A cluster randomized controlled trial to assess the impact of the 'Caring for Providers to Improve Patient Experience' intervention on person-centered maternity care in Kenya and Ghana: Study Protocol.

Background: Poor person-centered maternal care (PCMC) contributes to high maternal mortality and morbidity, directly and indirectly, through lack of, delayed, inadequate, unnecessary, or harmful care. While evidence on poor PCMC prevalence, as well as inequities, expanded in the last decade, there is still a significant gap in evidence-based interventions to address PCMC. We describe the protocol for a trial to test the effectiveness of the "Caring for Providers to Improve Patient Experience" (CPIPE) intervention, which includes five strategies for provider behavior change, targeting provider stress and bias as intermediate factors to improve PCMC and to address inequities. Methods: The trial will assess the effect of CPIPE on PCMC, as well as on intermediate and distal outcomes, using a two-arm cluster randomized controlled trial in 40 health facilities in Migori and Homa Bay Counties in Kenya and Upper East and Northeast Regions in Ghana. Twenty facilities in each country will be randomized to 10 intervention and 10 control sites. The primary intervention targets are all healthcare workers who provide maternal health services. The intervention impact will also be assessed first among providers, and then among women who give birth in health facilities. The primary outcome is PCMC measured with the PCMC scale, via multiple cross-sectional surveys of mothers who gave birth in the preceding 12 weeks in study facilities at baseline (prior to the intervention), midline (6 months after intervention start), and endline (12 months post-baseline) (N = 2000 across both countries at each time point). Additionally, 400 providers in the study facilities across both countries will be followed longitudinally at baseline, midline, and endline, to assess intermediate outcomes. The trial incorporates a mixed-methods design; survey data alongside in-depth interviews (IDIs) with healthcare facility leaders, providers, and mothers to qualitatively explore factors influencing the outcomes. Finally, we will collect process and cost data to assess intervention fidelity and cost-effectiveness. Discussion: This trial will be the first to rigorously assess an intervention to improve PCMC that addresses both provider stress and bias and will advance the evidence base for interventions to improve PCMC and contribute to equity in maternal and neonatal health.

Exploring infant and young child-feeding practices among mothers of well-nourished children in northern Ghana: An INPreP substudy.

This study investigated infant and young child-feeding (IYCF) practices among mothers of well-nourished children in northern Ghana. This was a qualitative study where in-depth individual interviews were conducted with participants. The interviews were audio recorded, transcribed, and QSR Nvivo software version 11 was used to organize the data before thematic analysis. It was observed that mothers of well-nourished children were likely to adhere to breastfeeding guidelines and also practice appropriate complementary feeding. Furthermore, these mothers mostly had some form of support from their husbands and mother-in-laws in feeding their infants. While adoption and adherence to appropriate IYCF practices contribute to improved nutrition outcomes in children, social support systems are needed to sustain the practice.

What works in engaging communities? Prioritising nutrition interventions in Burkina Faso, Ghana and South Africa.

BACKGROUND: "Choosing All Together" (CHAT), is a community engagement tool designed to give the public a voice in how best to allocate limited resources to improve population health. This process evaluation explored the mechanisms through which CHAT generates community engagement. METHOD: The CHAT tool was adapted and implemented for use in two rural communities (Nanoro, Burkina Faso, and Navrongo, Ghana) and one urban township (Soweto, South Africa) to prioritize maternal and child nutrition interventions. Community discussions were audio-recorded, transcribed, and translated into English. Twenty-two transcripts, including six each from Navrongo and Soweto and 10 from Nanoro, were analysed thematically to generate data driven codes and themes to explain mechanisms underlying the CHAT process. The process evaluation was based on the UK MRC process evaluation guidance. RESULTS: Seven themes describing the functions and outcomes of CHAT were identified. Themes described participants deliberating trade-offs, working together, agreeing on priorities, having a shared vision, and increasing their knowledge, also the skills of the facilitator, and a process of power sharing between participants and researchers. Participants came to an agreement of priorities when they had a shared vision. Trained facilitators are important to facilitate meaningful discussion between participants and those with lower levels of literacy to participate fully. CONCLUSION: CHAT has been shown to be adaptable and useful in prioritising maternal and child nutrition interventions in communities in Burkina Faso, Ghana, and South Africa. Conducting CHAT in communities over a longer period and involving policy-makers would increase trust, mutual respect and develop partnerships.

Situation Analysis of a New Effort of Community-Based Health Planning and Services (CHPS) for Maternal Health in Upper West Region in Rural Ghana.

A free maternal health policy started in Ghana in 2008, however, health facility utilization is still low, and out-of-pocket payments (OOPPs) are putting households at risk of catastrophic expenditure. To improve this situation, some rural communities have assigned a midwife to a health post called community-based health planning and services (CHPS), where only assistant nurses are allocated. This study explored the effectiveness of the new approach in Upper West Region, Ghana. We conducted a cross-sectional study and interviewed women who gave birth in the last year. We systematically selected communities matched into four criteria: communities near CHPS (functional CHPS), communities near CHPS with a midwife (advanced CHPS), communities near a health centre, and communities without a health facility in their neighbourhood. In total, 534 women were interviewed: functional CHPS 104, advanced CHPS 131, near health centre 173, and no facility 126. About 78% of the women were 20 to 34 years old. About half of the women incurred OOPP, however, catastrophic payment (household spending > 5% of annual income) was significantly lower in advanced CHPS communities for normal delivery compared with the other three communities. The new local approach of assigning a midwife to CHPS functioned well, improving access to healthcare facilities for childbirth.

Men's motivations, barriers to and aspirations for their families' health in the first 1000 days in sub-Saharan Africa: a secondary qualitative analysis.

Introduction: The first 1000 days of life are a critical period of growth and development that have lasting implications for health, cognitive, educational and economic outcomes. In sub-Saharan Africa, gender and social norms are such that many men have little engagement with maternal and child health and nutrition during pregnancy and early childhood. This study explores how men perceive their role in three sites in sub-Saharan Africa. Methods: Secondary qualitative analysis of 10 focus group discussions with 76 men in Burkina Faso, Ghana and South Africa. Data were thematically analysed to explore men's perceptions of maternal and child health and nutrition. Results: Men considered themselves 'providers' and 'advisors' within their families, particularly of finances, food and medicines. They also indicated that this advice was out of care and concern for their families' health. There were similarities in how the men perceive their role. Differences between men living in rural and urban settings included health priorities, the advice and the manner in which it was provided. Across all settings, men wanted to be more involved with maternal and child health and nutrition. Challenges to doing so included stigma and proscribed social gender roles. Conclusion: Men want a greater engagement in improving maternal and child health and nutrition but felt that their ability to do so was limited by culture-specified gender roles, which are more focused on providing for and advising their families. Involving both men and women in intervention development alongside policymakers, health professionals and researchers is needed to improve maternal and child health and nutrition.

Community Barriers, Enablers, and Normative Embedding of Second Year of Life Vaccination in Ghana: A Qualitative Study.

INTRODUCTION: Coverage rates for second year of life (2YL) vaccination still lag behind infant vaccination in most settings. We conducted a qualitative baseline study of community barriers and enablers to acceptance of 2YL vaccines in Ghana 4 years after introducing the second dose of the measles-containing vaccine. METHODS: We conducted 26 focus group discussions in 2016 with men and women caregivers from mixed urban, peri-urban, and rural areas, as well as pastoralists, using semistructured topic guides based on the Health Belief Model theory. We conducted a thematic analysis of the discussion using NVivo software. We use Normalization Process Theory to contextualize results as a snapshot of a dynamic process of community adaptation to change to a well-established routine immunization schedule following 2YL introduction. RESULTS: Routine immunization for infants enjoys resilient demand, grounded in strong community norms despite surprisingly low levels of vaccine literacy. Despite best practices like integration with the established 18-month "weighing visit," demand for 2YL vaccination is still conditional on individual awareness and competition for limited maternal time, household resources, and other health concerns. An embedded norm that children should be fully vaccinated by 12 months originally sustained Expanded Programme for Immunization goals but now discouraged some caregivers from seeking vaccines for children perceived to be "too old" to vaccinate. Caregivers cited greater costs and inconvenience of taking older, heavier children in for vaccination and anticipated criticism from both community members and health care providers for coming "too late." CONCLUSION: Closing the 2YL vaccination coverage gap will ultimately require modifying embedded norms among caregivers and health care providers alike. Time is necessary but not sufficient to reach this goal. Progress can be accelerated by increasing the level of community and institutional engagement and adapting services where possible to minimize added costs to caregivers of vaccinating older children.

Health professional's readiness and factors associated with telemedicine implementation and use in selected health facilities in Ghana.

Background: Telemedicine, which is the practice of medicine using technology to deliver health care remotely, has a low adoption rate in low- and middle-income countries (LMICs). However, the advent of coronavirus disease 2019 (COVID-19) has forced healthcare systems in these settings to begin implementing telemedicine programs. It is unknown how prepared health professionals and the healthcare system are to adopt this technology. Therefore, this study aimed to assess the readiness of health professionals and explore factors associated with telemedicine implementation in Ghana. Methods: A cross-sectional study was conducted in six health facilities between March and August 2021. Convenience sampling was used to select the six health facilities, and the participants were selected randomly for the study. Questionnaires were self-completed by participants. Data was exported into STATA 15.0 for analysis, and appropriate statistical methods were employed. All statistical tests were performed at a significance level of p < 0.05. Results: Of the 613 health professionals involved in the study, about 579 (94.5%) were comfortable using computers, and the majority, 503 (82.1%) of them, had access to computers at the workplace. Health professionals agreed that the measures outlined by the health facilities supported their readiness to use telemedicine for healthcare services. Analysis revealed a statistically significant positive relationship between health facilities' core readiness and health professionals' readiness, with a correlation coefficient (r) of 0.5484 and a p-value<0.0001. Of the factors associated with health professionals' readiness towards telemedicine implementation, facility core readiness, engagement readiness, staff knowledge and attitude readiness showed a statistically significant relationship with health professionals' readiness. Conclusion: The study revealed that health professionals are ready to adopt telemedicine. There was a statistically significant relationship between health facilities' core readiness, engagement readiness, staff knowledge and attitude readiness, and health professionals' readiness. The study identified factors facilitating telemedicine adoption.

An Ethnographic Study of Multiple Factors Influencing Perceptions, Attitudes, and Observance of COVID-19 Preventive Measures among Rural and Urban Slum Dwellers in Ghana.

Background: The COVID-19 pandemic and government-led interventions to tackle it have had life-changing effects on vulnerable populations, especially rural and urban slum dwellers in developing countries. This ethnographic study explored how the Ghanaian government's management of COVID-19, socio-cultural factors, infrastructural challenges, and poverty influenced community perceptions, attitudes, and observance of COVID-19 prevention measures in Ghana. Methods: The study employed focused ethnography using in-depth interviews (IDIs), focus group discussions (FGDs), and nonparticipant observations to collect data from an urban slum and a rural community as well as from government officials, from October 2020 to January 2021. The data were triangulated and analyzed thematically with the support of qualitative software NVivo 12. All ethical procedures were followed. Results: The Ghanaian government's strategy of communicating COVID-19-related information to the public, health-related factors such as health facilities failing to follow standard procedures in testing and tracing persons who came into contact with COVID-19-positive cases, poverty, and lack of social amenities contributed to the poor observance of COVID-19 preventive measures. In addition, the government's relaxation of COVID-19 restrictions, community and family values, beliefs, and misconceptions contributed to the poor observance of COVID-19 preventive measures. Nevertheless, some aspects of the government's intervention measures and support to communities with COVID-19 prevention items, support from nongovernmental organizations (NGOs), and high knowledge of COVID-19 and its devastating effects contributed to positive attitudes and observance of COVID-19 preventive measures. Conclusion: There is a need for the government to use the existing community structures to engage vulnerable communities so that their concerns are factored into interventions to ensure that appropriate interventions are designed to suit the context. Moreover, the government needs to invest in social amenities in deprived communities. Finally, the government has to be consistent with the information it shares with the public to enhance trust relations.

Cost of childbirth in Upper West Region of Ghana: a cross-sectional study.

BACKGROUND: Out-of-pocket payment (OOPP) is reported to be a major barrier to seeking maternal health care especially among the poor and can expose households to a risk of catastrophic expenditure and impoverishment.This study examined the OOPPs women made during childbirth in the Upper West region of Ghana. METHODS: We carried out a cross-sectional study and interviewed women who gave birth between January 2013 and December 2017. Data on socio-demographic characteristics, place of childbirth, as well as direct cost (medical and non-medical) were collected from respondents. The costs of childbirth were estimated from the patient perspective. Logistics regression was used to assess the factors associated with catastrophic payments cost. All analyses were done using STATA 16.0. RESULTS: Out of the 574 women interviewed, about 71% (406/574) reported OOPPs on their childbirth. The overall average direct medical and non-medical expenditure women made on childbirth was USD 7.5. Cost of drugs (USD 8.0) and informal payments (UDD 5.7) were the main cost drivers for medical and non-medical costs respectively. Women who were enrolled into the National Health Insurance Scheme (NHIS) spent a little less (USD 7.5) than the uninsured women (USD 7.9). Also, household childbirth expenditure increased from primary health facilities level (community-based health planning and services compound = USD7.2; health centre = USD 6.0) to secondary health facilities level (hospital = USD11.0); while home childbirth was USD 4.8. Overall, at a 10% threshold, 21% of the respondents incurred catastrophic health expenditure. Regression analysis showed that place of childbirth and household wealth were statistically significant factors associated with catastrophic payment. CONCLUSIONS: The costs of childbirth were considerably high with a fifth of households spending more than one-tenth of their monthly income on childbirth and therefore faced the risk of catastrophic payments and impoverishment. Given the positive effect of NHIS on cost of childbirth, there is a need to intensify efforts to improve enrolment to reduce direct medical costs as well as sensitization and monitoring to reduce informal payment. Also, the identified factors that influence cost of childbirth should be considered in strategies to reduce cost of childbirth.

The socio-economic and health effects of COVID-19 among rural and urban-slum dwellers in Ghana: A mixed methods approach.

BACKGROUND: Vulnerable populations such as rural and urban-slum dwellers are more likely to suffer greatly from the deleterious effects of the novel Coronavirus disease 2019 (COVID-19). However, in Ghana, most COVID-19 mitigating packages are not focused on vulnerable populations. METHODS: Concurrent mixed methods design was used to examine the socio-economic and health effects of COVID-19 among rural and urban-slum dwellers in Ghana. Four hundred respondents were sampled for the quantitative arm of the study, while 46 In-depth Interviews (IDIs) were conducted with community members and government officials. Sixty-four community members participated in Focus Group Discussions (FGDs) and non-participant observation was carried out for three months. Quantitative data were analysed using frequencies, percentages, Pearson Chi2 and ordered logistic regression. Interviews were recorded using digital recorders and later transcribed. Transcribed data (IDIs, FGDs) and observation notes were uploaded onto a computer and transferred to qualitative software NVivo 12 to support thematic coding and analysis. RESULTS: Majority of the respondents confirmed the deleterious socio-economic and health effects of COVID-19 on jobs and prices of food. Other effects were fear of visiting a health facility even when unwell, depression and anxiety. Young people (18-32 years), males, urban-slum dwellers, married individuals, the employed and low-income earners (those who earn GHC10/$1.7 to GHC100/ $17), were more likely to suffer from the socio-economic and health effects of COVID-19. Urban-slum dwellers coped by relying on family and social networks for food and other basic necessities, while rural dwellers created locally appropriate washing aids to facilitate hand washing in the rural communities. CONCLUSION: COVID-19 and the government's mitigation measures had negative socio-economic and health effects on vulnerable communities. While vulnerable populations should be targeted for the government's COVID-19 mitigating packages, special attention should be given to young people (18-32 years), males, urban-slum dwellers, married individuals and low-income earners. Communities should be encouraged to maintain coping strategies adopted even after COVID-19.

"I would have to sell things in order to get the money": A qualitative exploration of willingness to pay for the RTS,S/AS01 malaria vaccine in the Volta region, Ghana.

BACKGROUND: Malaria morbidity and mortality remain a challenge in Ghana. A promising childhood vaccine is being piloted in Ghana, however with the loss of its low-income status, Ghana is losing associated donor co-funding. User fees have been considered an alternative financing method, so this study utilised qualitative methods and explored caregivers' willingness to pay for the malaria vaccine (RTS,S/AS01) to inform future service provision. METHODS: The study design was cross-sectional. Twenty in-depth interviews were conducted between February 2020 and March 2020 amongst a purposive sample of caregivers of RTS,S/AS01 eligible children, in the Volta region, Ghana. Interviews were audio-recorded and transcribed into English Language. Thematic analysis followed, using NVIVO12 to organise this data. RESULTS: Caregivers could distinguish between RTS,S/AS01 and routine vaccines and were willing to pay median GH₵5 (US$0.94), interquartile range GH₵3.75-5 (US$0.71-0.94) per dose of RTS,S/AS01. The maximum amount participants were willing to pay per dose was GH₵10 (US$1.88), interquartile range GH₵6-10 (US$1.13-1.88). Caregivers mentioned that they would work more to cover this cost because they were happy with services rendered to them during the RTS,S/AS01 pilot phase, and preferred vaccines over vector control measures. The results suggest that a willingness to pay was based on beliefs that the vaccine is fully effective. Although no participant declared that they would be unwilling to pay hypothetical user fees, there were still widespread concerns about affordability, with the majority feeling that the government should be responsible to pay for RTS,S/AS01. CONCLUSIONS: Participants expressed a willingness to pay due to an appreciation of vaccines, shaped by personal experiences with immunisations and disease. Participants' average income was lower than the national average, potentially affecting the perceived affordability of RTS,S/AS01. Because of the belief that RTS,S/AS01 is fully effective, caregivers may pay less attention to other preventative measures, thus unintentionally undermining malaria vector control.

Mixed effect analysis of factors influencing the use of insecticides treated bed nets among pregnant women in Ghana: evidence from the 2019 Malaria Indicator Survey.

BACKGROUND: Malaria during pregnancy is a major cause of maternal morbidity globally and leads to poor birth outcomes. The World Health Organization has recommended the use of insecticide treated bed nets (ITN) as one of the effective malaria preventive strategies among pregnant women in malaria endemic areas. This study, therefore, seeks to examine the individual and household factors associated with the use of ITNs among pregnant women in Ghana. METHODS: Data for this study was obtained from the 2019 Ghana Malaria Indicator Survey (GMIS) conducted between September 25 and November 24, 2019. The weighted sample comprised 353 pregnant women aged 15-49 years. Data was analyzed with SPSS version 22 using both descriptive and multilevel logistics regression modelling. Statistically significant level was set at p < 0.05. RESULTS: The study found that 49.2% of pregnant women in Ghana use ITN to prevent malaria. Pregnant women aged 35-49 years (AOR = 3.403, CI: 1.191-9.725), those with no formal education (AOR = 5.585, CI = 1.315-23.716), and those who had secondary education (AOR = 3.509, CI = 1.076-11.440) had higher odds of using ITN. Similarly, higher odds of ITN usage was found among who belonged to the Akan ethnic group (AOR = 7.234, CI = 1.497-34.955), dwell in male-headed households (AOR = 2.232, CI = 1.105-4.508) and those whose household heads are aged 60-69 years (AOR = 4.303, CI = 1.160-15.966). However, pregnant women who resided in urban areas (AOR = 0.355, CI = 0.216-0.582), those whose household heads aged 40-49 years (AOR = 0.175, CI = 0.066-0.467) and those who belonged to richer (AOR =0.184, CI = 0.050-0.679) and richest (AOR = 0.107, CI = 0.021-0.552) households had lower odds of using ITN for malaria prevention. CONCLUSIONS: Individual socio-demographic and household factors such as pregnant women's age, educational level, place of residence, ethnicity, sex and age of household head, and household wealth quintile are associated with the use of ITN for malaria prevention among pregnant women. These factors ought to be considered in strengthening malaria prevention campaigns and develop new interventions to help increase ITN utilization among vulnerable population living in malaria- endemic areas.

Determinants of willingness to accept child vaccination against malaria in Ghana.

BACKGROUND: Malaria is a public health problem in Ghana with children being one of the most vulnerable. Given this, in 2019, Ghana decided to add the first malaria vaccine (RTS, S) as part of routine immunisations for children in the near future. This study, thus, examines the determinants of malaria vaccine awareness and willingness to uptake the vaccine for children in Ghana. METHOD: The study uses data from the 2019 Ghana Malaria Indicator Survey while employing the binary logistic regression as the empirical estimation technique. RESULTS: The study finds that religion, region of residence and awareness of the malaria vaccine, influence the willingness to uptake the vaccine for children. Moreover, younger mothers (15-26 years), households in the richest wealth quintile, male-headed households and the number of children aged five years and below in a household, are found to be associated with less willingness to uptake the vaccine for children. CONCLUSION: Paying attention to awareness creation, region, religion, younger mothers (15-26 years), households in the richest wealth quintile, male-headed households and households with more children aged five years and below, can ensure optimal uptake of the malaria vaccine for children in Ghana.

Engaging community members in setting priorities for nutrition interventions in rural northern Ghana.

This study used "Choosing All Together" (CHAT), a deliberative engagement tool to prioritise nutrition interventions and to understand reasons for intervention choices of a rural community in northern Ghana. The study took an exploratory cross-sectional design and used a mixed method approach to collect data between December 2020 and February 2021. Eleven nutrition interventions were identified through policy reviews, interaction with different stakeholders and focus group discussions with community members. These interventions were costed for a modified CHAT tool-a board-like game with interventions represented by colour coded pies and the cost of the interventions represented by sticker holes. Supported by trained facilitators, six community groups used the tool to prioritise interventions. Discussions were audio-recoded, transcribed and thematically analysed. The participants prioritised both nutrition-sensitive and nutrition-specific interventions, reflecting the extent of poverty in the study districts and the direct and immediate benefits derived from nutrition-specific interventions. The prioritised interventions involved livelihood empowerment, because they would create an enabling environment for all-year-round agricultural output, leading to improved food security and income for farmers. Another nutrition-sensitive, education-related priority intervention was male involvement in food and nutrition practices; as heads of household and main decision makers, men were believed to be in a position to optimise maternal and child nutrition. The prioritised nutrition-specific intervention was micronutrient supplementation. Despite low literacy, participants were able to use CHAT materials and work collectively to prioritize interventions. In conclusion, it is feasible to modify and use the CHAT tool in public deliberations to prioritize nutrition interventions in rural settings with low levels of literacy. These communities prioritised both nutrition-sensitive and nutrition-specific interventions. Attending to community derived nutrition priorities may improve the relevance and effectiveness of nutrition health policy, since these priorities reflect the context in which such policy is implemented.

Challenges and experiences in linking community level reported out-of-pocket health expenditures to health provider recorded health expenditures: Experience from the iHOPE project in Northern Ghana.

Out of pocket health payment (OOPs) has been identified by the System of Health Accounts (SHA) as the largest source of health care financing in most low and middle-income countries. This means that most low and middle-income countries will rely on user fees and co-payments to generate revenue, rationalize the use of services, contain health systems costs or improve health system efficiency and service quality. However, the accurate measurement of OOPs has been challenged by several limitations which are attributed to both sampling and non-sampling errors when OOPs are estimated from household surveys, the primary source of information in LICs and LMICs. The incorrect measurement of OOP health payments can undermine the credibility of current health spending estimates, an otherwise important indicator for tracking UHC, hence there is the need to address these limitations and improve the measurement of OOPs. In an attempt to improve the measurement of OOPs in surveys, the INDEPTH-Network Household out-of-pocket expenditure project (iHOPE) developed new modules on household health utilization and expenditure by repurposing the existing Ghana Living Standards Survey instrument and validating these new tools with a 'gold standard' (provider data) with the aim of proposing alternative approaches capable of producing reliable data for estimating OOPs in the context of National Health Accounts and for the purpose of monitoring financial protection in health. This paper reports on the challenges and opportunities in using and linking household reported out-of-pocket health expenditures to their corresponding provider records for the purpose of validating household reported out-of-pocket health expenditure in the iHOPE project.

Health-seeking behaviour and cost of fever treatment to households in a malaria-endemic setting of northern Ghana: a cross-sectional study.

OBJECTIVES: To examine the health-seeking behaviour and cost of fever treatment to households in Ghana. DESIGN: Cross-sectional household survey conducted between July and September 2015. SETTING: Kassena-Nankana East and West districts in Upper East region of Ghana. PARTICIPANTS: Individuals with an episode of fever in the 2 weeks preceding a visit during routine health and demographic surveillance system data collection were selected for the study. Sociodemographic characteristics, treatment-seeking behaviours and cost of treatment of fever were obtained from the respondents. RESULTS: Out of 1845 households visited, 21% (393 of 1845) reported an episode of fever. About 50% (195 of 393) of the fever cases had blood sample taken for testing by microscopy or Rapid Diagnostic Test, and 73.3% (143 of 195) were confirmed to have malaria. Of the 393 people with fever, 70% (271 of 393) reported taking an antimalarial and 24.0% (65 of 271) took antimalarial within 24 hours of the onset of illness. About 54% (145 of 271) of the antimalarials were obtained from health facilities.The average cost (direct and indirect) incurred by households per fever treatment was GH¢27.8/US$7.3 (range: GH¢0.2/US$0.1-GH¢200/US$52.6). This cost is 4.6 times the daily minimum wage of unskilled paid jobs of Ghanaians (US$1.6). The average cost incurred by those enrolled into the National Health Insurance Scheme (NHIS) was GH¢24.8/US$6.5, and GH¢50/US$11.6 for those not enrolled. CONCLUSIONS: Prompt treatment within 24 hours of onset of fever was low (24%) compared with the Roll Back Malaria Programme target of at least 80%. Cost of treatment was relatively high when compared with average earnings of households in Ghana and enrolment into the NHIS reduced the cost of fever treatment remarkably. It is important to improve access to malaria diagnosis, antimalarials and enrolment into the NHIS in order to improve the case management of fever/malaria and accelerate universal health coverage in Ghana.

Culture and community perceptions on diet for maternal and child health: a qualitative study in rural northern Ghana.

BACKGROUND: This study explored cultural and community perceptions of optimal diet for maternal and child health in northern Ghana. METHODS: This was an exploratory cross-sectional study using qualitative methods for data collection. Data were collected between March and April 2019 consisting of 10 focus group discussions with men and women community members between 18 and 50 years in the Kassena-Nankana districts of Ghana. Data were organised using QSR NVivo 12 qualitative software to facilitate thematic analysis. RESULTS: All study participants recognised the importance of an optimal diet for mother, child and better pregnancy and breastfeeding outcomes. However, there were different cultural beliefs and taboos about what foods are healthy and non-healthy for women at different stages of the reproductive period. Foods perceived to be unhealthy for pregnant women were fatty foods and fresh meat (uncooked or unprocessed meat) due to the belief that they can lead to delivery complications, which many women feared. In addition, some participants relayed the cultural belief that pregnant woman should not eat eggs because it would make the child a thief. Lactating mothers are not to eat foods such as vigna subterranean known locally as bambara bean and "gari" (local meal made from cassava) because it is believed to inhibit breastmilk production. Participants emphasised that food insecurity and economic constraints meant women could not achieve optimal diet and could not afford to be selective in food choices. CONCLUSION: Community members recognized the importance of optimal nutrition but were constrained by poverty and cultural barriers. A dual approach which targets improvements of local food production and economic empowerment in combination with community-based discussion and education of the impacts of food taboos on health, should facilitate improvement in the diets of women and future generations.

Effect of specificity of health expenditure questions in the measurement of out-of-pocket health expenditure: evidence from field experimental study in Ghana.

BACKGROUND: The effect of number of health items on out-of-pockets (OOPs) has been identified as a source of bias in measuring OOPs. Evidence comes mostly from cross-sectional comparison of different survey instruments to collect data on OOPs. Very few studies have attempted to validate these questionnaires, or distinguish bias arising from the comprehensiveness of the OOPs list versus specificity of OOPs questions. OBJECTIVES: This study aims to estimate biases arising from the specificity of OOPs questions by comparing provider and household's information. METHODS: A generic questionnaire to collect data on household's OOPs was developed following the nomenclature proposed in division 6 of the classification of household final consumption 2018. The four categories within such division are used to set the comprehensiveness of the OOPs list, the specificity within each category was tailored to the design of the nationally representative living standard survey in Ghana where a field experiment was conducted to test the validity of different versions. Households were randomised to 11, 44 or 56 health items. Using data from provider records as the gold standard, we compared the mean positive OOPs, and estimated the mean ratio and variability in the ratio of household expenditures to provider data for the individual households using the Bland-Altman method of assessing agreement. FINDINGS: We found evidence of a difference in the overall mean ratio in the specificity for OOPs in inpatient care and medications. Within each of these two categories, a more detailed disaggregation yielded lower OOPs estimates than less detailed ones. The level of agreement between household and provider OOPs also decreased with increasing specificity of health items. CONCLUSION: Our findings suggest that, for inpatient care and medications, systematically decomposing OOPs categories into finer subclasses tend to produce lower OOPs estimates. Less detailed items produced more accurate and reliable OOPs estimates in the context of a rural setting.

Supporting maternal and child nutrition: views from community members in rural Northern Ghana.

OBJECTIVE: Despite efforts to improve maternal and child nutrition, undernutrition remains a major public health challenge in Ghana. The current study explored community perceptions of undernutrition and context-specific interventions that could improve maternal and child nutrition in rural Northern Ghana. DESIGN: This exploratory qualitative study used ten focus group discussions to gather primary data. The discussions were recorded, transcribed and coded into themes using Nvivo 12 software to aid thematic analysis. SETTING: The study was conducted in rural Kassena-Nankana Districts of Northern Ghana. STUDY PARTICIPANTS: Thirty-three men and fifty-one women aged 18-50 years were randomly selected from the community. RESULTS: Most participants reported poverty, lack of irrigated agricultural land and poor harvests as the main barriers to optimal nutrition. To improve maternal and child nutrition, study participants suggested that the construction of dams at the community level would facilitate all year round farming including rearing of animals. Participants perceived that the provision of agricultural materials such as high yield seedlings, pesticides and fertiliser would help boost agricultural productivity. They also recommended community-based nutrition education by trained health volunteers, focused on types of locally produced foods and appropriate ways to prepare them to help improve maternal and child nutrition. CONCLUSION: Drawing on these findings and existing literature, we argue that supporting community initiated nutrition interventions such as improved irrigation for dry season farming, provision of agricultural inputs and community education could improve maternal and child nutrition.

Updated Emission Factors from Diffuse Combustion Sources in Sub-Saharan Africa and Their Effect on Regional Emission Estimates.

Diffuse emission sources outside of kitchen areas are poorly understood, and measurements of their emission factors (EFs) are sparse for regions of sub-Saharan Africa. Thirty-one in-field emission measurements were taken in northern Ghana from combustion sources common to rural regions worldwide. Sources sampled included commercial cooking, trash burning, kerosene lanterns, and diesel generators. EFs were calculated for carbon monoxide (CO), carbon dioxide (CO2), as well as carbonaceous particulate matter, specifically elemental carbon (EC) and organic carbon (OC). EC and OC emissions were measured from kerosene lighting events (EFEC = 25.1 g/kg-fuel SD = 25.7, EFOC = 9.5 g/kg-fuel SD = 10.0). OC emissions from trash burning events were large and highly variable (EFOC = 38.9 g/kg-fuel SD = 30.5). Combining our results with other recent in-field emission factors for rural Ghana, we explored updated emission estimates for Ghana using a region specific emissions inventory. Large differences are calculated for all updated source emissions, showing a 96% increase in OC and 78% decrease in EC compared to prior estimates for Ghana's emissions. Differences for carbon monoxide were small when averaged across all updated source types (-1%), though the household wood use and trash burning categories individually show large differences.