Poliovirus antibody levels and lameness among individuals in three regions of Ghana.

Introduction: Ghana recorded the last case of poliomyelitis caused by wild poliovirus in 2008 and the country was declared polio-free in 2015. Polio-neutralizing-antibody levels in the population of three geographically representative regions of Ghana was determined, to identify possible immunity gaps. Methods: Cross-sectional, hospital (1-70 years old) and school (primary, 1-15 years old)-based studies were undertaken in three regions in 2016. Individuals who visited the three teaching hospitals of the regions and were referred for haematology investigations were invited to participate in our study. Neutralizing-antibody titers to polio serotypes P1, P2, and P3 were assayed by WHO-standards. Antibody titers of ≥8 were considered protective. In the school lameness survey, clinical and epidemiological data were obtained from parents and their lamed children. Bivariate and multivariate analyses were conducted on subject characteristics, to assess potential factors for failure to seroconvert. P-values < 0.05 were considered statistically significant. Results: Neutralizing-antibodies against poliovirus types 1, 2 and 3 were detected in 86% (264/307), 84% (258/307) and 75% (230/307) of the samples, respectively. Overall, 60.1% (185/307) were seropositive for the three polio serotypes and 2.9% (9/307) were seronegative. Polio neutralizing-antibodies (P1and P2) decreased with age (p < .001). Low seroprevalence of polio-neutralizing-antibodies was significantly associated with low school attendance of mothers (p < .001). Prevalence of residual paralysis was <1.0/1,000 among the school children. Conclusion: Our study population is moderately protected against the three poliovirus serotypes. However, immunity appears to be lower with a higher age and low mother's education. This may suggest the need for young-adult booster-dose to minimize the risk of wild poliovirus infection.

Treating fever in children under 5 years of age: caregiver perceptions of community health worker services in Dangme West district, Ghana.

BACKGROUND: Integrated community case management of childhood illnesses is a key strategy to help reduce mortality in children under 5 years; particularly those with difficult access to treatment. However, the success of such strategies depends on community utilization of services. This study assessed community utilization, perceptions and related factors of community health worker services. METHODS: Data were gathered from a cross-sectional survey among 562 caregivers and focus group discussions among 84 caregivers. Factors related to utilization of community health workers (CHWs) for management of childhood fevers were analyzed using logistic regression and focus group discussions to explore caregiver perceptions of CHW activities. RESULTS: Utilization of CHWs for management of fever in under-5s was 59.4%. Caregivers who were exposed to the communication intervention were about four times more likely to use the services of the CHWs compared to those who were not exposed (OR 3.79; 95% CI: 2.62-5.49; p<0.001). Farmers were 84% more likely to use CHW services for children sick with fever compared to those who were unemployed (OR 1.84; 95% CI: 1.00-3.39; p=0.05). Caregiver perceptions of the program were generally positive; most caregivers expressed satisfaction with the CHW services, citing prompt treatment, friendliness and free medicines. Male involvement in the CHW program was comparatively low. CONCLUSIONS: Dissemination of information among priority groups can enhance utilization of CHW services. Exploring the perspective of both men and women to gain in-depth understanding on their views on male involvement will be useful for planning appropriate strategies to get more males involved in community-based child health programs.

Factors related to retention of community health workers in a trial on community-based management of fever in children under 5 years in the Dangme West District of Ghana.

BACKGROUND: In resource-constrained settings of developing countries, promotion of community-based health interventions through community health workers (CHWs) is an important strategy to improve child health. However, there are concerns about the sustainability of such programmes owing to the high rate of CHW attrition. This study examined factors influencing retention of volunteer CHWs in a cluster randomised trial on community management of under-5 fever in a rural Ghanaian district. METHODS: Data were obtained from structured interviews (n=520) and focus group discussions (n=5) with CHWs. Factors influencing CHWs' decisions to remain or leave the programme were analysed using a probit model, and focus group discussion results were used to elucidate the findings. RESULTS: The attrition rate among CHWs was 21.2%. Attrition was comparatively higher in younger age groups (25.9% in 15-25 years group, 18.2% in 26-45 years group and 16.5% in ≥46 years group). Approval of a CHW by the community (p<0.001) and the CHW's immediate family (p<0.05) were significant in influencing the probability of remaining in the programme. Motivation for retention was related to the desire to serve their communities as well as humanitarian and religious reasons. CONCLUSION: The relatively moderate rate of attrition could be attributed to the high level of community involvement in the selection process as well as other aspects of the intervention leading to high community approval and support. Attention for these aspects could help improve CHW retention in community-based health interventions in Ghana, and the lessons could be applied to countries within similar settings.

Illness meanings and experiences for pre-ulcer and ulcer conditions of Buruli ulcer in the Ga-West and Ga-South Municipalities of Ghana.

BACKGROUND: Ghana is a Buruli ulcer (BU) endemic country yet there is paucity of socio-cultural research on BU. Examining distinctive experiences and meanings for pre-ulcers and ulcers of BU may clarify the disease burden, illness experience and local perceptions of causes and spread, and environmental features of BU, which are useful to guide public health programmes and future research. This study aimed to explain local meanings and experiences of BU for persons with pre-ulcers and ulcers in the Ga-West and Ga-South municipalities in Accra. METHODS: Semi-structured interviews based on the Explanatory Model Interview Catalogue framework were administered to 181 respondents comprising 15 respondents with pre-ulcers and 166 respondents with ulcers. The Wilcoxon rank-sum test was used to compare categories of illness experiences (PD) and perceived causes (PC) among respondents with pre-ulcer and ulcer conditions. The Fisher's exact test was used to compare the most troubling PD and the most important PC variables. Qualitative phenomenological analysis of respondents' narratives clarified illness experiences and meanings with reference to PC and PD variables. RESULTS: Families of respondents with pre-ulcers and the respondents themselves were often anxious about disease progression, while families of respondents with ulcers, who had to give care, worried about income loss and disruption of school attendance. Respondents with pre-ulcers frequently reported swimming in ponds and rivers as a perceived cause and considered it as the most important PC (53.3%). Respondents with ulcers frequently attributed their BU illness to witchcraft (64.5%) and respondents who claimed they had no water contact, questioned the credibility of health messages CONCLUSIONS: Affected persons with pre-ulcers are likely to delay treatment because of social and financial constraints and the absence of pain. Scepticism on the role of water in disease contagion and prolonged healing is perceived to make ideas of witchcraft as a PC more credible, among respondents with ulcers. Health messages should address issues of locally perceived risk and vulnerability. Guided by study findings, further research on the role of environmental, socio-cultural and genetic factors in BU contagion, is also needed to clarify and formulate health messages and strengthen public health initiatives.

Socio-cultural determinants of timely and delayed treatment of Buruli ulcer: Implications for disease control.

INTRODUCTION: Public health programmes recommend timely medical treatment for Buruli ulcer (BU) infection to prevent pre-ulcer conditions from progressing to ulcers, to minimise surgery, disabilities and the socio-economic impact of BU. Clarifying the role of socio-cultural determinants of timely medical treatment may assist in guiding public health programmes to improve treatment outcomes. This study clarified the role of socio-cultural determinants and health system factors affecting timely medical treatment for BU in an endemic area in Ghana. METHODS: A semi-structured explanatory model interview based on the explanatory model interview catalogue (EMIC) was administered to 178 BU-affected persons. Based on research evidence, respondents were classified as timely treatment (use of medical treatment 3 months from awareness of disease) and delayed treatment (medical treatment 3 months after onset of disease and failure to use medical treatment). The outcome variable, timely treatment was analysed with cultural epidemiological variables for categories of distress, perceived causes of BU, outside-help and reasons for medical treatment in logistic regression models. The median time for the onset of symptoms to treatment was computed in days. Qualitative phenomenological analysis of respondents' narratives clarified the meaning, context and dynamic features of the relationship of explanatory variables with timely medical treatment. RESULTS: The median time for initiating treatment was 25 days for pre-ulcers, and 204 days for ulcers. Income loss and use of herbalists showed significantly negative associations with timely treatment. Respondents' use of herbalists was often motivated by the desire for quick recovery in order to continue with work and because herbalists were relatives and easily accessible. However, drinking unclean water was significantly associated with timely treatment and access to health services encouraged timely treatment (OR 8.5, p = 0.012). Findings show that health system factors of access are responsible for non-compliance to treatment regimes. CONCLUSIONS: Findings highlight the importance of an integrated approach to BU control and management considering the social and economic features that influence delayed treatment and factors that encourage timely medical treatment. This approach should consider periodic screening for early case-detection, collaboration with private practitioners and traditional healers, use of mobile services to improve access, adherence and treatment outcomes.

Help-seeking for pre-ulcer and ulcer conditions of Mycobacterium ulcerans disease (Buruli ulcer) in Ghana.

This study examined sociocultural features of help-seeking for Buruli ulcer-affected persons with pre-ulcers and ulcers in a disease-endemic area in Ghana. A sample of 181 respondents were purposively selected. Fisher's exact test was used to compare help-seeking variables for pre-ulcers and ulcers. Qualitative phenomenologic analysis of narratives clarified the meaning and content of selected quantitative help-seeking variables. For pre-ulcers, herbal dressings were used to expose necrotic tissues and subsequently applied as dressings for ulcers. Analgesics and left-over antibiotics were used to ease pain and reduce inflammation. Choices for outside-help were influenced by the perceived effectiveness of the treatment, the closeness of the provider to residences, and family and friends. Health education is required to emphasize the risk of self-medication with antibiotics and the importance of medical treatment for pre-ulcers, and to caution against the use of herbs to expose necrotic tissues, which could lead to co-infections.

Community Health Education in Rural Ghana: the Danfa project-an assessment of accomplishments. 1981-82.

The Danfa Comprehensive Rural Health and Family Planning Project was a joint effort of the Ghana Medical School, the Ministry of Health, UCLA, and USAID. A health education component was developed as an integral part of program inputs during the initial conceptual phase of the project. As a result non-equivalent experimental and control areas were designated permitting an assessment of program impact during a five-year period (1972-1977) for which baseline and follow-up study data were available. A new cadre of community-based workers (Health Education Assistants) was developed from existing health personnel in the country, and trained in health education and multipurpose health work. Although the HEAs were found to have difficulty in bringing about changes in health practices when other support services were not available, they did have measurable impact on villagers' adoption of family planning methods and a number of specific health practices.