community guides were employed to take the team round the community and familiarize the team with the Ga-Kenkey makers. The Ga-kenkey makers were informed of the study purpose, procedure and timeline for the data collection. 20 University of Ghana http://ugspace.ug.edu.gh Purposive sampling was used to select the 52 participants for this study. Ga- Kenkey makers who were available at the time of the data col1ection period and approved to participate in the study and met the inclusion criteria were recruited. 3.9 Spirometer A highly portable Spiro lab III diagnostic spirometry with oximetry option was used for the measurement of lung function (FVC, FEVI and FEV1IFVC ratio). The Spirolab III spirometer is a portable, easy to read and use, rechargeable, battery powered equipment with disposable mouthpieces. The advantages involve in using Spirobab III include the fact that functions can be easily accessed using the high-definition color touchscreen; it provides a built-in high-resolution printer and the option to print on external printers using a USB connection and the full flow volume and volume time curves allow for inspection of maneuvers as you follow test-quality prompts on the screen. It can store up to 6,000 readings and can display up to 8 test results on the screen. 3.10 Data coUection Tools The data collection tool was a modified respiratory questionnaire, spirometer for measuring pulmonary function, a Seca stadiometer with an incorporated weighing scale for anthropometry. 3.11 Questionnaire The interview questionnaire was in five sections. The first contained the sociodemographic information of the study participant. The second focused on the respondent's work, with regards to issues such as their role and duration ofw ork. The third enquired ab.out respiratory symptoms and history of respiratory disease. 21 University of Ghana http://ugspace.ug.edu.gh to smoke The fmal focused on kitchen characteristics The fourth exp Io re d 0 th er exp osure . and environmental factors influencing their exposure. The questionnaire was piloted at Madina. 3.12 CliDieal EDJDination Clinical examination was performed by measuring the participant anthropometry and performing respiratory examination. 3.13 Anthropometric Measurement Anthropometric measurements were done using Seca stadiometer with an incorporated weighing scale. The participants' weight was recorded in kilograms (kg), whilst wearing their indoor clothes, but without their shoes. Their height was measured with their feet together, heels against the stadiometer, standing as tall and straight as possible, and recorded in metres (m). 3.14 Lung function measurement (Spirometry) Lung function measurements was performed according to the guidelines of the American Thoracic SocietylERS (1995). Standing height in meters and weight in kilograms was measured prior to the performance of the lung function test as measurement of stature is a requirement for the determination of the normal lung function and reference equations are grounded on stature (standing height) (Renstrmn, Andersen, Pedersen, & Madsen, 2012). The Leicester stadiometer was used to measure height of the participants in the standing position without shoes on and the shoulders in an upright position. After data entry, the participants were assisted to perform manouvres for measuring forced vital capacity, vital capacity and maximum ventilation volume. 22 University of Ghana http://ugspace.ug.edu.gh Computation of lung function volumes was based on variations in the height, age, sex and respiratory history of respondents. Participants with FEVIIFVC ratio < 0.70 were considered as having reduced pulmonary function. 3.1S QuaUty Control Research assistants and translators were adequately trained and supervised to help carry out the study. The principal researcher was actively involved in and supervise the data collection procedures to ensure that there will be no deviation from the protocol. The purpose and nature of the study was disclosed to the participants. All the completed questionnaires were given a unique identification number in order to trace every information. Every document was handled and stored in a safe and confidential manner. All the data sheets were signed and filed by the appropriate research assistants. The data was stored on an external storage device and access to the information was restricted to the principal investigator alone. 3.16 Data Maaagement 3.16.1 Data Processing Each questionnaire was coded, for example 00 I, 002, 003, etc. to help prevent double entry and easy verification of any observed anomaly. nata was entered and analysed using STATA software version 14. 3.17 Statiatieal Aoalysis Means, standard errors, standard deviations, ranges, percentages as well as p-values were used in describing the data obtained. 23 University of Ghana http://ugspace.ug.edu.gh Socio-demographic data obtained was presented in frequencies and percentages in a table. The prevalence of both respiratory symptoms was presented in percentages. Graphical representation of data was done to improve cJarity of data. Chi square was carried out to compare variables across categories. P-values <0.05 was considered as statistically significant. Correlational analysis was done to determine the relationship between exposure to BMF smoke and respiratoryl pulmonary function. 3.18 Etbical wues Ethical Clearance was pursued from the Ghana Health Service Ethical Review Committee afore the study. Permission was further obtained from the participants before the study. The relevance and nature of the study was explained to the participants, and their consent obtained before they are enrolled into the study. They were also informed that they could opt out of the study at any point if they wish to do so. The participants were assured of confidentiality and this was ensured during the data collection and processing. Participants with impaired pUlmonary function found during the study were duly notified and upon discussion referred to the appropriate specialist health facility for further investigation and management. 24 University of Ghana http://ugspace.ug.edu.gh 4.0 RESULTS 4.1 Socio-demograpbie ehaneteristic:s of participants The socio-demographic characteristic of study participants is shown in Table 4.1 below Table 4.1: SociCHIemographie eharaeteristic:s of Ga-Kellley makers (D=52) CII ....e teristics of Study Partidpants Frequency (N=52) Pen:eDtage (%) Age (years) 20-29 7 13.46 30-39 16 30.77 40-49 15 28.85 >49 14 26.92 Ge.der Female 52 100 Marital Statu Single 12 23.08 Manied 24 46.15 Divorced 6 11.54 Widowed 10 19.23 Highest level ofEdueatioD None 16 30.17 Primary 15 28.85 MiddlelJHS 17 32.69 25 University of Ghana http://ugspace.ug.edu.gh 7.69 SBSlVocationaI 4 Duration orworkiDg 4 7.69 6months-l year 15.38 2years-3years 8 9.62 4years-5years 5 >5years 35 67.31 Duration or eookiDg 2-3hours 25 48.08 4-5hours 13 25.00 5-6hours 14 26.92 Number or days per week 3 5.77 4 10 19.23 5 13 25.00 6 18 34.62 7 8 15.38 A total of 52 healthy females who were able to complete three acceptable spirograms were used in the study. Among the 52 participants enrolled, the ages ranged from 22 to 66 years with a mean age±SDof41.87±ll.11 years. The height also ranged from 149 to 168cm with a mean height ±SD of IS8.88±5.llcm. Body weight ranged from 51 to 118kgwith a mean weight:t::SD of 74.17± 16.86kg. Body mass index (BMI) also ranged from 19.43 to 48kgm-2, with a mean BMl of 26 University of Ghana http://ugspace.ug.edu.gh 29.67±6.69. All participants were females and non-smokers. Forty-six (46.15%) of participants were married (46.15%). Only 4 (7.69%) had had education beyond middle/JHS levels. More than halfof the participants, 35(67.31 %) have been making Ga-Kenkey for more than 5 years and spend a mean duration of2.79±SD 0.85 hours in cooking. Pie Chart of Type of Fuel used by participants 1_ Charcoal _ Wood/Firewood Figure 4.1: Type of Fuel used by participants Of the 52 participants, 36 (69.23%) used firewood as their source of biomass fuel. Majority of the participants, 36 (75.00%) had a special place allocated for making the Ga- KenNL -ty. G a- nv. .enNL_tY was prepared either in an open space 26 (50%) or enclosed area 26 (50%). 27 University of Ghana http://ugspace.ug.edu.gh 4.2 Chrome Respiratory Dlnesse8 ill G. . XDIkey maken The participants recruited for the study were asked whether they have been diagnosed of any chronic respiratory illness. Only 2 (3.85%) answered in the affinnative of being diagnosed of asthma and confumed by a medical doctor. One participant's said hcrchronic respiratory condition got exacerbated due to her work as a Ga-Kenkey maker. Table 4.2: Respiratory health among Ga-KeIlUy maken Variable Yes No Total Chronic Respiratory Illness 2 50 52 Diagnosis by Doctor 2 50 52 Illness made worse by work 51 52 4.3 Prevalence orRespintory Symptoms Prevalence of respiratory symptoms experienced by the Ga-kellkey makers within the last 3 months is presented in Jl'lpre 4.2 below. Most Ga-Kenkey makers had high prevalence of itchy and watery eyes, 40 (76.92%); itchy ears and throat, 32 (61.54%); prolonged or repeated sneezing 30 (57.69%) and colds, 29 (55.77%). However, symptoms such as sore throat, wheezing, skin irritation as well as shortness of breath were not commonly experienced. 28 University of Ghana http://ugspace.ug.edu.gh 76.92 80 70 60 ~50 ;::40 z: 30 '-l UZO ffi 10 Q,. 0 .;-q, ,," 'F",r.., e'-~ 0" ~ 11.4.11." #<'0 <;-11,. ," <.-pdce space space Itchy and watery Prolonced 5neezln8 Itchy ears and throat Colds eyes 69.23 76.92 76.92 • Ye.., 42.31 69.23 53.85 61.54 53.85 38.46 46.15 38.46 23.08 23.08 .No 5769 iIl.n 46.15 RfSPIRATORY SYMPTOMS .Yes .No Figure 4.5: Relationship between type of cooking space and Respiratory Symptoms 4.7 Mean values of Pulmonary Function of Participants The mean value::l: SO of the parameters FVC, FEV1, FVCIFEVI were 2.45L:1: 0.58L, 1.65L1s ± 0.48L1s and 68. 12s·1 ::I: 4.09 S·I respectively. (Table 4.3).22 (42.31%) of the participants had their FEVIIFVC less than 70.00s· l . Table 4.3: SlIlIfItIIIry ofm ean values ofp ulmonary Junction measures Pulmonary function parameters Mean±SD FVC(L) 2.45±0.58 FEVI (LIs) 1.65±O.48 FEVIIFVC rio) 68.12±14.09 32 University of Ghana http://ugspace.ug.edu.gh 4.8 Relationship betweeD age, duratioD of maldng Ga-kelrkq aDd resplratiOD indices (FVC, J'EVI aDd FEVI/FVC) The relationship among the study parameters was exploited using correlation analysis. Negative correlation was found between age as Ga-kenkey makers and FVC and FEV 1 pulmonary indices and was significant at 5% statistical significance level. Furthermore, positive correlation was found between duration of working and FVC; negative correlation between duration of working and FEVI and FVClFEVI pulmonary indices as presented in Table 4.4. However, the values were all not statistically significant. Multivariate regression analysis done revealed there was a negative association between age of participant and FVC and FEVl pulmonary indices. There was no significant association between duration ofw orking as a Ga-kenkey maker and pUlmonary function (PF). Table 4.4: Pearson's product moment co"eiation between age, d",ation of worlcing and plllmonary indices Variables Age DaratioD ofFVC FEVl FVCJ1i'EVl worldDIE Age 1.00 010.43* 1.00 DuratioD worJdng FVC -0.39* 0.15 1.00 FEVl -8.35* -0.19 0.69* 1.00 FVC/FEVl -0.07 -0.09 -0.23 -8.53* 1.00 *Significant at 0.05 level 33 University of Ghana http://ugspace.ug.edu.gh Table 4.5: Rellltiollship betweell dll1'Q/io1l ofw ork IIIIdp llbrlolltuy indices Pearson's Correlation p"'value Variables Coefficient (R) FVC Duration of work -0.152 0.281 FEV} Duration of work -0.194 0.169 FEVIIFVC Duration of work -0.068 0.631 Table 4.6: Association between duration ofw ork and FVC (L) among Ga-kmkey maken ad respiratory function (n=52) Variable Correlation Coefficient 95% CI p- value (R) Age -0.204 -0.036,-0.005 0.010 Duration of work 0.009 -0.158,0.177 0.912 34 University of Ghana http://ugspace.ug.edu.gh Table 4.7: AssociatiOD betweeu duratiou of work aud FEVI (lis) amoug Ga- kmkey maken ad respiratory (uudiou (a=52) Correlation Coefficient 95% CI p-vaJue Variable (R) Age -0.0]4 -0.027,-0.001 0.031 Duration of work -0.025 -0.167,0.116 0.072 Table 4.8: Association between duratiou of work aud FVCIFEVl (%) amoug Ga-lellkey maken aDd respiratory faDdiou (0=52) Variable Correlation Coefficient 95% CI p-value (R) Age -0.056 -0.457,0.346 0.781 Duration of work -0.688 -5.105,3.729 0.756 3S University of Ghana http://ugspace.ug.edu.gh 5.0 DISCUSSION 5.1 Sammary of Main Findings The study assessed BMF use and respiratory health among Ga-kenkey makers at Chorkor, a community in Greater Accra Region. The frequently of self- reported respiratory symptoms among the Ga-kenkey makers included colds, prolonged sneezing, itchy ears and throat and itchy and watery eyes. There were few cases of sore throat and skin irritation. There was a negative correlation between age and pulmonary function (PF) indices (FVC and FEV). The duration of working as a Ga-kenkey maker did not significantly impact on PF indices. The power of the study was however low to identify any remarkable effect. 5.l Methodologic:aJ validity To the best of my insight, this is the first study to assess associations between occupational BMF smoke exposure and lung function indices among traditional food processors. The study was a cross-sectional study limiting the ability to determine causality. Questionnaire administration was administered objectively as well as spirometry to minimize information bias. Confounders such as smoking and use of clean fuel were controlled for during the questionnaire administration. Language barrier was a principal challenge in the study. Most of the inhabitants of the community spoke and understood mainly Ga, a local Ghanaian dialect not understood nor spoken by the researcher. A native Ga was engaged to assist with interpretation of the questionnaire and general communication to overcome this obstacle. The study was under-powered due to the sma)) sample size debarring detection of significant effect of the study. 36 University of Ghana http://ugspace.ug.edu.gh 5.3 Exposure to biomass fuel and respiratory symptoms Chronic occupational exposure to BMP smoke has been associated with increased respiratory symptoms and decreased PF (Adewole, Desalu, Nwogu, Adewole, & Erhabor, 2013).The use of BMF can be ascribed to the fact that BMPs are the inexpensive and most available sources of energy in most parts of Africa. The role of socioeconomic status as a basis of the type of cooking fuel used in the household has been reported in other studies in developing countries (Mchopa, Kazungu, & Moshi, 2014).The age of the Ga-A:enA:ey makers ranged from 22-66 years, with low level of education. The final process of cooking kenkey with BMF averaged of2-3hours a day. In a household study conducted among women in Nepal with similar objectives revealed the mean (standard deviation) age of36.I years (16.7 years), SO.4% of the respondents involved in the study were married and 52.4% had low or no education (Shrestha & Shrestha, 2005). The study found the commonly self-reported respiratory symptoms among the Ga-Kenkey makers were colds, prolonged sneezing, itchy ears and throat and itchy and watery eyes. While studies done to assess the relationship between indoor pollution due to use of BMF and PF/respiratory symptoms available (Jaakkola & Jaakkola, 2006; Mudway et aI., 2005), there are few from Africa. For example, in a study done in Nigeria. Adewole et al. (2013) compared respiratory symptoms among women who used BMF for cooking to non- BMF users. They found a greater self- reporting respiratory symptoms among the women who regularly used BMF. The commonly reported respiratory symptoms included cough (13.7%); wheezing (8.7%); chest pain (7.5%); breathlessness (1I.S%); nasal symptoms (9.3%); and chronic bronchitis (10.6%). Also, Regalado et aI. (2006) determined pulmonary symptoms in women exposed to BMF smoke in Mexico. The study revealed statistically significant association between age of women and adverse respiratory symptoms on exposure to BMF smoke. 37 University of Ghana http://ugspace.ug.edu.gh Other studies done have not found a relationship between exposures to BMF smoke and respiratory symptoms (ElJegArd, 1996; Maier, Arrighi, Morray, Llewellyn, & Redding, 1997). The present study found a moderately significant decline in FEVIIFVC (68.12%) among the GaKenkey makers. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) standard of FEVIIFVC < 0.70 for obstructive disorders has been implemented as an epidemiological principle by the Burden of Obstructive Lung Disease (BOLD) initiative and the Latin-American Project for the Investigation of Pulmonary Obstruction (Guide & Copd, 20 I 0). This result is consistent with previous studies that have found a relationship between the use of biomass fuels used for cooking and a decrease in FEVIIFVC function. The decline in the lung function in biomass fuel users may be due to the chronic breathing of particulate matter and toxic gases produced during biomass combustion leading to inflammatory changes and is indicative of obstructive type of lung disorder (Mangat, Dashora, Singh, & Chouhan, 2013). In a study conducted in Nigeria on association between household air pollution from BMF smoke exposure and pulmonary dysfunction in rural women and children; the percentage predicted values of pulmonary function parameters FVC78.63±1O.99; FEVI 69.78±16.58 and FEVIIFVC ratio _ 74± 13 were significantly reduced in the biomass exposed women (Oluwole et al., 2013). Comparative reviews have established an association between reduced values of pUlmonary indices, airflow obstruction and chronic exposure to BMF smoke (Orozco-Levi et aI., 2006; Rabe et aI., 2007). A study done in Ekiti state found that all the pUlmonary indices assessed were lower in women using BMF compared to nonBMF users (Desalu, Adekoya, & Ampitan, 2010). The regression analysis results revealed no association between working as a Ga-kenkey maker over the years and reduced pulmonary indices. The lack of significant association observed may be due to inadequate sample size used for the study. 38 University of Ghana http://ugspace.ug.edu.gh 6.0 CONCLUSION AND RECOMMENDATIONS 6.1 CODclusioD In conclusion, this study demonstrated that the commonly self-reported respiratory symptoms among Ga-kenkey makers included colds, prolonged sneezing, itchy ears and throat and itchy and watery eyes and reduced pulmonary function indices (FVC, FEV J and FEVJ/FVC). However, there was no significant statistical relationship between duration of work as a Ga-kenkey maker and lung function parameters among the study participants. 6.2 RecommeDdatioD There is the need for a study with larger number of participants which uses exposure assessment tools for measuring indoor emissions and personal exposures and biomarkers to help establish significant associations with exposure to BMF. This will help in the education and advocacy for the use of clean fuel for cooking. 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PLoS Medicine, 4(1), e20. bttp:lldoi.orgll 0.137 Jljoumal.pmed.0040020 Liu, G., Zou, H., Luo, T., Long, M., Bian, J., Liu, X., .. , Liu, Z. (2016). CaspaseDep~de~t and Caspase-Independent Pathways Are Involved in CadmiumInduced Apoptosls m PrimaJY Rat Proximal Tubular Cell Culture. PloS One, 11(11), e0166823. http://doi.org/I0.137J1joumal.pone.0166823 Mishra, V. K., Retherford, R. D., & Smith, K. R. (1999). Biomass cooking fuels and prevalence of tuberculosis in India. International Journal of 17ifectious Diseases: IJID: Official Publication of the International Society forInjectiousDiseases,3(3),119-29. Retrieved from bttp://www.ncbi.nlm.nih.gov/pubmedll0460922 Naeher, L. P., Brauer, M., Lipsett, M., Zelikoff, J. T., Simpson, C. D., Koenig, J. Q., & Smith, K. R. (2007). Woodsmoke Health Effects: A Review. Inhalation Toxicology, 19( I), 67-106. bttp:lldoi.orgllO.1080/089583 70600985875 Ngahane, B. H. M., Ze, E. A., Chebu, C., Mapoure, N. Y., Temfack, E., Nganda, M., & Luma, N. H. (2015). Effects of cooking fuel smoke on respiratory symptoms and lung function in semi-rural women in Cameroon. International Journal o/Occupational and Environmental Health, 21(1), 61--65. bttp:l/doi.org/lO.1l7912049396714Y.0000000090 OWUSU BOADI, K., & KUlTUNEN, M. (2006). FACTORS AFFECTING TIIE CHOICE OF COOKING FUEL, COOKING PLACE AND RESPIRATORY HEALTH IN TIIE ACCRA METROPOLITAN AREA, GHANA. Journal ofBiosocial Science, 38(3), 403. http://doi.orgll0.1017/S0021932005026635 Penney, D. G., & Howley, J. W. (1991). Is there a connection between carbon monoxide exposure and hypertension? Environmental Health Perspectives, 95,191-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedlI821371 Perez-Padilla, R., Perez-Guzman, C., Baez-Saldafia, R., & Torres-Cruz, A. (2001). Cooking with biomass stoves and tuberculosis: a case control study. The International Journal of Tuberculosis and Lung Disease: The Official Journal of the International Union against Tuberculosis and LU17g Disease, 5(5), 441-7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedll1336275 Po,. J. ~. T .• FitzGerald, J. M., & Carlsten, C. (2011). Respiratory disease associated with sohd ~Iomass fuel exposure in rural women and children: systematic review and meta- analYSIS. Thorax, 66(3), 232-239. http://doi.orgllO.l136/thx.201 0.147884 43 University of Ghana http://ugspace.ug.edu.gh Prasad, R, Singh, A., Garg, R, & Giridhar, G. B. (20l2). Biomass fuel e~posure and respiratory diseases in India. Bioscience Trends, 6(5), 219-28. Retneved from http://www.ncbi.nlm.nih.gov/pubmedl23229] ]4 Ramanathan, V., Ramana, M. V., Roberts, G., Kim, D., Corrigan, C., ChWlg, C., & Winker, D. (2007). Warming trends in Asia amplified by brown cloud solar absorption. Nature, 448(7153), 575-578. http://doi.orglI0.1038/nature060]9 Regalado, J .• Perez-Padilla, R, Sansores, R, Ramirez, J. I. P., Brauer, M., Pare, P., & Vedal, s. (2006). The effect of biomass burning on respiratory symptoms and lWlg function in rural Mexican women. American Journal ofR espiratory and Critical Care Medicine, 174(8), 90 1-905. http://doi.orglIO.lI64/rccm.2005034790C Rehfuess, E., Mehta, S., & Priiss-Vstiln, A. (2006). Assessing household solid fuel use: multiple implications for the Millennium Development Goals. Environmental Health Perspectives, 114(3), 373-8. http://doi.orgl10.1289/ehp.8603 RenstnmJ, S. B. H., Andersen, C. S., Pedersen, C. H. B., & Madsen, F. F. (2012). Correct measurement of height is important when assessing lung function values. DANISH MEDICAL JOURNAL. http://doi.orgl2012;59(2):A4376 Saalia, F. K., Asante, N. D. N., & Kyeretwie, O. B. N. K. (2013). Evaluation and Design of a Steam Cooking Process for Ga-Kenkey Production, (Jul-2013). Retrieved from http://hdl.handle.netlI2345678915398 Seddon, J. A., Hesseling, A. C., Godfrey-Faussett, P., Fielding, K., & Schaaf, H. S. (2013). Risk factors for infection and disease in child contacts of multidrugresistant tuberculosis: a cross-sectional study. BMC Infoctious Diseases, 13, 392. http://doi.orglI0.1l86/147]- 233413-392 Shrestha, I. L., & Shrestha, S. L. (2005). Indoor Air Pollution from Biomass Fuels and Respiratory Health of the Exposed Population in Nepalese Households. International Journal of Occupational and Environmental Health, 11(2), 150-160. http://doi.orgllO.1179/oeh.2005.l1.2.l50 Singh, V., Garg, A., Rani, B., Maheshwari, R., & Prasad, M. (n.d.). Indoor Air Pollution & Its Impact on Public Health: A Review MAJOR AIR POLLUTANTS RELEASED FROM BIOMASS COMBUSTION. Smith, G. S., Van Den Eeden, S. K., Garcia, C., Shan, J., Baxter, R., Herring, A. H., ... Gammon, M. D. (2016). Air Pollution and Pulmonary Tuberculosis: A Nested 44 University of Ghana http://ugspace.ug.edu.gh Case- Control Study among Members of a Northern California Health Plan. Environmental Health Perspectives, 124(6). http://doi.orglJO.l289/ehp.l408166 Smith, K. R, Aggarwal, A. L., & Dave, R. M. (n.d.). AIR POLLUTION AND RURAL BIOMASS FUELS IN DEVELOPING COUNTRIES: A PILOT VILLAGE STUDY IN INDIA AND IMPLICATIONS FOR RESEARCH AND POLICY. Afmosyheric Enuironmenr, 17(1), 2343-2362. Sood, A. (2012a). Indoor Fuel Exposure and the Lung in Both Developing and Developed Countries: An Update. Clinics in Chest Medicine. http://doi.orglI0.1016/j.ccm.2012.08.003 Sood, A. (2012b). Indoor fuel exposure and the lung in both developing and developed countries: an update. Clinics in Chest Medicine, 33(4), 649-65. http://doi.orgllO.1016lj.ccm.2012.08.003 Sood, A., Kunni, O. P., Lam, K. B., Ayres, J. G., Organization, W. H., Sood, A., ... Basu, R. s. (2012). Indoor fuel exposure and the lung in both developing and developed countries: an update. Clinics in Chest Medicine, 33(4), 649-65. http://doi.orglIO.I 0 l6lj.ccm.20 12.08.003 Standardization of Spirom en y, 1994 Update. American Thoracic Society. (1995). American Journal of Respiratory and Critical Care Medicine, 152(3), 1107-1136. http://doi.orglJO.l164Iajrccm.I52.3.7663792 Straif, K., Baan, R., Grosse, Y., Secretan, B., El Ghissassi, F., Cogliano, V., & WHO International Agency for Research on Cancer Monograph Working Group. (2006). Carcinogenicity of household solid fuel combustion and of high-temperature frying. The Lancet. Oncology, 7(12), 977-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedlI7348122 Sultana, R., & Buggi, S. (n.d.). CO-RELATION OF PULMONARY FUNCTION TEST AND CHEST X-RAYS IN BIOMASS FUEL USER IN RURAL AREA OF SOUTH INDIA. rerzano, C., ~i Stefano,.F:, Conti, V., Graziani, E., & Petroianni, A. (2010). Air pollution ultrafme particles: toXICity beyond the lung. European Review for Medical and Pharmacological Sciences, 14(10), 809-21. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedl2I222367 J.~gzi, Y., Singh, S. P., Foster, J. E., Kubatko, J., Barr, E. 8., Fine, P. M., ... Mauderly, 45 University of Ghana http://ugspace.ug.edu.gh (2002). Health effects of subchronic exposure to low levels of wood smoke in rats. Toxicological Sciences: An Official Journal 0/t he Society o/Toxicology, 65( 1), 115-25. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedlI1752691 Torres-Duque, C., Maldonado, D., Perez-Padilla, R., Ezzati, M., Viegi, G., & Fo~ of International Respiratory Studies (FIRS) Task Force on Health Effects of BJomass Exposure. (2008). Biomass Fuels and Respiratory Diseases: A Review of the Evidence. Proceedings 0/ the American Thoracic Society, 5(5), 577- 590. http://doi.org/10.1513/pats.200707-100RP Vliet, E. D. S. van. (2016). No Title. Household Air Pollution Exposures and Respiratory Health Among Women in Rural Ghana. World Energy Outlook (2016). Chapter 15 -Energy for Cooking in Developing Countries ENERGY FOR COOKING IN DEVELOPING COUNTRIES Household Energy Use in Developing Countries. INTERNATIONAL ENERGYA GENCY Together Secure Sustainable Executive Summary, 419-420. Retrieved from www.iea.orglpublicationslfreepublicationslpublicationlcooking.pdf WHO. (2014). INDOOR AIR POLLUTION, HEALTH AND THE BURDEN OF DISEASE. WHO I Fuel for life: household energy and health. (2014). WHO. WHO I Household air pollution and health. (2016). WHO. Yen, Y.-F., Yen, M.-Y., Lin, Y.-S., Lin, Y.-P., Shih, H.-C., Li, L.-H., ... Deng, C.Y. (2014). Smoking increases risk of recurrence after successful antituberculosis treabnent: a population-based study. The International Journal 0/ Tuberculosis and Lung Disease, 18(4),492-498. http://doi.org/10.s5881ijtld.13.0694 Yurtlu, S., Saygl, A., Sanman, N., AlICI, E., YurtJu, ~., Ydmaz, H., & Dtlzglln, Y. (2012). Evaluation of Clinical and Functional Parameters in Female Patients With Biomass Smoke Exposure. Respiratory Care, 58(3), 424-30. http://doi.org/10.4187/respcare.01772 Zhang, J., Smith, K. R., KR, S., R, B., J, Z., I, Z., ... KR, s. (2003). Indoor air pollution: a global . health concern. British Medical Bulletin, 68(1 ), 209-225 http://dol.0 rg/1O.1093Ibmblldg029 . Zhao, Y:, W~g, ~., Aunan, K .• Martin Seip, H., & Hao, I. (2006). Air pollution and lung cancer nsks 10 Ch~a-e meta-analysis. Science o/The Total Environment, 366(2-3) 500-5 13.http://dOl.org/10.1016/j.scitotenv.2005. 10.010 ' 46 University of Ghana http://ugspace.ug.edu.gh 7.0 APPl:NDICES A. RESPONDENT INFORMATION CONFIRMATION Seperated 5- Widowed Smoldagltatu SMS lB. WORK ;l ... I What does your won 1. Making 2. Selling eDtails? ~_I_I lOWE 2 How IoDg have you 11. 6months- 1 year 2.2years- 3 years 3. beeD workiog? iLON 4years- 5years 4. > 5years 5. Other. .................... 3 How maay boon dll 1. 0-1 hour. yoo spead makiDl ~S 2. 2-3 hours. _key? 3. 4-5 hours. 4. 5-6 hours. 6. Other: 4 Bow maay days doyoll work ia • week? pYS t--- C.KITCHEN ' f.~r:: ' CHARAClERISTICS " ·,:\·;·~~i~ 47 University of Ghana http://ugspace.ug.edu.gh TOF I. What type of fuel ill 1. Electricity used for eooking? 2. Kerosene 3. Charcoal 4. Wood/Firewood 5. LPG 6. Natural Gas 7. Biogas 8. Straw/shrub/grass 9. Agricultural crop residue 10. Animal dung 11. Others ... .. , .... ,. ........ , ........ 2 Do you bave a spedal 1. Yes 2.NO SPL space for eookiDg tbe kenkey? I I I 1. Yes 2.NO Have you ever been diagnosed of oy cbronic respiratory illness? H yes, was it diagnosed by a 1. Yes 2.NO dodor? WOS 1. YES 2. NO 1. YES 2. NO 1. YES 2. NO 1. YES 2. NO 48 University of Ghana http://ugspace.ug.edu.gh 7. Easy tiredness EAT 1. YES 2. NO 1_1_1 8. Chestpaiu CHP 1. YES 2. NO 1_ 1_1 9. Sore throat STT 1. YES 2. NO 1_1_1 10. IBringiJag oat excessive BEP 1. YES 2. NO 1_1_1 P. .... 11. .tday ears and throat ffiT 1. YES 2. NO 1_1_1 12. ~ and watery eyes lAW 1_ 1_1 1. YES 2. NO 13. ~g WHE 1. YES 2. NO I_I~ 14. ~hortneu of breath SOB 1. YES 2. NO 1_1_1 IS. ~ in breathing Dm 1. YES 1_1_1 2. NO 16. ~Ja.t tiptaess 1. YES 2. NO I _1_1 CHT 17. ~Idn irritation or skiD disease 1. YES2. NO SIT 1_1_1 18 If you llD8Wered yes to any question pI- give detaiJa: 19. ~ theaesymptolDlstop SOT when you are away from your work place? 1. YES 2. NO I 1 1 SPIROMETRY DATA ENTRY SECTION Height Weight SPo2 FEV-I FVC FEV-IIFVC TEST GRADE 49 University of Ghana http://ugspace.ug.edu.gh Additional Test Comments: Thank you very much. We really appreciate your participation in this study. 50 University of Ghana http://ugspace.ug.edu.gh Appendix 2: Consent Form Title: Respiratory health among Ga-unuy makers in Accra Principal investigator: Yaw Barima Twam Qaa6fication: Bachelor of Medicine and Bachelor of Surgery Address: School of Public Health, University of Ghana, Legon. General information about the research This research is being conducted to collect data on the effects biomass fuel use on the respiratory health of Ga-unlcey makers in Accra. The use of biomass fuel for cooking is associated with the discharge of smoke formed by fine particulate matter, carbon monoxide and other toxic compounds which are released into the atmosphere. These compounds are deleterious to the human respiratory health when inhaled. The study is purely an academic research which forms part oft he researcher's work towards the award of a Master Degree in Occupational Medicine. Possible risk of discomfort There are no major risks associated with participating in this study. The procedures involved in this study are non-invasive and will not cause any discomfort to the participants. However, a few participants may experience dizziness during the lung function measurement. Description of level of research burden Study participants would be asked to answer a questionnaire, clinically examined and participate in a lung function test. Possible benefits There will be no direct benefit to the participants. However, the information given will guide government and other relevant agencies for any future interventions on biomass fuel use in Ghana. Confidentiality nata secarity All study recordin~s and field notes will be kept in locked files by the principal investigator. The field notes will be expanded and typed into computer files with secured pass codes Plans for record keeping . The study m~terials ~J~boratory data and results, questionnaires, inform consents) will not be JabeJe~ ~Jth participant's names but instead a unique identification number for each study pamclpant. S1 University of Ghana http://ugspace.ug.edu.gh Person responsible and phone number The person responsible for the data storage will be Yaw Barima Twum(Student) School of Public Health. University of Ghana, Legon. Mobile number: 0207260017. Voluntary participation and the right to leave the research Potential study participants will be told that participating in the study is entirely voluntary and that declining to enter the study, answer a question or tenninating the interview wi)) have no negative consequences. Contacts for additional infonnation Please caU the person responsible for this study Yaw Barima Twum, on 0207260017 if you have questions about the study. If you have any questions about your rights as a research participant or feel you have not been treated fairly, call the Institutional Review Board (IRB) of the Ghana Health Service administrator, Madam Hannah Frimpong on the telephone numbers 0243235225 or 0507041223 to seek further clarification or redress. Your rights as a participant This research has been reviewed and approved by the Ghana Health Service Ethical Review Board. If you have any further questions about your rights as a research participant, you may contact the chairman of the Board. Volunteer agreement The above document describing the benefits, risks and the procedures for the research title ("Respiratory health among Ga-/cen/cey makers in Accra") has been read and explained to me. I have been given the opportunity to ask questions and all the questions that I have asked about the research have been answered to my satisfaction. I agree to participate as a volunteer. ................................................ . .............................................. Date Signature or mark of volunteer If volunteers cannot read the fonn themselves, a witness must sign here: I was pre~ent while the benefits, risks and procedures were read to the volunteer. All questIOns were answered and the volunteer has agreed to take part in the research . ........................................... .. ............................................ . Date Signature of witness 52 University of Ghana http://ugspace.ug.edu.gh I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this research have been explained to the above individual. Date Signature of persons who obtained consent 53 University of Ghana http://ugspace.ug.edu.gh GHANA HEALTH SERVICE ETHICS REVIEW cOMMI1TEE ... In case ofr eply the ..........~ !"~. .. Research & Development DIvIsIon number and date oft his /",// 1" "-L. Ghana Health Service leiter should be quoted. ~ ( ~_\. ) ~ ~~;aBOX MB 190 Tel: +233-302-68/l09 Fax + 233-302-685424 MyRef GHSlRDDIERCIAdminiApp /51 ':).. Email: ghserc@gmail.com Your Ref No. Twum Barima Yaw University of Ghana School of Public Health Legon, Accra The Ghana Health Service Ethics Review Committee has reviewed and given approval for the implementation of ~'Our Study Protocol. i GHS·ERC Number GHS·ERC: 13/03/17 • Project Title Respiratory Health among Ga-Kenkey Makers in Accra IA pproval Date 10111 May, 2017 Expiry Date 9m May, 2018 . GHS-ERC Decision Approved This approval requires the following from the Principal Investigator Submission of yearly progress report of the study to the Ethics Review Committee (ERC) Renewal of ethical approval if the study lasts for more than 12 months, Reporting of all serious adverse events related to this study to the ERC within three days verbally and seven days in writing. Submission of a final report after completion of the study Informing ERe if study cannot be implemented or is discontinued and reasons why Infonning the ERC and your sponsor (where applicable) before any publication of the research findings. Please note that any modification of the study without ERC approval of the amendment is invalid. !he ERC may observe or cause to be observed procedures and records of the study during and after Implementation. Kindly quote the protocol identification number in all future correspondence in relation to this approved protocol ~ SIGNED ......... q>..~.~ ............................. . DR. CYNTHIA BANNERMAN (mIS-ERC CHAIRPERSON) Cc: The Director. Research & Development Division. Ghana Health Service. Aecra