Effectiveness of a culturally tailored text messaging program for promoting cervical cancer screening in accra, Ghana: a quasi-experimental trial.

INTRODUCTION: Despite breakthroughs in cervical cancer detection, resource-constrained countries continue to have a disproportionately high incidence and death rate. Mhealth has been identified as an important tool for increasing cervical cancer screening rates in Sub-Saharan Africa. We determined whether sending Ghanaian women culturally tailored one-way mobile phone SMS text messages about cervical cancer would encourage the uptake of the human papillomavirus (HPV) test. METHODS: From August to November 2016, 88 women aged 18 to 39 living or working in an urban community (Accra, Ghana) participated in a quasi-experimental study. For 8 weeks, 32 SMS messages regarding cervical cancer were developed and sent to the personal phones of intervention arm participants (n = 42). Women in the control group (n = 46) received SMS texts with general health and lifestyle advice. Fischer's exact tests were performed to assess cervical cancer screening uptake and associated reasons for non-uptake between the intervention and control groups (p < 0.05). RESULTS: At the baseline, women differed in terms of ethnicity and wealth. After the intervention, participants' self-reported risk factors for cervical cancer, such as early menarche, usual source of medical treatment, family history of cancer, smoking, and alcohol history, changed. None of the women in the intervention group sought cervical cancer screening after the intervention, but only one (2.2%) of the control arm participants did. Almost all the women (> 95%) agreed that an HPV test was essential and that regular healthcare check-ups could help prevent cervical cancer. Some women believed that avoiding particular foods could help prevent cervical cancer (23.8% intervention vs. 58.7% control, p < 0.001). Time constraints and out-of-pocket expenses were significant barriers to cervical cancer screening. CONCLUSION: A one-way SMS delivered to urban women did not increase cervical cancer screening attendance. The time spent in screening facilities and the lack of coverage by the National Health Insurance Scheme limited screening uptake. We urge for the establishment of screening centers in all healthcare facilities, as well as the inclusion of cervical cancer screening in healthcare programs through cost-sharing.

Leveraging Lessons Learned from Yellow Fever and Polio Immunization Campaigns during COVID-19 Pandemic, Ghana, 2021.

Ghana is a yellow fever-endemic country and experienced a vaccine-derived polio outbreak in July 2019. A reactive polio vaccination campaign was conducted in September 2019 and preventive yellow fever campaign in November 2020. On March 12, 2020, Ghana confirmed its first COVID-19 cases. During February-August 2021, Ghana received 1,515,450 COVID-19 vaccines through the COVID-19 Vaccines Global Access initiative and other donor agencies. We describe how systems and infrastructure used for polio and yellow fever vaccine deployment and the lessons learned in those campaigns were used to deploy COVID-19 vaccines. During March-August 2021, a total of 1,424,008 vaccine doses were administered in Ghana. By using existing vaccination and health systems, officials in Ghana were able to deploy COVID-19 vaccines within a few months with <5% vaccine wastage and minimal additional resources despite the short shelf-life of vaccines received. These strategies were essential in saving lives in a resource-limited country.

Community-Based Surveillance and Geographic Information System‒Linked Contact Tracing in COVID-19 Case Identification, Ghana, March‒June 2020.

In response to the COVID-19 pandemic, Ghana implemented various mitigation strategies. We describe use of geographic information system (GIS)‒linked contact tracing and increased community-based surveillance (CBS) to help control spread of COVID-19 in Ghana. GIS-linked contact tracing was conducted during March 31-June 16, 2020, in 43 urban districts across 6 regions, and 1-time reverse transcription PCR testing of all persons within a 2-km radius of a confirmed case was performed. CBS was intensified in 6 rural districts during the same period. We extracted and analyzed data from Surveillance Outbreak Response Management and Analysis System and CBS registers. A total of 3,202 COVID-19 cases reported through GIS-linked contact tracing were associated with a 4-fold increase in the weekly number of reported SARS-CoV-2 infected cases. CBS identified 5.1% (8/157) of confirmed cases in 6 districts assessed. Adaptation of new methods, such as GIS-linked contact tracing and intensified CBS, improved COVID-19 case detection in Ghana.

Determinants of metabolic syndrome among patients attending diabetes clinics in two sub-urban hospitals: Bono Region, Ghana.

BACKGROUND: Over 70% of individuals with type 2 diabetes mellitus (T2DM) may have metabolic syndrome in sub-Saharan Africa. Evidence about the prevalence, clustering, and determinants of metabolic syndrome components is needed to guide the implementation of interventions to prevent cardiovascular diseases in low-income countries. METHODS: A clinic-based cross-sectional study was conducted among 430 out-patients attending two-selected diabetes mellitus clinics in the Bono Region of Ghana. Data was collected in June 2016 among participants aged 30-79 years. The prevalence of metabolic syndrome was assessed using the harmonized definition. Patients were interviewed using semi-structured questionnaires and T2DM status was confirmed by reviewing medical records. The components of MS that were assessed included body mass index, waist circumference, systolic blood pressure, diastolic blood pressure, triglycerides, high-density lipoprotein (HDL)-cholesterol, and blood glucose. Multiple logistic regression models were constructed to evaluate the risk factors of MS. RESULTS: The mean age of participants was 58.8 ± 11.49 years. The prevalence of MS was 68.6% (95% CI: 64.0-72.8), higher among women (76.3%, 95% CI: 70.6-81.2) than men (58.0%, 95% CI: 35.0-49.4) and in the 50-59-year age group (32.1%). The majority of participants [248 (57.7%)] had either two [124 (28.8%)] or four [124 (28.8%)] components of MS. Excluding fasting blood glucose (78.4%), the predominant components of MS identified in the study were reduced HDL cholesterol (70.2%), high waist circumference (60.9%), and elevated systolic blood pressure (49.8%). The study found that the odds of MS in women are 2.2-fold higher than in men (95% CI: 1.29-3.58, p = 0.003). Duration of T2DM (OR 5.2, 95% CI: 2.90-9.31, p < 0.001) and overweight status (OR 6.1, 95% CI: 3.70-10.07 p < 0.001) were also found to be significant determinants of MS. CONCLUSIONS: Metabolic syndrome was common among patients attending routine diabetes mellitus clinics in sub-urban hospitals in the middle belt of Ghana. Significant factors associated with metabolic syndrome included being female, living with diabetes for more than five years, and being overweight. Nationwide advocacy for routine screening and prevention of the syndrome should be initiated to prevent cardiovascular disease and mortality in this vulnerable population.

Socio-economic determinants of maternal health care utilization in Kailahun District, Sierra Leone, 2020.

BACKGROUND: Ascertaining the key determinants of maternal healthcare service utilization and their relative importance is critical to priority setting in policy development. Sierra Leone has one of the world's highest maternal death ratios in the context of a weak health system. The objectives of this study were to determine; the level of utilization of Antenatal Care (ANC), Skilled Delivery Attendants (SDA), Postnatal Care (PNC) services, and factors that influence the utilization of these services. METHODS: We conducted a community-based cross-sectional study involving 554 women of reproductive age (15-49 years) who had at least one delivery in the last 3 years and lived in the Kailahun District, Sierra Leone from November 2019 to October 2020. Data were analysed using analysed using bivariate, multivariate and multinomial logistic regression models. RESULTS: The median age of respondents was 25 years (Q1 = 17 years, Q3 = 30 years). Eighty-nine percent (89%) had 4 or more ANC visits. Only 35.9% of women were delivered by SDA. Women residing in urban areas had over six-fold increased odds of utilizing SDA as compared to women residing in rural areas (AOR = 6.20, 95% CI = 3.61-10.63). Women whose husbands had a primary level of education had 2.38 times increased odds of utilizing SDA than women whose husbands had no education (AOR = 2.38, 95% CI = 1.30-4.35). Women that walked longer distances (30-60 min) to seek healthcare had 2.98 times increased odds of utilizing SBA than those that walked shorter distances (< 30 min) (AOR = 2.98, 95% CI = 1.67-5.33). Women who had a secondary/vocational level of education had 2.35 times increased odds of utilizing the standard PNC category as compared to those with no education (OR = 2.35, 95% CI = 1.19-4.63). CONCLUSION: The majority of women had 4 or more ANC visits yet the use of skilled birth attendants was low. Urban residence and education were significantly associated with the use of the standard PNC category. To improve the utilization of maternal health care services, national healthcare policies should target the advancement of education, train skilled Maternal Healthcare (MHC) attendants, rural infrastructure, and the empowerment of women.

Obstetric determinants of preterm delivery in a regional hospital, Accra, Ghana 2016.

BACKGROUND: Globally, prematurity is a major determinant of morbidity and mortality contributing 30-40% of neonatal mortality. The consequences of preterm deliveries are enormous with developmental and childhood complications as well as high economic and psycho-social burden on the parents (family) and society. Some risk factors include ever having preterm delivery, multiple births and some medical conditions like sexually transmitted infection and urinary tract infections but these have not been ascertained in our study area. Much research into these risk factors is needed in Ghana. We assessed the obstetric determinants of preterm delivery. METHODS: We conducted a 1:2 unmatched case-control study in Greater Accra Regional Hospital (GARH) -Ridge, a secondary referral facility in Accra, Ghana (from October, 2015 -May, 2016). A case was a mother who delivered between 28 and 36 weeks of gestation (preterm) and a control was a mother who delivered after 37 to 42 completed weeks (term). We used structured questionnaire to collect data, reviewed maternal and foetal records using a checklist. Categorical variables were analysed and expressed as frequencies and proportions. We determined the association between obstetric factors and preterm delivery with multiple logistic regression. Significance level of the strength of association was determined at 95% CI and p-value < 0.05. RESULTS: We recruited 390 mothers, 130 had preterm deliveries (cases) and 260 had term deliveries (controls). Experiencing premature rupture of membrane (aOR: 2.3; 95% CI:1.0-5.5), pre-eclampsia/eclampsia (aOR: 3.4; 95% CI: 1.0-11.9) were found to be associated with preterm delivery. However, four or more ANC visit was protective factor for preterm delivery (aOR: 0.2; 95% CI: 0.1-0.4). CONCLUSION: Premature rupture of membrane, hypertensive complications and antepartum haemorrhage were found to be risk factors associated with preterm delivery in Ridge Hospital. Health workforce providing ANC services need to identify risk factors and refer these mothers to the doctor for early management and improved outcome decreasing preterm delivery.

Emergency response time and pre-hospital trauma survival rate of the national ambulance service, Greater Accra (January - December 2014).

BACKGROUND: Every year, about 1.2 million people die through road traffic crashes worldwide. Majority of these deaths occur in Africa where most of their emergency medical services are underdeveloped. In 2004, Ghana established the National Ambulance Council to provide timely and efficient pre-hospital emergency medical care to the sick and injured. Pre-hospital emergency medical service is essential for accident victims since it has the potential of saving lives. The study sought to determine the relationship between pre-hospital trauma survival rate and response time to emergencies and factors associated to pre-hospital trauma survival  in Accra, Ghana. METHODS: The study was a cross sectional study which reviewed pre-hospital care forms of trauma patients from the fourteen ambulance stations in the Greater Accra region from January to December 2014. Data were extracted from these forms and the response time estimated. Conscious patients who were alert were categorized as responsive under the AVPU scale. The proportion of patients who survived pre-hospital trauma and  the time pre-hospital trauma cases were responded to was estimated. Multiple logistic regression analysis was conducted to determine which variables were associated with survival. RESULTS: A total of 652 pre-hospital care forms were reviewed. About 87% survived pre-hospital trauma. The average response time to patients was (16.9 ± 0.7) minutes and the median transportation time of the patient was 82 min. Level of consciousness of a patient and response time of patients transported was found to be significantly associated with pre-hospital trauma survival. CONCLUSION: There was a high trauma patient survival rate among victims attended to by an NAS. The average response time in Greater Accra region in the 14 ambulance stations is 16.9 min which is not different from the 17 min recorded in 2013 by NAS. Factors that were associated with pre-hospital survival were alertness in the level of consciousness and response time less than 17 min.

Epidemiological link of a major cholera outbreak in Greater Accra region of Ghana, 2014.

BACKGROUND: Cholera remains an important public health challenge globally. Several pandemics have occurred in different parts of the world and have been epidemiologically linked by different researchers to illustrate how the cases were spread and how they were related to index cases. Even though the risk factors associated with the 2014 cholera outbreak were investigated extensively, the link between index cases and the source of infection was not investigated to help break the transmission process. This study sought to show how the index cases from various districts of the Greater Accra Region may have been linked. METHODS: We carried out a descriptive cross sectional study to investigate the epidemiological link of the 2014 cholera outbreak in the Greater Accra region of Ghana. An extensive review of all district records on cholera cases in the Greater Accra region was carried out. Index cases were identified with the help of line lists. Univariate analyses were expressed as frequency distributions, percentages, mean ± Standard Deviation, and rates (attack rates, case-fatality rates etc.) as appropriate. Maps were drawn using Arc GIS and Epi info software to describe the pattern of transmission. RESULTS: Up to 20,199 cholera cases were recorded. Sixty percent of the cases were between 20 and 40 years and about 58% (11,694) of the total cases were males. Almost 50% of the cases occurred in the Accra Metro district. Two-thirds of the index cases ate food prepared outside their home and had visited the Accra Metropolis. CONCLUSIONS: The 2014 cholera outbreak can be described as a propagated source outbreak linked to the Accra Metropolis. The link between index cases and the source of infection, if investigated earlier could have helped break the transmission process. Such investigations also inform decision-making about the appropriate interventions to be instituted to prevent subsequent outbreaks.

Prevalence and correlates of diarrhoea among children under five in selected coastal communities in Ghana.

INTRODUCTION: Diarrhoea is a preventable disease affecting children under five years disproportionately. Globally, thousands of children die from diarrhoea related diseases each year, most deaths occuring in sub-Saharan Africa where Ghana is located. Coastal communities bear the greatest brunt due to poor sanitary conditions. We assess the prevalence of diarrhoea in selected coastal communities along the eastern coast of Ghana. METHODS: We conducted a cross-sectional study in Mumford, Opetekwei, Anyako, Anyauni and Ateteti communities in the Central, Greater Accra and Volta region respectively. We interviewed households with children under five years on the occurrence of diarrhoea and health seeking practices. We also used a checklist to assess the sanitary conditions of the household. Frequencies and proportions were generated. We determined significant differences using modified Poisson regression models at p < 0.05. Results were presented in tables and text. RESULTS: The prevalence ratio of diarrhoea was 36% (95% CI 33-40%). Most cases were from Anyako community. All interviewed households in Mumford and Opetekwei used improved water sources whiles 94% in Atetetio used improved water sources. Children who were fully vaccinated had 32% lower prevalence of diarrhoea compared to those who were not (aPR: 0.68, 95% CI 0.55-0.84). CONCLUSION: Diarrhoea prevalence was high inspite of the reported use of improved water sources and sanitation facilities by majority of households in the communities. Fully vaccinated children had a relatively lower prevalence of diarrhoea compared to children who were not fully vaccinated. We recommend in-depth analysis of the use of water and sanitation facilities in these settings to understand the reasons for the observed diarrhoea prevalence.

A study to evaluate WASH interventions and risk factors of diarrhoea among children under five years, Anloga district, Ghana: A research protocol.

INTRODUCTION: Good Water, Sanitation and Hygiene (WASH) practices, introduction of Rotavirus vaccination, zinc supplementation and improved nutrition have contributed significantly to the reduction of diarrhoea morbidity and mortality globally by 50%. In spite of these gains, diarrhoea still remains a leading cause of morbidity and mortality in children under-five. Causes of diarrhoea are multifaceted with many factors such as seasonality, behaviour, pathogenicity, epidemiology, etc. However, assessments on the causes of diarrhoea have generally been tackled in silos over the years focusing only on particular causes. In this study, we describe an integrated approach (evaluating WASH interventions implantation processes, assessing epidemiolocal risk factors, and identifying pathogens causing diarrhoea) for assessing determinants of diarrhoea. METHODS: The study has ethical approval from the Ghana Health Service Ethical Review Committee (GHSERC:020/07/22). It will employ three approaches; a process evaluation and a case-control study and laboratory analysis of diarrhoea samples. The process evaluation will assess the detailed procedures taken by the Anloga district to implement WASH interventions. A desk review and qualitative interviews with WASH stakeholders purposively sampled will be done. The evaluation will provide insight into bottlenecks in the implementation processes. Transcribed interviews will be analysed thematically and data triangulated with reviews. A 1:1 unmatched case-control study with 206 cases and 206 controls to determine risk factors associated with diarrhoea in children under-five will also be done. Odds ratios at 5.0% significance level would be calculated. Stool samples of cases will be taken and tested for diarrhoea pathogens using Standard ELISA and TAQMAN Array Card laboratory procedures. EXPECTED OUTCOME: It is expected that this framework proposed would become one of the robust approaches for assessing public health community interventions for diseases. Through the process evaluation, epidemiological case-control study and pathogen identification, we would be able to identify the gaps in the current diarrhoea assessments, come up with tailored recommendations considering the existing risk and assumptions and involve the relevant stakeholders in reducing the diarrhoea burden in a coastal setting in Ghana.

Hypertension Among Cohort of Persons With Human Immunodeficiency Virus Initiated on a Dolutegravir-Based Antiretroviral Regimen in Ghana.

Background: Dolutegravir (DTG), a new antiretroviral drug, is being integrated into antiretroviral regimens for people with human immunodeficiency virus (PWH) in Ghana. There is little evidence of the effect of DTG on blood pressure (BP) levels in sub-Saharan Africa, especially West Africa. Our aim was to assess the incidence and predictors of hypertension (HTN) among PWH initiated on a DTG-based antiretroviral regimen in Ghana. Methods: An observational multicenter longitudinal study was conducted among PWH in Ghana from 2020 to 2022. BPs of nonhypertensive patients with BP ≤120/80 mm Hg at baseline were measured at 3, 6, 12, and 18 months post-DTG initiation. The primary outcome of the study was incidence of HTN, defined as BP ≥140/90 mm Hg. Kaplan-Meier estimator was used to estimate risk of developing HTN. Cox proportional hazards model with robust standard errors was used to estimate hazard ratios (HRs). Results: HTN prevalence among PWH screened was 37.3% (1366/3664). The incidence of de novo HTN among nonhypertensive PWH at 72 weeks was 598.4 per 1000 person-years (PY) (95% confidence interval [CI], 559.2-640.3) with incidence proportion of 59.90 (95% CI, 57.30-62.44). A quarter of those with de novo HTN developed it by month 6. Obesity (adjusted HR [aHR], 1.27 [95% CI, 1.05-1.54]), abnormal serum urea (aHR, 1.53 [95% CI, 1.27-1.85]), and low high-density lipoprotein (aHR, 1.45 [95% CI, 1.22-1.72]) were risk factors for HTN. Conclusions: Incidence of HTN was high among PWH on DTG. There is a need to monitor BP for HTN in adult PWH as well as traditional risk factors to reduce the burden of HTN and its complications.

Validating the indicator "maternal death review coverage" to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record data.

BACKGROUND: Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility- versus district-level data. METHODS AND FINDINGS: We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of a review, the percentage of reviews that met the World Health Organization defined standard for maternal and perinatal death surveillance and response. Results were stratified by sociodemographic characteristics of women and facility location and type. We compared these estimates to that obtained using district-level data. and looked at evidence of the review at the district/provincial level. Study teams reviewed facility records at 34 facilities in Argentina, 51 facilities in Ghana, and 282 facilities in India. In total, we found 17 deaths in Argentina, 14 deaths in Ghana, and 58 deaths in India evidenced at facilities. Overall, >80% of deaths had evidence of a review at facilities. In India, a much lower percentage of deaths occurring at secondary-level facilities (61.1%) had evidence of a review compared to deaths in tertiary-level facilities (92.1%). In all three countries, only about half of deaths in each country had complete reviews: 58.8% (n = 10) in Argentina, 57.2% (n = 8) in Ghana, and 41.1% (n = 24) in India. Dramatic reductions in indicator value were seen in several subnational geographic areas, including Gonda and Meerut in India and Sunyani in Ghana. For example, in Gonda only three of the 18 reviews conducted at facilities met the definitional standard (16.7%), which caused the value of the indicator to decrease from 81.8% to 13.6%. Stratification by women's sociodemographic factors suggested systematic differences in completeness of reviews by women's age, place of residence, and timing of death. CONCLUSIONS: Our study assessed the validity of an important indicator for ending preventable deaths: the coverage of reviews of maternal deaths occurring in facilities in three study settings. We found discrepancies in deaths recorded at facilities and those reported to districts from facilities. Further, few maternal death reviews met global quality standards for completeness. The value of the calculated indicator masked inaccuracies in counts of both deaths and reviews and gave no indication of completeness, thus undermining the ultimate utility of the measure in achieving an accurate measure of coverage.

Validating the implementation of an indicator reporting policies and laws on free public maternal health-related services in the era of universal health coverage: A multi-country cross-sectional study.

BACKGROUND: The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization's Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, "Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?", captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries. METHODS AND FINDINGS: We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15-49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures. CONCLUSIONS: Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.

Self-medication with antibiotics among out-patient attendants at Madina Polyclinic prior to medical consultation.

Objectives: The study aimed to determine the prevalence of self-medication with antibiotics among attendants of the Out-patient Department (OPD) at Madina Polyclinic before seeking medical consultation and associated factors. Design: Cross-sectional study. Setting: The study was conducted at Madina Polyclinic. Participants: The study involved 319 general OPD attendants aged 18 years and above accessing healthcare services at the Madina Polyclinic between May and June 2019. Main outcome measures: The prevalence of antibiotic self-medication and the factors associated with this practice. Results: From the study, 46.4% (95% CI 40.8%- 52.0%) had self-medicated with antibiotics before presenting for medical consultation at the hospital. Less than half of the respondents (44.5%) had adequate knowledge about the use of antibiotics. Having a tertiary level of education was significantly associated with self-medication (aOR= 8.09, 95% CI 2.31-28.4, p = 0.001), whilst adequate knowledge on the use of antibiotics reduced the odds of self-medication by 53% (aOR= 0.47, 95% CI 0.23- 0.66, p<0.001). The level of education modified the relationship between knowledge and self-medication with antibiotics. Conclusion: The practice of antibiotic self-medication is rife among OPD attendants. Therefore, adequate public education on the use of antibiotics and the effects of using them inappropriately must be done. The Antimicrobial Resistance (AMR) policy ought to be reinforced and made known to all, especially among the pharmacies that dispense antibiotics indiscriminately. Funding: None declared.

Universal coverage and utilization of free long-lasting insecticidal nets for malaria prevention in Ghana: a cross-sectional study.

Background: Malaria continues to be one of the leading causes of mortality and morbidity, especially among children and pregnant women. The use of Long-Lasting Insecticide Nets (LLINs) has been recognized and prioritized as a major intervention for malaria prevention in Ghana. This study aims to establish the factors influencing the universal coverage and utilization of LLINs in Ghana. Methods: The data used for this study was from a cross-sectional survey carried out to assess LLINs ownership and use in 9 out of the 10 old regions of Ghana from October 2018 to February 2019 where free LLIN distribution interventions were implemented. The EPI "30 × 7" cluster sampling method (three-stage sampling design) was modified to "15 × 14" and used for the study. A total of 9,977 households were interviewed from 42 districts. Descriptive statistics using percentages as well as tests of associations such as Pearson Chi-square and the magnitude of the associations using simple and multivariable logistic regression were implemented. Results: Of the 9,977 households in the study, 88.0% of them owned at least one LLIN, universal coverage was 75.6%, while utilization was 65.6% among households with at least one LLIN. In the rural and urban areas, 90.8% and 83.2% of households, respectively, owned at least one LLIN. The was a 44% increase in universal coverage of LLINs in rural areas compared to urban areas (AOR: 1.44, 95% CI: 1.02-2.02). There were 29 higher odds of households being universally covered if they received LLIN from the PMD (AOR: 29.43, 95% CI: 24.21-35.79). Households with under-five children were 40% more likely to utilize LLIN (AOR: 1.40, 95% CI: 1.26-1.56). Respondents with universal coverage of LLIN had 25% increased odds of using nets (AOR: 1.25 95% CI: 1.06-1.48). Rural dwelling influences LLIN utilization, thus there was about 4-fold increase in household utilization of LLINs in rural areas compared to urban areas (AOR: 3.78, 95% CI: 2.73-5.24). Household size of more than 2 has high odds of LLINs utilization and awareness of the benefit of LLINs (AOR: 1.42, 95% CI: 1.18-1.71). Conclusion: About nine in 10 households in Ghana have access at least to one LLIN, three-quarters had universal coverage, and over two-thirds of households with access used LLIN. The predictors of universal coverage included region of residence, rural dwellers, and PMD campaign, while households with child under-five, in rural areas, and with universal coverage were positively associated with utilization.

Comparative analysis of clinical characteristics of COVID-19 among vaccinated and unvaccinated patients in a major treatment facility in Ghana.

Objectives: To compare clinical characteristics of COVID-19 among vaccinated and unvaccinated patients in a major treatment facility in Ghana. Design: A retrospective study drawing on data from COVID-19 patients' records visiting the facility from March 2021 to December 2021. Setting: Ghana Infectious Disease Centre, Ga East Municipality, Greater Accra Region, Ghana. Participants: In-patients and outpatients who reported to the facility from 1st March 2021 to December 2021 were included in the study, and patients with missing data on vaccination were excluded. Outcome measures: underlying conditions, symptoms, case management information, hospital service rendered (OPD, HDU or ICU), length of hospital stay, treatment outcome. Results: The study included 775 patient records comprising 615 OPD and 160 hospitalised cases. Less than one-third (26.25%; 42) of the patients hospitalised were vaccinated compared to almost 40.0% (39.02%; 240) of the patients seen at the OPD. Vaccinated individuals were nearly three times (aOR = 2.72, 95%CI:1.74-4.25) more likely to be managed on an outpatient basis as compared to the unvaccinated. The death rate among the vaccinated group and the unvaccinated were (0.71%; 2) and (3.45%; 17), respectively, with a significant reduction in the risk of dying among the vaccinated compared to the unvaccinated (aOR = 0.13, 95%CI: 0.028 0.554). Conclusions: Less than half of the in-patient and OPD patients were vaccinated. Mild infections, fewer days of hospitalisation, outpatient treatment and higher chances of survival were associated with being vaccinated against SARS-CoV-2. Prudent measures should be implemented to encourage the general public to take up SARS-CoV-2 vaccines. Funding: None declared.

Evaluation of Container Clinics as an Urban Immunization Strategy: Findings from the First Year of Implementation in Ghana, 2017-2018.

BACKGROUND: In 2017, the Expanded Programme on Immunization in Ghana opened two container clinics in Accra, which were cargo containers outfitted to deliver immunizations. At each clinic, we assessed performance and clinic acceptance during the first 12 months of implementation. METHODS: We employed a descriptive mixed-method design using monthly administrative immunization data, exit interviews with caregivers of children of <5 years (N = 107), focus group discussions (FGDs) with caregivers (n = 6 FGDs) and nurses (n = 2 FGDs), and in-depth interviews (IDIs) with community leaders (n = 3) and health authorities (n = 3). RESULTS: Monthly administrative data showed that administered vaccine doses increased from 94 during the opening month to 376 in the 12th month across both clinics. Each clinic exceeded its target doses for the 12-23 month population (second dose of measles). Almost all (98%) exit interview participants stated that the clinics made it easier to receive child health services compared to previous health service interactions. The accessibility and acceptability of the container clinics were also supported from health worker and community perspectives. CONCLUSIONS: Our initial data support container clinics as an acceptable strategy for delivering immunization services in urban populations, at least in the short term. They can be rapidly deployed and designed to serve working mothers in strategic areas.

Measuring adequacy of the midwifery workforce using standards of competency and scope of work: Exploring the density and distribution of midwives in three low- and middle-income countries using cross-sectional and geospatial data.

BACKGROUND: A global midwifery shortage hampers the goal of ending preventable maternal/newborn mortality and stillbirths. Whether current measures of midwifery workforce adequacy are valid is unknown. We compare two measures of density and distribution of midwifery professionals to assess their consistency, and explore how incorporating midwifery scope, competency, and the adjusting reference population impacts this critical metric. METHODS AND FINDINGS: We collected a census of midwives employed in eligible facilities in our study settings, (422 in Ghana; 909 in India), assessed the number practicing within the scope of work for midwifery professionals defined in the International Labor Organization International Standard Classification of Occupations, and whether they reported possessing the ICM essential competencies for basic midwifery practice. We altered the numerator, iteratively narrowing it from a simple count to include data on scope of practice and competency and reported changes in value. We altered the denominator by calculating the number of midwives per 10,000 total population, women of reproductive age, pregnancies, and births and explored variation in the indicator. Across four districts in Ghana, density of midwives decreased from 8.59/10,000 total population when counting midwives from facility staffing rosters to 1.30/10,000 total population when including only fully competent midwives by the ICM standard. In India, no midwives met the standard, thus the midwifery density of 1.37/10,000 total population from staffing rosters reduced to 0.00 considering competency. Changing the denominator to births vastly altered subnational measures, ranging from ~1700% change in Tolon to ~8700% in Thiruvallur. CONCLUSION: Our study shows that varying underlying parameters significantly affects the value of the estimate. Factoring in competency greatly impacts the effective coverage of midwifery professionals. Disproportionate differences were noted when need was estimated based on total population versus births. Future research should compare various estimates of midwifery density to health system process and outcome measures.

Under-reporting of adverse drug reactions: Surveillance system evaluation in Ho Municipality of the Volta Region, Ghana.

BACKGROUND: Adverse Drug Reactions (ADRs) can occur with all medicines even after successful extensive clinical trials. ADRs result in more than 10% of hospital admissions worldwide. In Ghana, there has been an increase of 13 to 126 ADR reports per million population from 2012 to 2018. ADR Surveillance System (ADRSS) also known as pharmacovigilance has been put in place by the Ghana Food and Drugs Authority (FDA) to collect and manage suspected ADR reports and communicate safety issues to healthcare professionals and the general public. The ADRSS in Ho Municipality was evaluated to assess the extent of reporting of ADRs and the system's attributes; determine its usefulness, and assess if the ADRSS is achieving its objectives. METHODS: We evaluated the ADRSS of the Ho Municipality from January 2015 to December 2019. Quantitative data were collected through interviews and review of records. We adapted the updated CDC guidelines to develop interview guides and a checklist for data collection. Attributes reviewed included simplicity, data quality, acceptability, representativeness, timeliness, sensitivity, predictive value positive and stability. RESULTS: We found a total of 1,237 suspected ADR during the period, of which only 36 (3%) were reported by healthcare professionals in the Ho Municipality to the National Pharmacovigilance Centre (NPC). Only 43.9% of health staff interviewed were familiar with the ADRSS and its reporting channel. Staff who could mention at least one objective of the ADRSS were 34.2%, and 12.2% knew the timelines for reporting ADR. Reports took a median time of 41 (IQR = 25, 81) days from reporter to NPC. Reports sent on time constituted 37.5%. Fully completed case forms constituted 77.1% and the predictive value positive (PVP) was 20%. About 53% of ADRs were reported for female patients. Up to 88.9% of ADRs were classified as drug related. Anti-tuberculosis agents and other antibiotics constituted (40.6%) and (18.8%) of all reports. The ADRSS was not integrated into the disease surveillance and response system of Ghana's Health Service and so was not flexible to changes. A dedicated ADR surveillance officer in regions helped with the system's stability. Data from Ghana feeds into a WHO database for global decision making. CONCLUSIONS: There was under-reporting of ADRs in the Ho Municipality from January 2015 to December 2019. The ADR surveillance system was simple, stable, acceptable, representative, had a strong PVP but was not flexible or timely. The ADRSS was found useful and partially met its objectives.

Validation of a measure to assess decision-making autonomy in family planning services in three low- and middle-income countries: The Family Planning Autonomous Decision-Making scale (FP-ADM).

BACKGROUND: Integrating measures of respectful care is an important priority in family planning programs, aligned with maternal health efforts. Ensuring women can make autonomous reproductive health decisions is an important indicator of respectful care. While scales have been developed and validated in family planning for dimensions of person-centered care, none focus specifically on decision-making autonomy. The Mothers Autonomy in Decision-Making (MADM) scale measures autonomy in decision-making during maternity care. We adapted the MADM scale to measure autonomy surrounding a woman's decision to use a contraceptive method within the context of contraceptive counselling. This study presents a psychometric validation of the Family Planning Autonomous Decision-Making (FP-ADM) scale using data from Argentina, Ghana, and India. METHODS AND FINDINGS: We used cross-sectional data from women in four subnational areas in Argentina (n = 890), Ghana (n = 1,114), and India (n = 1,130). In each area, 20 primary sampling units (PSUs) were randomly selected based on probability proportional to size. Households were randomly selected in Ghana and India. In Argentina, all facilities providing reproductive and maternal health services within selected PSUs were included and women were randomly selected upon exiting the facility. Interviews were conducted with a sample of 360 women per district. In total, 890 women completed the FP-ADM in Argentina, 1,114 in Ghana and 1,130 in India. To measure autonomous decision-making within FP service delivery, we adapted the items of the MADM scale to focus on family planning. To assess the scale's psychometric properties, we first examined the eigenvalues and conducted a parallel analysis to determine the number of factors. We then conducted exploratory factor analysis to determine which items to retain. The resulting factors were then identified based on the corresponding items. Internal consistency reliability was assessed with Cronbach's alpha. We assessed both convergent and divergent construct validity by examining associations with expected outcomes related to the underlying construct. The Eigenvalues and parallel analysis suggested a two-factor solution. The two underlying dimensions of the construct were identified as "Bidirectional Exchange of Information" (Factor 1) and "Empowered Choice" (Factor 2). Cronbach's alpha was calculated for the full scale and each subscale. Results suggested good internal consistency of the scale. There was a strong, significant positive association between whether a woman expressed satisfaction with quality of care received from the healthcare provider and her FP-ADM score in all three countries and a significant negative association between a woman's FP-ADM score and her stated desire to switch contraceptive methods in the future. CONCLUSIONS: Our results suggest the FP-ADM is a valid instrument to assess decision-making autonomy in contraceptive counseling and service delivery in diverse low- and middle-income countries. The scale evidenced strong construct, convergent, and divergent validity and high internal consistency reliability. Use of the FP-ADM scale could contribute to improved measurement of person-centered family planning services.