Examining Ethical Tensions Inherent in Non-Communicable Diseases Prevention Interventions in Ghana.

Abstract

Background: Non-communicable diseases (NCDs) account for 71% of global deaths, raising concerns about their classification as "non-communicable," given some can spread through social network. In low- and middle-income countries, factors like dietary shifts to processed foods and declining physical activity contribute to the rising NCD burden. In Ghana, policies such as the Framework Convention on Tobacco Control (FCTC) and the National Alcohol Policy aim to combat NCDs. Recent initiatives, including the Food-Based Dietary Guidelines for Ghana (2023) and a sugar-sweetened beverages tax, reflect efforts to address these health challenges along nutrition lines. However, as interventions like the Healthier Diets for Healthy Lives (HD4HL) intervention seek to create a policy bundle addressing food marketing, labelling, and public procurement, ethical tensions around health initiatives and the rights of individuals in making dietary choices among others emerge. Ethical tensions, defined as decision making situations where one must choose between two or more moral imperatives, none of which are clearly adequate (ten Have et al., 2012), arise in NCD prevention efforts. This study aims to explore these ethical dilemmas within the context of Ghana's NCD prevention initiatives, using the HD4HL intervention as a case study. Objectives: To evaluate the ethical dimensions of the HD4HL NCD prevention intervention in Ghana by focusing on tensions in its policy bundle. Methods: The data for this study were sourced from three secondary documentary materials of the Healthier Diets for Healthy Lives (HD4HL) intervention in Ghana: (1) the technical proposal, outlining objectives and policy strategies (HD4HL Technical Proposal, 2022); (2) the project framework, detailing the conceptual structure and implementation pathways (HD4HL Project Framework, 2022); and (3) the guiding principles, articulating the intervention’s foundational values (HD4HL Guiding Principles, 2022) (Available on publicly on project website). These documents were selected as they comprehensively represent the HD4HL policy bundle on food marketing, labelling, fiscal policies, and public procurement. Data analysis utilized normative content analysis within a qualitative research design, guided by the ethical framework of ten Have et al. (2012), titled "An ethical framework for the prevention of overweight and obesity." In Part I, document content was systematically coded against the framework’s reflective questions, mapping text segments to eight ethical values (e.g., liberty, equality). For example, sections on fiscal policies were coded for “equality” to identify potential disproportionate impacts. In Part II, coded themes were evaluated to identify ethical tensions, such as autonomy versus health promotion, using a matrix to categorize unique and shared tensions. An audit trail ensured transparency, with iterative cross referencing to resolve ambiguities. Results: The research reveals 12 unique ethical tensions within the HD4HL food policy bundle. Key among them include tensions between economic impact and equality, as taxes on unhealthy foods disproportionately affect low-income groups. Ethical concerns include balancing transparency with anxiety, as nutritional labels can stress certain consumers. Unequal access to information due to literacy levels, and misleading marketing practices that exploit label trust, are also issues. Tensions between cultural sensitivity and standardized nutritional guidelines may exclude culturally specific foods. Relying on public institutions for healthy food reduces personal responsibility, while healthy eating policies may stigmatize overweight persons. Conflicts between health promotion and cultural values arise when advertising restrictions clash with cultural values. Tensions also include balancing corporate responsibility with consumer accountability and limiting individual freedom through strict regulations. Common ethical tensions across the food policy package include struggles with equality and accessibility, informed choice vs. perceived autonomy, and cultural sensitivity vs. standardized health goals. Privacy concerns related to data collection for policy monitoring also present ethical challenges. Conclusion: While the HD4HL intervention promotes health, it risks infringing on personal choice and cultural autonomy, especially in lower-income communities. In settings where high-calorie, processed foods are common due to affordability, policies may limit individuals' freedom without fully addressing the root causes of unhealthy diets, such as food deserts or economic barriers