Food Security in Ghanaian Urban Cities: A Scoping Review of the Literature

Urbanisation in Ghana could be negatively impacting the state of food security, especially in economically vulnerable groups. Food supply, safety, and quality are all aspects of food security which could be impacted. We conducted a scoping literature review to understand the nature and magnitude of evidence available on the urban food security situation in Ghana. A literature search was conducted in Medline, CINAHL, Embase, Global Health, Scopus, Web of Science, Africa Wide Information and Google Scholar to identify relevant peer-reviewed and grey literature. 45 studies, mainly cross-sectional surveys/food samples analysis, met the inclusion criteria. The majority of studies were concentrated in the Greater Accra Region (n = 24). Most studies focused on food safety and quality (n = 31). Studies on supply and stability were, however, scarce. Qualitative research methods were uncommon in the included studies. The existing literature on food security are concentrated in two regions: The Greater Accra and Ashanti regions. Future studies exploring food security in urban Ghana should focus on exploring the lived experiences and perceptions of food insecurity and food stability by urban-dwellers using qualitative methods. The evidence suggesting that the safety/quality of foods sold in Ghanaian markets is poor should be a concern to consumers and policy makers.


Introduction
Currently, more than half of the Ghanaian population lives in urban areas [1]. Living in urban areas increases access to income-generating opportunities as well as infrastructure and services that improve quality of living. Such services may include potable water, electricity, health care, schooling, information communication technologies, and paved roads, among others [2]. However, rapid and unplanned urbanization can adversely affect human health and wellbeing. Without appropriate planning and interventions, urban areas can quickly become slums where a combination of poverty, inadequate and unsafe housing, and limited opportunities to access basic services can affect residents ability to access basic necessities of life, including availability, and access to quality food and water [1]. Ghana is Several studies in Ghana have highlighted the need for multi-sector interventions to address the complex interactions between food systems, and how they affect urbandwellers' nutrition (e.g., [18,[20][21][22]). However, currently, there is limited evidence on the scale of the food insecurity situation in urban Ghana, especially evidence around food supply, food access, safety/quality of food, and the utilization of foods among urban dwelling Ghanaians. A better understanding of the available evidence is needed to guide future research, and inform the development of context-specific interventions, in order to improve the food security situation in urban Ghana [23]. For this reason, this scoping review was conducted with the aim to identify and describe the literature on urban households' food security in Ghana, focusing on food supply, access, utilization, safety and quality.

Design and Setting
A scoping review of the literature on the urban food security research situation in Ghana was conducted. Daudt et al. [24] describe a scoping review as a 'type of research synthesis that aims to map the literature on a particular topic or research area, and provide an opportunity to identify key concepts; gaps in the research; and types and sources of evidence to inform practice, policymaking, and research'. This type of review is different from a systematic review, which aims to 'provide answers to questions from a relatively narrow range of quality assessed studies' [25]. This scoping review of urban food security in Ghanaian cities is intended as a basis for developing interventions that will aim to address food systems in urban Ghana and subsequently for other urban settings in Sub-Saharan Africa. To the best of our knowledge no scoping review has yet examined the literature on urban households' food security in urban Ghanaian cities, focusing on food supply, access, utilization, safety and quality.

Framework Guiding this Review
The framework defined by Arksey and O'Malley [25], updated by Colquhoun et al. [26], and further detailed in the Joanna Briggs Institute Reviewers Manual: Scoping Reviews [27] was followed in conducting this scoping review. The framework outlines five key steps to conducting a scoping review: (i) identifying the review question, (ii) identifying relevant studies, (iii) study selection, iv) charting the data, and v) collating, summarising and reporting results. Detailed description of how we applied the framework is presented as follows: Stage 1: Identifying the review question In this review, we sought to understand the extent of research conducted on urban food security on Ghana in order to determine the value of undertaking a full systematic review [25]. Thus, our review addressed the key questions "what studies currently exist in relation to urban food security in Ghana?" Stage 2: Identifying relevant studies We conducted searches in seven databases MEDLINE, EMBASE, CINAHL, SCO-PUS, Web of Science Core Collection, African-wide information, and Global Health, from June to July 2020, with an update search completed in July 2021. Google Scholar and websites of the Ministries of Health, and Food and Agriculture were searched for grey literature. Supplementary Materials Table S1 carried out included checking the reference list of included studies (backward chasing), and citation follow-up (forward chasing). These additional search efforts helped identify additional potentially eligible, published studies which were not captured earlier by the academic databases or grey literature sources. Authors in this field were contacted if full texts papers were not available, as well as to ask them for ongoing studies or any rejected manuscripts relevant to the review. Search terms were selected and developed in collaboration with our information specialist (VC) and used for each data base. Stage 3: Study selection All citations were imported into EndNote reference manager and screened for relevance. Two levels of relevant screening that best meet the review inclusion criteria were conducted after removal of duplicates citations. Guided by an inclusion and exclusion criteria (Box 1), three reviewers independently screened all titles and abstracts of the search outputs (HOK, EAA and EI). Discrepancies were resolved by a third reviewer and topic expert (RAO). Full texts of potentially qualified abstracts were downloaded and read by all reviewers independently based on the a priori inclusion criteria (Box 1), to select the papers that best addressed the review questions. To eliminate selection bias, a meeting was held to discuss the full texts which were listed as 'not relevant' by reviewers, where consensus was agreed. Box 1. Inclusion and exclusion criteria.

Inclusion criteria
We included studies/reports in the review if they;

•
Presents findings measuring the level of food security experience with respect to: food supply: includes information on food quantity produced, available within community from multiple vendors in urban settings Food access: includes information on ability to obtain food without hindrance in urban settings, e.g., price of food, household ability to afford food. Food quality/safety: includes information on quality of food with respect to contamination from heavy metals, microorganisms, plastic leaching, polycyclic aromatic hydrocarbons, visual contamination, unhygienic environment, including perceived poor hygiene. Food utilization: includes information on food consumption, food allocation at household level but all in the urban setting Food stability: includes information on food availability and access over longer duration, including effect of seasonality of food availability and access Perceived food security: includes information on scales for assessing food insecurity, including household food security access scale (HFIAS), food insecurity experience scale (FIES), other measures of perceived and experiences food insecurity as well as coping mechanisms Studies that did not meet the above criteria were excluded.
Stage 4: Charting the data Key data that were extracted included study reference details (country and year of study); study setting (urban); study target population or food samples studied (including sample size); study design; aspect of food security studied, outcomes that were measured, and key findings on food security. We coded the data in Microsoft Excel and thereafter, conducted a narrative synthesis. We then mapped the evidence against the food security aspects of interest in each included study. The findings are described and presented according to the key food security themes examined. This review does not address the methodological quality of included studies since that was not an aim of this study [26].
Stage 5: Collating, summarising, and reporting results Here, we have provided a summary description of the study selection process, a description of the study characteristics, including the geographical distribution of the included studies, the study designs the studies used, the population and/or food sample studied, and the sample size.

Results of Study Selection
Overall, a total of 3236 citations were retrieved, following the searches that were conducted from all sources. Altogether, 784 duplicates citations were excluded, leaving a total of 2452 papers to be screened. After titles and abstract level screening, 2326 citations were removed. The potentially eligible full texts (n = 126) were downloaded and read in full to ascertain their relevance. After this level of screening, 81 citations were excluded, leaving a final set of 45 citations to be included in the review. A summary of the screening process is illustrated in the PRISMA flow chart below ( Figure 1).  Table 1 summarises the characteristics of the included studies, and the aspect of food security that the studies have focused on. Overall, 45 (all peer-reviewed) studies were included in the review. The year of publication of the documents ranged from 2000 to 2021.

Characteristics of the Included Studies
The studies were all conducted in urban or peri-urban settings in Ghana. The distribution of the included studies by the geographical regions of Ghana are as follows; twenty-four studies in Greater Accra [20,, eight studies in Ashanti Region [51][52][53][54][55][56][57][58], three studies in the Northern region [22,59,60], and two studies each in the Central region [61,62], Western region [21,63], Eastern [64,65]. Volta [66] and Brong Ahafo [67] regions contributed one study each, while two studies were conducted in two or more regions [49,68]. There were no included studies from the Upper East and Upper West regions. The categories of participants or data units reported in the studies were farmers, street food vendors, restaurant, hotel operators, consumers at household level and on the streets, and foods and vegetables samples (see Table 1). The sample sizes stated in the included studies ranged from 21 (minimum) [20] to 7000 (maximum) [44] human participants, and 6 (minimum) [56] to 3486 (maximum) [36] food samples. Three studies [32,43,62] did not report sample size, and in terms of study designs, all 45 studies were cross-sectional surveys of consumers and or households, and food samples purchased and analysed in the laboratory.  Students' concern on food temperature as a food safety issue. Clean and hygienic eating tables as a key food safety concern and predictor of choice of eating place.

Domains of Food Security Studied
Five domains of food security that have been studied and reported in the literature included food access, food supply, food safety and quality, food utilisation, and perceived food security. Of the 45 included studies, food safety and quality were frequently studied (n = 31 studies), followed by food access (n = 8 studies), and food ulitisation (n = 7 studies). Fewer studies on food supply and perceived food insecurity were identified (Table 1). No studies on food stability were identified. The following sections presents the key results according to the aspects of food security area studied, as well as a summary of the evidence which could potentially be useful to Ghanaian policy makers.

Food Access
Food access information was reported in eight studies [21,31,32,50,51,57,61,66]. Two of these studies were conducted in the Ashanti region [51,57], one each in the Western region [21], Central Region [61], Volta region [66], and three in the Greater Accra region [31,32,50]. These studies largely examined the factors that consumers consider as crucial in making decisions to access food from their neighborhood. In the Volta and the Greater Accra regions, cleanliness of the local surroundings, where food is sold, and the hygienic nature of the food handler, plays a key role in consumer choice of food access [50,66]. For instance, one study conducted in the Volta region in Ho [66] examined diners' decision-making to eat at traditional catering establishments. In this study, factors such as cleanliness of the place, sanitation and hygiene, cleanliness of staff, quality of food, and service staff behaviour were identified as influencers of consumers decisions to access and patronise cooked food sold in their neighbourhoods [66]. Additionally, in the Greater Accra, Central and Western regions, secure food was explained in terms of convenience in accessing food, the availability of food in the local area, and the perceived quality or healthiness of the foods that are available and accessible [21,50,61]. The quantity and cost of the foods were the least worried factors consumers considered, with respect to food access. For examples, in the Central regional capital of Cape Coast, the factors that influenced the respondent's choice of food and place of eating were the surrounding environments where the food was sold and the cleanliness of the food handlers. Price of the food was less of an issue if the food environment was clean and tidy [61]. On the contrary, two studies from the Ashanti [51] and Western regions [21] revealed that, price of food and vendor's willingness to offer food on credit influenced consumer food access decision-making.

Food Supply
Food supply to urban areas depends largely on food type and seasonality, and usually arrives from multiple sources. In this review, we described food supply to include information on food quantity produced and is available within community from multiple vendors in urban settings (see inclusion criteria). In our search, we found only two relevant studies that reported on food supply in urbans areas in Ghana [22,50]. One study was conducted in Northern region [22], and the other in the Greater Accra [50]. The study in the Northern region, Karg et al. [22] indicated that most of the food supply in urban areas in Ghana are from small-scale suppliers, usually originating from rural areas. In the Greater Accra region, studies reported that limited food supply was observed in low-income households. For instance, in the study published by Nagai et al. [50], it was revealed that due to high prices of raw foods or their processing cost mothers of low socioeconomic status were unable to acquire/process baby weaning foods, e.g., weanimix-a nutritional meal designed for children who are newly weaned from breast milk-for their newly weaned babies.

Food Utilisation
Food utilisation was reported in seven studies [21,29,31,32,60,67,69]; three in the Greater Accra Region [29,31,32], one each in Northern [60], Western [21] and Brong Ahafo [67] regions. Authors of one these seven studies [69] did not indicate in which specific Ghana region the study was conducted. One of these studies (unspecific region) reported that skipping meals was common among the older age groups (50-64 years) compared to young adults or children [69]. In this study, 36% of the elderly were reportedly skipping meals because of lack of food in their households. In the study conducted in the Western region, the authors reported that energy-dense street foods were more frequently purchased and consumed by residents [21]. In the Sackey et al. [29] study in the Greater Accra region assessing food security and dietary diversity issues, fish compared to meat consumption was frequently observed. After following the study participants over time, the authors reported that the pattern of fish and meat consumption did not change. More people were consuming fish compared with meat consistently [29]. In another study in the Greater Accra region that examined urban household characteristics and dietary diversity, Dake et al. [32] reported that the low socio-economic class group were consumed less fruits and vegetables compared to their higher economic class counterparts. Similarly, Northern region, Saaka and colleagues [60] reported that women of low household wealth index were found to be 48% less likely to meet the minimum dietary diversity for women (MDD-W).

Perceived Food Insecurity
Perceived food insecurity was scarcely studied, with only five studies reporting on this domain of food security [29,30,49,65,69]. Of these studies, two studies were conducted in the Greater Accra region [29,30], and one from the Eastern region [65]. Two studies [49,69] were conducted in multiple urban cities. The study by Bannor et al. [49] was conducted in four different contrasting cities: The Greater Accra, Bono, Ahafo and Bono East Regions, but the remaining study [69] did not specify the particular urban cities or regions data were collected from. These five studies assessed perceived food insecurity at the household level, using different food security questionnaires/scales, including the Household Food Insecurity Access Scale (HFIAS) [29,30,49,65], the Food Insecurity Experience Scale (FIES) [49], and the Household Food Insecurity Access Prevalence (HFIAP) [30,49]. In the study conducted in the Eastern region, Pobee et al. [65] reported, perceived food insecurity was reported among 23% of households surveyed, with 28% of women aged 18-35 years in these households reportedly suffering from multiple micronutrient deficiencies. In the nonspecified urban setting study, involving a sample of 1200 individuals aged ≥50 years [69], the prevalence of perceived food insecurity ranged from moderate to severe. In this study, food insecurity indicators were hunger, skipped meals or late intake of first daily meal. The results from this study show that 36% of urban households in Ghana suffer from hunger, and 29% and 5% skipped meals, and had late intake of daily meals respectively. In contrast, the study reported by Bannor et al. [49], conducted in Greater Accra region, Bono, Ahafo and Bono East regions, that compared perceived food insecurity between Urban Ghana and India, concluded that food insecurity in Ghana appear to be mild with an average food insecurity score of 4.05 for each household. This study surveyed 400 urban households from the four regions, using the HFIAS scale to assess perceived food security. In Accra, food insecurity, reported in Tuholke et al. [30] was prevalent among 70% of households. Only one household reported sourcing food from modern supermarkets and fewer than 3% produce food for consumption through gardening, farming, or fishing.

Discussion
This scoping review has identified studies that addressed different dimensions of urban household food security in Ghana. We identified 45 studies that explored five food security domains: food access, food supply, food safety and quality, food utilisation and perceived food insecurity. The majority of the studies were conducted in the Greater Accra and Ashanti Regions. This finding is not surprising as most health and nutrition research carried out in the last three decades in Ghana have been concentrated in the major Ghanaian cities, especially Accra (in the Greater Accra Region) and Kumasi (in the Ashanti Region). Two possible explanations could be given for this: First the two regions host the most prominent academic and research institutions in Ghana (the University of Ghana and the Noguchi Memorial Centre for Medical Research, based in Accra, and the Kwame Nkrumah University of Science and Technology in Kumasi and the Kumasi Centre for Research in tropical medicine (KCCRTM), in Kumasi). The existence of these institutions, partly explain implementation of the majority of the studies in these two regions. Secondly, the two regions are the most urbanized in Ghana. This situation thus serves as an important prioritization criterion for understanding challenges of rural-urban migration and its potential impact on food security [70]. Although the review findings, overall, suggest that there is a need to promote further studies on food security in urban settings in Ghana, future research in the Ghanaian context should focus on other regions where food security research is limited. This approach will help deepen our understanding of the urban food security situation in more urban cities in Ghana, and not just a few bigger cities.
Notably, three out of the five food security domains (food safety/quality, food access, and food utilization) have been studied the most, especially food safety/quality (n = 31 studies). We did not find any study focusing on food stability; only few studies have examined the other food security domains (See Table 1 for results). There is, thus, a clear need to prioritize these unaddressed domains in future studies. The limited number of studies in these other domains may be due to the focus of our review on the urban environment. It is not unusual that food safety and quality was a major focus of the extant food security literature. However, there were several adverse findings regarding poor food safety, especially those sold in Ghanaian markets, despite existing policies and standards for addressing these food safety issues, in urban areas [70]. For the majority of studies that examined food safety and quality in urban Ghana, the findings were similar across studies and suggest that most foods, including raw vegetables, meat and fish sold in Ghanaian markets have characteristics that make them unsafe for human consumption [28,[33][34][35][36][37][38][42][43][44][45][46][47][48][51][52][53][54][55][56]59,[62][63][64]. These food safety issues include microbial, chemical, and heavy metal contamination. These findings suggest that the challenge is systemic. The evidence also points to non-compliance with existing standards. These findings suggest the need for urgent enforcement of the existing regulations and standards [71,72]. In terms of the nature of the literature reviewed, the review found that food security issues in Ghana are rarely investigated qualitatively.
All the 45 documents included were quantitative studies, conducted using crosssectional designs. The lack of qualitative studies addressing food security issues in urban settings in Ghana suggest a need for attention to this aspect of research. Qualitative studies are crucially helpful for us to understand the views and perceptions held by urban residents on food security issues in their household, and the lack of these types of studies call for further studies that adopt a qualitative approach to assessing food security. The numerous quantitative studies identified by this review addressing food security issues in urban Ghana suggest that a systematic review, possibly with meta-analysis, could be conducted, and including other African countries, to critically examine the evidence in detail, and to assess the strength and quality of the evidence. Based on the data extracted for this scoping review, the methodological quality of the included studies is likely to be poor resulting in weak evidence, given that some studies were unclear on providing key information on the study including the study location [49], sampling and detailed procedures. [32,37,43]. There was also inadequate information on recruitment and the specific population studied (e.g., [31,57,58]).

Strengths and Limitations
A key strength of this scoping review is the use of a robust methodological approach, the Arksy framework [25], to guide the review to understand what has been studied with regards to food security in urban Ghana. The framework allows reviewers to systematically search for relevant literature using a search strategy, select studies for inclusion using an inclusion and exclusion criteria, as well as organise and report the findings. At each stage of the study selection and data extraction process, two reviewers independently performed the tasks. This helped eliminate literature selection bias, and ensure rigor. Further, an information specialist (VC) performed the literature search in all academic and grey literature sources using a robust and comprehensive search strategy. The limitations of the review were that no evaluation of the included studies methodological quality was conducted, and restricting the setting to only urban and peri-urban contexts. Thus, the conclusion (below) drawn from the review are based on the available studies and not their intrinsic quality or strength of the evidence.

Conclusions
This scoping review has presented a rapid overview of the existing research published on urban household food security situation in Ghana, by reporting data from 45 academic literature/studies that reported on the issue explored. This review has identified that, in urban settings in Ghana, food safety and quality as a key component of food security has been widely studied, and the evidence reported suggesting that the safety/quality of foods sold in Ghanaian markets is poor, and below the Ghanaian and international food safety acceptable standards. These findings are useful in not only informing our understanding of what has been studied in Ghana, in terms of urban food security and where research gaps are, the findings will aid policy formulation, interventions and further research decision making about food security in Ghanaian urban cities. Literature is limited on other key aspects of food security such as food access, supply, and utilization and perceive food insecurity. The existing literature on food security is concentrated in two region-the Greater Accra region and Ashanti regions-and largely quantitative in nature. Future studies exploring food security issues should focus on the other regions of the countries where food insecurity remains a challenge. Qualitative studies are also needed to better understand the important contextual issues affecting food security in urban Ghana. Additionally, future research could explore how Ghanaians living in urbans settings perceive their food security situation, and food stability issues.