Hypertension and diabetes control: faith-based centres offer a promise for expanding screening services and linkage to care in Ghana.

BACKGROUND: Hypertension and type 2 diabetes mellitus (T2DM) are important contributors to noncommunicable disease related morbidity and mortality. Health systems could benefit from exploring the use of Faith-Based Centres (FBC) to screen and link suspected cases for further care in order to help achieve Sustainable Development Goal (SDG) 3. The study investigated the role of faith-based screening for T2DM and hypertension and the linkage of cases to the healthcare system and examined the care cascade in the Kassena Nankana Districts of Northern Ghana. METHODS: We screened individuals from 6 FBCs for elevated blood pressure and hyperglycaemia. Suspected hypertension and T2DM cases were referred to health facilities for confirmation and subsequently followed them up for 3 months. We assessed the prevalence of behavioural and metabolic risk factors, including hypertension and T2DM, and the retention of referred cases in the healthcare system over follow up period. We further assessed levels of awareness, treatment and adequate control of hypertension and T2DM. RESULTS: A total of 631 participants were screened, (mean age 49 ± 16years, 73% female) from 6 Faith based Centres. More males than females reported smoking tobacco (14.5% vs. 0.7%) and been physically active (64.5% vs. 52.7%) while more females were obese (29.6 kg/m2 vs. 14.5 kg/m2) and had a higher mean waist circumference (89.0 cm IQR 75-116 cm vs. 84.2 cm IQR 72-107 cm), hip circumference (101.5 ± 10.6 cm vs. 96.4 ± 8.6 cm) and waist-to-hip ratio (0.86 ± 0.1 cm vs. 0.87 ± 0.1 cm) than males. The prevalence of confirmed hypertension and T2DM was 27.9% and 3.5% respectively with no observed sex differences. We observed deficits in the hypertension and T2DM care cascade with reported low awareness, treatment and uncontrolled levels. A 3-month follow up showed a retention in care of 100% in month one and 94.9% in the third month. There was an increase in treatment (39.4% in month-1 and 82.8% in month-3) and control (26.3% in month-1 and 76.3% in month-3) of hypertension and T2DM combined. CONCLUSION: Faith-based centres have the potential to enhance the screening, linkage to the healthcare system, and management of hypertension and T2DM. This improvement over the routine system could lead to earlier diagnoses, a reduction in complications, and decreased premature mortality from cardiovascular diseases. Consequently, these efforts would contribute significantly to achieving SDG 3.

Hypertension knowledge, attitudes and perceptions among adults in the Navrongo Health and Demographic Surveillance Site: a mixed methods analysis.

BACKGROUND: This study assessed knowledge, behaviors, and perceptions towards hypertension following community dissemination on cardiovascular disease (CVD) risk within the Navrongo Health and Demographic Surveillance Site in Northern Ghana. METHODS: A cross-sectional mixed methods study was conducted among middle aged men and women following education on CVD and their risk factors. Knowledge and attitudes of participants regarding hypertension were measured in 310 participants using a survey tool and the resultant data was analyzed with descriptive statistics. Focus group discussions (FDG) were used to assess perceptions of 40 study participants on their lived experiences with hypertension. Recorded interviews were transcribed verbatim and coded into themes using Nvivo 12 software before thematic analysis. RESULTS: Of the 310 surveyed participants, 54% were women and the mean age was 50 ± 6 years. The results showed that 84% of participants had heard about hypertension, 70% knew it was an increase in blood pressure and could be caused by excess salt intake, poor diet and physical inactivity. About 22.3% of participants were aware of the had hypertension. In terms of management, majority of the participants were aware that hypertension could be treated with antihypertensive medication and that untreated or uncontrolled hypertension could result in adverse health consequences. Few participants had ever had their blood pressure measured and did not access screening or healthcare care services and rather perceived the health system as inadequate to screen, and manage hypertension. CONCLUSION: Though, knowledge on hypertension was high, awareness of hypertension status and access to screening and healthcare services was low. Community beliefs and perceptions strongly influence treatment, and control of hypertension. Effective sustained community dissemination efforts addressing misperceptions could improve hypertension treatment and control.

Barriers and facilitators to community acceptability of integrating point-of-care testing to screen for sickle cell disease in children in primary healthcare settings in rural Upper East Region of Northern Ghana.

INTRODUCTION: Sickle cell disease (SCD) remains a public health problem especially in sub-Saharan Africa including Ghana. While pilot initiatives in Africa have demonstrated that neonatal screening coupled with early intervention reduces SCD-related morbidity and mortality, only 50-70% of screen-positive babies have been successfully retrieved to benefit from these interventions. Point-of-care testing (POCT) with high specificity and sensitivity for SCD screening can be integrated into existing immunization programs in Africa to improve retrieval rates. This study explored community acceptability of integrating POCT to screen for SCD in children under 5 years of age in primary healthcare facilities in Northern Ghana. METHOD: This was an exploratory study using qualitative research approach where 10 focus group discussions and 20 in-depth interviews were conducted with community members and health workers between April and June 2022. The recorded interviews were transcribed verbatim after repeatedly listening to the recordings. Data was coded into themes using QSR Nvivo 12 software before thematic analysis. RESULTS: Most participants (70.9%) described SCD as serious and potentially life-threatening condition affecting children in the area. Of 148 community members and health workers, 141 (95.2%) said the screening exercise could facilitate diagnosis of SCD in children for early management. However, discrimination, fear of being tested positive, stigmatization, negative health worker attitude linked with issues of maintaining confidentiality were reported by participants as key factors that could affect uptake of the SCD screening exercise. Most participants suggested that intensive health education (78.3%), positive attitude of health workers (69.5%), and screening health workers not being biased (58.8%) could promote community acceptability. CONCLUSION: A large majority of participants viewed screening of SCD in children as very important. However, opinions expressed by most participants suggest that health education and professionalism of health workers in keeping patients' information confidential could improve the uptake of the exercise.

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.

Perceived impact of digital health technology on health professionals and their work: A qualitative study in Southern Ghana.

Background: Digital health technology (DHT) has become an essential part of an effective and efficient healthcare information system. Although DHT promises great potential it does not always meet the expectation of users. Often, in low- and middle-income countries (LMICs), the implemented DHT does not function as intended and impacts negatively on health professionals and their work. Therefore, this study explored the views of participants about the impact of DHTs on the work of health professionals after it has been introduced in Ghana. Methodology: The study used a qualitative research approach where in-depth interviews (IDIs) were conducted with study participants across three health facilities in Ghana. A purposive sampling technique was used to select participants. All interviews were audio recorded, transcribed, and coded into themes using QSR Nvivo 12 software before thematic content analysis. Results: Our findings revealed that DHT reduced the workload on the healthcare providers and also ensures continuity of care. Participants perceived that DHT was fast, and ensures quality and accurate information, which could be easily accessed by health professionals for better decision making. However, poor internet connectivity and erratic power supplies were reported as the main impediments causing delays and frustrations to the staff at the study health facilities. Conclusion: The study found that DHT has a positive effect on the work of health professionals. However, poor internet connectivity and unstable power supply caused delays in the provision of care and disruptions in the work process affecting the smooth operation of the DHT and threatening to erode the potential benefits to the health system and users.

Cardiovascular disease prevention: Community Based Asset Mapping within religious networks in a rural Sub-Saharan African neighbourhood.

Prevalence of conditions which raise cardiovascular risk, such as hypertension and type 2 diabetes are seeing a dramatic rise in Sub Saharan Africa. A large proportion of these cases remain undiagnosed and there is limited resource to provide patients with self-management support and education once diagnosed. This study aimed to identify and catalogue community-based assets for the purposes of developing and deploying a screening and education programme for cardiometabolic risk factors (diabetes and hypertension) within religious organisations in a local community in a rural Ghanaian context. We utilised a community-based form of participatory research made up of a number of different components including community-based asset mapping and stakeholder consultation, supplemented by 18 in-depth interviews and 10 focus groups with n = 115 service users, to map existing assets with relevance to cardiometabolic health in this setting and context. Thematic analysis of interview and focus group data was performed to identify themes related to successful implementation of health screening. Two stakeholder workshops with local healthcare professionals, faith leaders and health policy makers were delivered to co-produced a prioritised list of recommendations and 'asset map' to aid deployment of mass screening within faith organisations in this context. The findings of this research highlight a number of 'hidden' community assets and motivational mechanisms at an individual, community and institutional levels; these have informed a list of recommendations which have been co-developed with the stakeholder group and local community to support the development of effective screening strategies for cardiometabolic conditions within faith organisations in this context. We have identified key mechanisms and assets which would support a sustainable screening approach designed to engage an underserved community at high CVD risk to promote general community health and well-being.

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.

Factors affecting trust in clinical trials conduct: Views of stakeholders from a qualitative study in Ghana.

Evidence exists that scientists' dehumanization and exploitation of people in the name of science led to suspicion and mistrust in clinical trials conduct. In Ghana, there are equally signs of public distrust in the conduct of biomedical research. Typical examples are the unsuccessful conduct of the Ebola vaccine trial and the initial refusal of parents to allow their children to receive the recently piloted malaria vaccine in Ghana. Therefore, this study explored participants' views on factors affecting trust in clinical trials conduct in Ghana. This was a cross-sectional exploratory study using qualitative research approach. Forty-eight in-depth interviews and Key informant interviews were conducted with stakeholders. Purposive sampling technique was used to select participants. All the interviews were recorded, transcribed and coded into themes using QSR Nvivo 12 software to aid thematic analysis. Overall, participants saw the need for the conduct of clinical trials in Ghana because clinical trial studies enable scientists to come out with effective medicines for the management of diseases. Pre-implementation factors such as inadequate stakeholder engagement, rumours and negative influence affected trust. Implementation factors such as perceived risks about clinical trials medicines, apprehensions on drawing and use of blood samples, poor informed consent administration and perceived no illness all negatively affected trust in clinical trials conduct. Trust is a fundamental factor affecting a successful conduct of clinical trials. Thus, there is need for collective efforts by all stakeholders including research institutions and clinical trial regulatory bodies to take the issue of trust in clinical trials conduct seriously.

Electronic health records post-implementation challenges in selected hospitals: A qualitative study in the Central Region of southern Ghana.

BACKGROUND: Electronic health records (EHRs) are useful tools in healthcare settings but implementation in low and middle-income countries (LMIC) face challenges. OBJECTIVE: To explore post-implementation challenges affecting the deployment of EHRs and their use in selected health facilities in Ghana. METHOD: Using a qualitative research approach, 21 in-depth interviews were conducted with health workers in two hospitals in the study area in Ghana, in February and June 2020. Purposive sampling was used to select participants. All interviews were audio recorded, transcribed, and coded into themes using QSR Nvivo12 software to aid thematic analyses. RESULTS: Post-implementation challenges were grouped into lack of technological, logistical and managerial support, and inadequate training. Inadequate equipment was the most reported post-implementation challenge that affected EHR use. Unreliable Internet and network connectivity was a source of frustration, which caused staff to develop negative attitudes towards use of the system. Lack of funding stalled implementation of the system and limited its use to critical care units only. It was also the reason replacement of equipment delayed. CONCLUSION: While EHR post-implementation challenges facing health facilities are surmountable, managerial support, backed with the requisite logistical and technical support is needed. It is not enough to rely on funding; health institutions should prioritise emerging EHR post-implementation challenges in their operating budgets. IMPLICATIONS: A national framework is needed to guide effective and sustainable EHR implementation across the country.

Children born during the hunger season are at a higher risk of severe acute malnutrition: Findings from a Guinea Sahelian ecological zone in Northern Ghana.

Heightened food insecurity in the hunger season increases the risk of severe acute malnutrition (SAM) in childhood. This study examined the association of season of birth with SAM in a Guinean Sahelian ecological zone. We analyzed routine health and sociodemographic surveillance data from the Navrongo Health and Socio-demographic Surveillance System collected between 2011 and 2018. January-June, the period of highest food insecurity, was defined as the hunger season. We defined moderate acute malnutrition as child mid-upper arm circumference (MUAC) between 115 mm and 135 mm and SAM as MAUC ≤ 115 mm. We used adjusted logistic regression to quantify the association between the season of birth and SAM in children aged 6-35 months. From the 29,452 children studied, 24% had moderate acute malnutrition. Overall, 1.4% had SAM, with a higher prevalence (1.8%) in the hunger season of birth. Compared with those born October-December, adjusted odds ratios (aOR) and 95% confidence interval (95% CI) for SAM were increased for children born in the hunger season: January-March (1.77 [1.31-2.39]) and April-June (1.92 [1.44-2.56]). Low birth weight, age at an assessment of nutritional status, and ethno-linguistic group were also significantly associated with SAM in adjusted analyses. Our study established that being born in the hunger season is associated with a higher risk of severe acute malnutrition. The result implies improvement in the food supply to pregnant and lactating mothers through sustainable agriculture or food system change targeting the hunger season may reduce the burden of severe acute malnutrition.

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.

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.

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.

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.

Stakeholder Perspectives on Barriers and Facilitators on the Implementation of the 1000 Days Plus Nutrition Policy Activities in Ghana.

Optimizing nutrition in the preconception and 1000 days periods have long-term benefits such as higher economic productivity, reduced risk of related non-communicable diseases and increased health and well-being. Despite Ghana's recent progress in reducing malnutrition, the situation is far from optimal. This qualitative study analyzed the maternal and child health nutrition policy framework in Ghana to identify the current barriers and facilitators to the implementation of nutrition policies and programs relating to the first 1000 days plus. Data analyzed included in-depth interviews and focus group discussions conducted in Ghana between March and April 2019. Participants were composed of experts from government agencies, civil society organizations, community-based organizations and international partners at national and subnational levels. Seven critical areas were identified: planning policy implementation, resources, leadership and stakeholders' engagement, implementation guidance and ongoing communication, organizational culture, accountability and governance and coverage. The study showed that, to eradicate malnutrition in Ghana, priorities of individual stakeholders have to be merged and aligned into a single 1000 days plus nutrition policy framework. Furthermore, this study may support stakeholders in implementing successfully the 1000 days plus nutrition policy activities in Ghana.

Correction: How does it affect service delivery under the National Health Insurance Scheme in Ghana? Health providers and insurance managers perspective on submission and reimbursement of claims.

[This corrects the article DOI: 10.1371/journal.pone.0247397.].

How does it affect service delivery under the National Health Insurance Scheme in Ghana? Health providers and insurance managers perspective on submission and reimbursement of claims.

INTRODUCTION: In 2003, the Government of Ghana launched the National Health Insurance Scheme (NHIS) to enable all Ghanaian residents to have access to health services at the point of care without financial difficulty. However, the system has faced a number of challenges relating to delays in submission and reimbursement of claims. This study assessed views of stakeholders on claims submission, processing and re-imbursement under the NHIS and how that affected health service delivery in Ghana. METHODS: The study employed qualitative methods where in-depth interviews were conducted with stakeholders in three administrative regions in Ghana. Purposive sampling method was used to select health facilities and study participants for the interviews. QSR Nvivo 12 software was used to code the data into themes for thematic analysis. RESULTS: The results point to key barriers such as lack of qualified staff to process claims, unclear vetting procedure and the failure of National Health Insurance Scheme officers to draw the attention of health facility staff to resolve discrepancies on time. Participants perceived that lack of clarity, inaccurate data and the use of non-professional staff for NHIS claims vetting prolonged reimbursement of claims. This affected operations of credentialed health facilities including the provision of health services. It is perceived that unavailability of funds led to re-use of disposable medical supplies in health service delivery in credentialed health facilities. Stakeholders suggested that submission of genuine claims by health providers and regular monitoring of health facilities reduces errors on claims reports and delays in reimbursement of claims. CONCLUSION: Long delays in claims reimbursement, perceived vetting discrepancies affect health service delivery. Thus, effective collaboration of all stakeholders is necessary in order to develop a long-term strategy to address the issue under the NHIS to improve health service delivery.

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.

'I am still confused as to what caused the problem': Perceptions of mothers on communication regarding newborn illness and death in Northern Ghana.

Neonatal morbidity and mortality remain a significant challenge in Ghana. Given the relationship between care-seeking and understanding of illness, this study aimed to explore mothers' perceptions of the cause of illness and/or death in Northern Ghana. All neonatal deaths and near-misses (babies who survived a life-threatening complication) in 2015 and 2016 were identified through a community - and facility-based surveillance system. Mothers of the deceased or ill infants participated in open narrative qualitative interviews. Narratives that included discussion of whether the mother understood what caused the baby's illness or death were analysed. Interviews with 155 mothers included discussion of their perception of the cause of newborn illness or death. Of the 155 interviews, 108 interviews involved mothers whose babies died, and 47 interviews involved mothers whose newborns survived a life-threatening illness, a neonatal 'near-miss'. Very few expressed a clear understanding of the cause of death or illness. Those mothers who did not understand were either not told or did not understand the cause of illness or death. Newborn health outcomes may be improved by increased maternal awareness and understanding of neonatal illnesses. Future interventions need to address communication issues that impair mothers' understanding, facilitate recognition of danger signs, and prompt timely care-seeking.