Many countries in sub-Saharan Africa including Ghana are currently faced with a double burden of malnutrition. On one end of the spectrum is undernutrition and related communicable diseases. The other end of the spectrum shows increasing prevalence of over nutrition and diet-related chronic diseases, and their associated deaths. Overweight and obesity are also common and it is possible to find overweight/obese adults with micronutrient deficiencies [1]. Cardiovascular diseases (CVD), including coronary heart disease (CHD), stroke and heart failure, are associated with 16.7 million deaths in the world every year [2], with 80% of all CVD deaths occurring in developing countries [3]. In Ghana, the national prevalence of hypertension was estimated at 28.7% [4]. Heart diseases and diabetes are on the rise in the region and figures for hypertension show levels ranging from 3% in rural areas to more than 30% among urban dwellers [4]. Over 80% of the diabetics are of type 2, the form associated with obesity and physical inactivity. The WHO predicts increases in deaths from chronic diseases in low- and middle-income countries such as Ghana by 2030 [3].

Generally, dietary patterns characterized by high intake of fatty foods and refined carbohydrates, and a low consumption of fruits and vegetables are commonly reported to be strongly associated with metabolic risk factors for Cardiovascular Diseases (CVDs) and other chronic diseases [1, 5]. Referred to as the nutrition transition, increased sedentariness and a shift in patterns of dietary intake towards more westernised foods [6], characterised by increased intake of saturated fat, salt and refined foods and decreased fruits, vegetables and fibre intake have been reported in many developing countries [7, 8]. The nutrition transition has also contributed to an epidemiological transition characterised by increasing incidence of diet-related chronic diseases [9]. In Ghana, where the percentage of adults who consume sufficient amounts of fruits and vegetables is less than 5%, increased consumption of foods high in fats, sugars and salt is a major contributor to the increasing prevalence of CVD currently observed [10]. Thus, although the threat of undernutrition remains, the observed trend shows that diet-related chronic disease incidence and its consequences require national interventions.

The changing pattern of dietary intake and lifestyle is spurred by urbanization, liberalisation of market and trade (especially in foods), physical inactivity and demographic shifts [11–13]. Consequently, international institutions, non-government agencies and academics have recommended the use of trade policy tools in food policies designed to improve the healthfulness of the food supply [14, 15]. Recommendations include the use of food composition standards, reducing import tariffs on fruits and vegetables, maintaining high tariffs on unhealthy food imports and reducing imports of unhealthy foods.

The importation of cheap fatty cuts of meat has been identified in Africa and the Pacific as a contributor to both poor health (due to high fat intakes) and agricultural under-development [16, 17]. Research in the Pacific has documented policies banning imported fatty meat products [18]. However, an ongoing challenge has been the development of non-discriminatory food policy tools that are consistent with international trade commitments. In the early 1990s, the Government of Ghana implemented an innovative policy to limit the amount of fat in meat products (both imported and domestically produced) in order to protect human health [19]. The policy sets the standards for fat content in meat at 25% or less for pork, mutton and beef, and 15% or less for poultry. To date, however, the only products banned under the standard have been imported turkey tails and chicken feet. In August 2013, a study to evaluate the process, outcomes and lessons learned from this innovative policy was carried out. Case study research and policy analysis methodologies were used to evaluate the policy, which enabled in-depth assessment of the policy process and outcomes in Ghana, while enabling maximization of the usefulness of the case study for policy learning in other contexts. Based on the ‘health policy analysis triangle’, data on the process (agenda-setting, policy development, implementation), context, content and actors (local and international) for the policy as well as the policy outcomes were collected [20].

Findings of this evaluation showed that the policy had led to reduced availability of ‘low quality’ meats, especially turkey tails and chicken feet, which were mostly imported in the Ghanaian food supply [20]. It was expected that the reduction in ‘low quality’ meat availability would lead to consumption of ‘healthier’ meat types, especially the locally-produced ones, since these were deemed to have lower fat content and formed part of the context for the implementation of the policy. However, questions regarding public awareness and perception of this policy, in terms of its implementation, enforcement and impact, as well as general attitude towards fatty meat, preference for, and consumption of different meat types remained unanswered. Little is known about the contribution of fatty meat to the Ghanaian diet and the landscape, including the extent to which fatty meat is still a problem, 20 years after the implementation of the standards on fatty meats. The aim of this paper is to determine public awareness, perceptions and attitudes towards the policy’s implementation, enforcement and impact. It also sought to assess the general attitude, preference and consumption of meat types by Ghanaian adults.

The policy evaluation study was carried out in August 2013, using in-depth assessment of the policy process and outcomes in Ghana, including agenda-setting, policy development, implementation, context, content and actors (local and international) for the policy as well as the policy outcomes [20]. Twenty-seven (27) semi-structured interviews were conducted with policy makers in Trade, Health and Agriculture; Implementers in Ghana Standards Authority, Ghana Food and Drugs Authority, Animal Extension and Customs Excise and Preventive Service (CEPS); Traders and importers; and Agricultural producers. Also, broad contextual questions regarding the historical trade policy context, changes in food prices and agricultural production, and the perceived effect of food imports on agricultural production were delved into [20].

Majority of the participants in this study were between 18 and 35 years old. The gender, age and occupational distribution of participants reflect the average adult Ghanaian. The average BMI puts the females as overweight and the males as normal weight. Although the females had a higher proportion of body fat, the fact that visceral fat in the males was higher reflect a higher tendency of intra-abdominal obesity in the males. Mean blood pressures were also higher in the males although both systolic and diastolic blood pressures were within the normal ranges for both gender. Combined, the study participants represented a generally healthy adult Ghanaian population.

The findings suggest that respondents’ awareness regarding Ghana’s trade-related standards policy that restricts meat importation based on fat content remains fairly high and attitudes towards the restriction  is positive, over two decades after the ban was implemented. About half of those interviewed were aware of the restrictions, although more than half thought the public was not aware and majority felt enforcement done is ineffective. There does not seem to be a lot effort to raise public awareness about this policy. A search of newspaper coverage of the restrictions in the early 1990s, when the restrictions were passed, showed little coverage on the restrictions in general and the ban on turkey tail. The relatively high awareness, however, may also reflect regular enforcement efforts, which included destruction of 1452 cartons of turkey tail imports in Kumasi in 2010 [22]. The fact that majority (60%) thought the restriction in the long-term could improve health, prevent disease and reduce death was reassuring.

The findings also showed a good attitude of participants towards fatty meat and this may be indicative of a general good attitude towards healthy eating. It did seem that there has been some effort to sensitize the public on the effect of high fat intake and diet related chronic diseases by the level of knowledge/perception of these respondents. Also, close to 70% said they considered the fat content of the meat they bought and all seemed to know the negative effects of fat on health. This good attitude could also be due to the increasing trends of non communicable diseases in the country [4], which are associated with the diet and lifestyles of people [23] and which have gained some attention in the country. However, it was not clear whether awareness of these issues had increased over time because of lack of earlier studies to compare our findings.

Among the meat types, half of the population consumed local beef compared to less than 20% consuming the imported version, while half of the population consumed imported chicken regularly compared to less than a third consuming the local version. The disparity between the consumption of beef and chicken is mainly because imported chicken is commonly available and cheaper than its local counterpart, while local beef is more commonly available and cheaper than its imported counterpart. The very low consumption of turkey tails reported in this survey (less than 3%) indicates that the restrictions have been effective in significantly reducing availability and consumption of turkey tail, which was banned as a result of the restrictions. This is contrary to perception of respondents’ that the restriction is not well enforced. For all the meat types, with the exception of pork, participants predominantly preferred the local to the imported. The reasons given for the preference were better taste, access/cost, freshness, healthiness and religion. These factors, among others are known to influence people’s food habits and choice [24]. These factors seemed to be interwoven in their effect on preference and consumption. Irrespective of whether it is local or imported, some participants chose their meat based on health reasons and for this group, perception as to which version is more or less healthy informed their preference. But looking at the interplay of the factors, it seemed that availability and cheapness were the ultimate determinants and drivers of consumption of meat products. Majority of participants said imported meat products were more available and cheaper but our findings showed the vast majority of participants interviewed preferred the local to the imported meat types due to better taste and healthiness. Therefore, the fact that consumption of imported chicken, pork and processed meat were higher than the local types, although the local types were preferred suggests that availability/cheapness drove consumption, and confirms the worry about the food environment becoming more obesogenic [25]. This is why public health policies which restrict access to unhealthy diet, thereby making the food environment healthier as part of a package of interventions for prevention of non communicable diseases are recommended [14, 15].

This study could not evaluate the impact of the fatty meat restriction on consumption of meat products, since data on consumption before the restriction was not available. Little is known about the contribution of fatty meat to the Ghanaian diet. Moreover, although the participants of this study were all adults, majority were between 18 and 35 years old, and thus a large proportion were not old enough to share their experience before and after the implementation of the policy, nor was it possible to evaluate the impact of the policy on their consumption of meat types. However, the policy was passed in response to concerns that fatty meat, especially turkey tail and chicken feet were commonly imported and available on the market. The policy analysis paper earlier published explains the contexts and content of the policy [20]. The overall effect of the ban has been to reduce availability of specific ‘low quality’ meats in the Ghanaian food supply, namely turkey tails and chicken feet [20]. It was useful to understand the landscape 20 years after the policy implementation. Is fatty meat still a problem? What is the nutritional situation in Ghana now? Is it possible that this policy has helped to minimize this aspect of the nutrition transition? It was expected that the reduction in availability may have influenced consumption of fatty meat products. The very low consumption of turkey tail from the present study findings supports this.

In conclusion this study showed appreciable awareness among Ghanaian adults regarding Ghana’s innovative trade policy, which restricts importation of meat and meat products based on fat content, two decades after implementation. There was a general good knowledge and positive attitude towards the restrictions and diet for health, reflected in preference for local meat types, which were considered to be healthier, tastier and fresher. However, consumption was driven more by availability and cheapness. Most respondents supported the restriction and were positive about the long-term positive effect of this policy on health and nutrition but thought the policy was not well enforced. There is therefore a call to improve enforcement and to implement other public health policies in order to make the food environment healthier and contribute towards preventing diet-related chronic diseases, which are on the rise in the country.