Individual risk preference as a predictor of health behaviour: evidence from the use of condoms against HIV/AIDS in Ghana.

BACKGROUND: It is evident that public health education interventions to promote the use of condoms against HIV infections in Ghana have yielded modest results. However, existing studies in the field of sexual and reproductive health in Ghana have failed to account for differences in risk preferences of individuals. This study fills the gap by investigating how individuals' risk preferences predict their behaviour toward using condoms against HIV in Ghana. METHOD: Conceptually, the study followed the Grossman health capital theoretical model for risk preference and health behaviour nexus. Data were obtained from the most recent Ghana Living Standards Survey Round 7 (GLSS 7), conducted in 2017. Using data from GLSS 7, a probit regression model was estimated to show how the risk preferences of individuals that did not abstain from sex predicted their use of condoms against HIV. To ensure robustness, two scenarios of declared risk preferences were used to predict the use of condom behaviour against HIV. RESULTS: Probit regression estimation shows that the risk preferences of individuals that did not abstain from sex significantly predicted their use of condoms against HIV in Ghana. Even though the study found that the predicted probability of using a condom reduces among risk-averse individuals that do not abstain from sex, not using a condom against HIV was found to be worse among risk lovers. CONCLUSION: The study provides empirical evidence that public health education against HIV/AIDS in Ghana cannot continue to ignore the risk preference of individuals. The results of this study have immediate implications, first for a comprehensive and continuous measurement of risk preferences among Ghanaians in major household surveys going forward. At the moment, the latest round of the GLSS is just about the only household survey in Ghana that has attempted to collect some data on individual time and risk preferences using only hypothetical monetary rewards. Second is the immediate consideration of individual risk preferences in public health education campaigns against HIV/AIDS in Ghana.

Response to patient safety incidents in healthcare settings in Ghana: the role of teamwork, communication openness, and handoffs.

BACKGROUND: Patient safety incidents (PSIs) in healthcare settings are a critical concern globally, and Ghana is no exception. Addressing PSIs to improve health outcomes requires various initiatives to be implemented including improving patient safety culture, teamwork and communication between healthcare providers during handoffs. It is essential to acknowledge the significance of teamwork, communication openness, and effective handoffs in preventing and managing such incidents. These factors play a pivotal role in ensuring the well-being of patients and the overall quality of healthcare services. AIM: This study assessed the occurrence and types of PSIs in health facilities in Ghana. It also examined the role of teamwork, handoffs and information exchange, and communication openness in response to PSIs by health professionals. METHODS: A cross-sectional study was conducted among 1651 health workers in three regions of Ghana. Using a multi-staged sampling technique, the Survey on Patient Safety Culture Hospital Survey questionnaire and the nurse-reported scale were used to collect the data and it was analysed by descriptive statistics, Pearson correlation, and linear multiple regression model at a significance of 0.05. RESULTS: There was a reported prevalence of PSIs including medication errors (30.4%), wound infections (23.3%), infusion reactions (24.7%), pressure sores (21.3%), and falls (18.7%) at least once a month. There was a satisfactory mean score for responses to adverse events (3.40), teamwork (4.18), handoffs and information exchange (3.88), and communication openness (3.84) among healthcare professionals. Teamwork, handoffs and information exchange and communication openness were significant predictors of response to PSIs, accounting for 28.3% of the variance. CONCLUSIONS: Effective teamwork, handoffs and information exchange, and communication openness in the healthcare environment are critical strategies to enhance PSI response. Creating a culture that encourages error response through teamwork, communication and handoffs provides healthcare professionals with opportunities for learning and improving patient outcomes. Training programs should therefore target health professionals to improve patient safety and competency. Through the implementation of evidence-based practices and learning from past incidents, the healthcare system will be able to deliver safe and high-quality care to patients nationwide. Patient safety must be recognized as an ongoing process. Therefore, a meaningful improvement in patient outcomes requires all stakeholders' commitment.

The effect of community engagement on healthcare utilization and health insurance enrollment in Ghana: Results from a randomized experiment.

Health insurance enrollment in many Sub-Saharan African countries is low, even with highly subsidized premiums and exemptions for vulnerable populations. One possible explanation is low service quality, which results in a low valuation of health insurance. Using a randomized control trial in 64 primary health care facilities in Ghana, this study assesses the impact of a community engagement intervention designed to improve the quality of healthcare and health insurance services on households living nearby the facilities. Although the intervention improved the medical-technical quality of health services, our results show that households' subjective perceptions of the quality of healthcare and insurance services did not increase. Nevertheless, the likelihood of illness and concomitant healthcare utilization reduced, and especially households who were not insured at baseline were more likely to enroll in health insurance. The results show that solely increasing the technical quality of care is not sufficient to increase households' subjective assessments of healthcare quality. Still, improving technical quality can directly contribute to health outcomes and further increase health insurance coverage, especially among the previously uninsured.

Financing COVID-19 vaccination in sub-Saharan Africa: lessons from a nation-wide willingness to pay (WTP) survey in Ghana.

BACKGROUND: Over 13 million doses of the corona virus disease, 2019 (COVID-19) vaccines have been administered in Ghana as at March, 2022; 28.5% of the population have received one dose while 16.3% have been fully vaccinated. Cost associated with COVID-19 vaccinations in low- and middle-income countries (LMICs) requires rethinking on sustainable funding arrangements to consolidate gains made towards containing the COVID-19 pandemic. OBJECTIVE: Ascertain the determinants of willingness to pay (WTP) for COVID-19 vaccination among adult eligible population in Ghana, and prefer evidence-based policy recommendations on sustainable financing regime for COVID-19 vaccination in the global south. METHODS: Setting/design: A cross-sectional web-based survey was conducted among adult population aged 18 years and above across the sixteen (16) administrative regions of Ghana. PARTICIPANTS: A sub-sample of 697 participants willing to receive the COVID-19 vaccine was used as the unit of analysis. OUTCOME MEASURES: main outcome measures of interests were willingness to pay for COVID-19 vaccination and the specific amount respondents were willing to pay. The odds of WTP and specific amount were predicted using the step-wise backward logistic regression and backward step-wise OLS, respectively. RESULTS: A total of 2,107 adult respondents aged 18 years and above were reached out to answer the questionnaire; 1,556 successfully completed the questionnaire, representing 74% response rate. Out of the 1,556 valid responses, 697 said they will receive the COVID-19 vaccine. Out of the 697 sub-sample willing to accept the vaccine, 386 (55%) were willing to pay an average of US$6.00 for the vaccine. Positive predictors of WTP were: being an educated male (OR = 0.55, 95% [CI = 0.366, 0.826], p = 0.004), married and educated (OR = 2.19, 95% [CI = 1.077, 4.445], p = 0.030), being a married health worker (OR = 0.43, 95% [CI = 0.217, 0.845], p = 0.015), and having positive perception of the vaccine (OR = 2.40, 95% [CI = 1.144, 5.054], p = 0.021). High WTP amounts correlated positively with adherence to COVID-19 prevention protocols (Coef. = 10.30, 95% [CI = 0.463, 20.137], p = 0.040) and being a health worker with tertiary education (Coef. = 56.339, 95% [CI = 8.524, 104.154], p = 0.021). Christians who are also health workers by occupation were less likely to pay higher amounts for the vaccine (Coef. = -71.431, 95% [CI = 118.821, -24.040], p = 0.003). CONCLUSIONS: WTP for COVID-19 vaccination in Ghana is low relative to comparative studies in the sub-region. There is the need for accelerated, advocacy and public education on the benefits of vaccination. Likewise, there should be broader stakeholder engagement and national dialogue on sustainable financing options for COVID-19 vaccination as donor support continues to dwindle for LIMCs like Ghana.

Hospital managers' views on the state of patient safety culture across three regions in Ghana.

BACKGROUND: Improving patient safety culture in healthcare organisations contributes positively to the quality of care and patients' attitudes toward care. While hospital managers undoubtedly play critical roles in creating a patient safety culture, in Ghana, qualitative studies focussing on hospital managers' views on the state of patient safety culture in their hospitals remain scanty. OBJECTIVE: This study aimed to explore the views of hospital managers regarding compliance to patient safety culture dimensions in the selected hospitals in the Bono, Greater Accra, and Upper East regions of Ghana. METHODOLOGY: This was a qualitative exploratory study. A purposive sampling of all hospital managers involved in patient safety practices was conducted. The sampled managers were then invited to a focus group discussion. Twelve focus group discussions with each consisting of a maximum of twelve participants were conducted. The ten patient safety culture dimensions adapted from the Agency for Healthcare Research and Quality's patient safety culture composite measures framed the interview guide. Deductive thematic content analysis was done. Lincoln and Guba's methods of trustworthiness were applied to ensure that the findings are valid and reliable. FINDINGS: Positive patient safety culture behaviours such as open communication, organisational learning, and strong teamwork within units, were an established practice in the selected facilities across Ghana. Lack of teamwork across units, fear of reporting adverse events, the existence of a blame culture, inconsistent response to errors, extreme shortage of staff, sub-standard handover, lack of management support with resources constrained the patient safety culture. The lack of standardised policies on reporting adverse events and response to errors encouraged managers to use various approaches, some resulting in a blame culture. Staff shortage contributed to poor quality of safety practices including poor handover which was also influenced by lateness to duty. CONCLUSION: Prompt and appropriate responses by managers to medical errors require improvements in staffing and material resources as well as the enactment of standard policies across health facilities in the country. By so doing, hospital managers would contribute significantly to patient safety, and help build a patient safety culture in the selected hospitals.

Satisfied or not satisfied? Electronic health records system implementation in Ghana: Health leaders' perspective.

BACKGROUND: Electronic Health Records (EHR) has been espoused to be an innovation from the paper-based system, with benefits such as fast access to patient information thereby facilitating healthcare provider communication, healthcare continuity and improved quality of care. However, it is the extent of the quality of the electronic health records that determines the access to these stated benefits. The quality of health care records indirectly contributes to patient safety because inaccurate patient data can lead to improper diagnosis and consequently wrong treatment of patients. Most hospitals in Ghana, have recently transitioned into the EHR system, hence, there is a need to assess its accuracy, impact on workflow, staff training on usage, support from the EHR team, and the overall satisfaction of the EHR system. As health leaders are at the frontline of its implementation, their views on the challenges and successes of the EHR system are imperative. METHOD: This qualitative study sought to explore the views of the health leaders on the implemented electronic health records system in nine (9) hospitals within three (3) regions in Ghana. Following ethical approval, GHS-ERC:007/04/21, focus group discussions were conducted with a minimum of 10 hospital leaders in each facility. These included quasi, government and private hospitals. Data was collected between September and November 2021. RESULTS: The study found poor quality of records, lack of involvement of frontline clinicians in the development of the EHR system, inadequate training of staff and limited workstations as some of the challenges associated with the use of EHR in hospitals. Health leaders were generally not satisfied with the EHR system. CONCLUSION: It is recommended that addressing inputs from end-users as well as circulating more computers will motivate EHR usage and acceptance. Provision of additional workstations for the various units and involvement of staff in the system development would be most prudent to enable health workers to accept the EHR system in improving the quality of care.

Trends and correlates of maternal, newborn and child health services utilization in primary healthcare facilities: an explorative ecological study using DHIMSII data from one district in the Volta region of Ghana.

BACKGROUND: Sustainable Development Goal 3 aims at reducing global neonatal mortality to at least 12 per 1000 livebirths, under-five mortality to at least 25 per 1000 livebirths and maternal mortality ratio to less than 70 per 100,000 livebirths by 2030. Considering the achievement so far, many countries in sub-Saharan Africa, including Ghana are not likely to achieve these targets. Low utilization of maternal, newborn and child health (MNCH) services partly account for this predicament. This study explored the trend and correlates of MNCH services utilization in one administrative district in the Volta Region of Ghana. METHODS: This is an explorative ecological study employing trend analysis of 2015-2017 data from Ghana Health Service District Health Information Management System II. Univariate Poisson regression models were used to determine the factors associated with MNCH services utilization at 95% confidence level. RESULTS: Cumulative record of 17,052 antenatal care (ANC) attendance and 2162 facility-based spontaneous vaginal deliveries (SVDs) was discovered. Compelling evidence of potential unskilled deliveries was observed in 23% of the 26 facilities reported in the DHIMSII data. High cumulative number of midwives in health facilities associated positively with high records of ANC visits (IRR = 1.30, [95% CI:1.29, 1.32]; p = 0.0001), facility-based SVDs (IRR = 1.30 [95% CI:1.25, 1.35]; p = 0.0001) and BCG immunizations (IRR = 1.32 [95% CI:1.29, 1.34]; p = 0.0001). Likewise, high records of ANC visits correlated positively with high facility-based SVDs and child immunizations records (p < 0.0001). CONCLUSION: Targeted health system and community level interventions alongside progressive frontline health staff motivation and retention strategies could further enhance enrollment and retention of mothers in pre-natal and postnatal care services throughout the continuum of care to guarantee better MNCH health outcomes. Investments in universal coverage for quality ANC services has the potential to enhance utilization of supervised deliveries and post-natal care services such as immunizations.

Impact of a bottom-up community engagement intervention on maternal and child health services utilization in Ghana: a cluster randomised trial.

BACKGROUND: Ghana is among African countries not likely to achieve the Sustainable Development Goal (SDG) three (3) target of reducing maternal mortality to 70 per 100,000 live births by the year 2030 if maternal and child health services utilization are not improved. Community engagement in health is therefore advocated to help address this challenge. This study evaluated the impact of a community engagement intervention on maternal and child health services utilization in Ghana. METHODS: This study was a cluster randomised trial among primary healthcare facilities (n = 64) in the Greater Accra and Western regions in Ghana. Multivariate multiple regression analysis and paired-ttest were used to determine impact of the community engagement intervention on maternal and child health indicators at baseline and follow-up. RESULTS: Intervention health facilities recorded significant improvements over control facilities in terms of average spontaneous vaginal deliveries per month per health facility (baseline mean = 15, follow-up mean = 30, p = 0.0013); child immunizations (baseline mean = 270, follow-up mean = 455, p = 0.0642) and female condoms distribution (baseline mean = 0, follow-up mean = 2, p = 0.0628). Other improved indicators in intervention facilities were average number of Human Immunodeficiency Virus (HIV) tests for non-pregnant women (baseline mean = 55, follow-up 104, p = 0.0213); HIV tests for pregnant women (baseline mean = 40, follow-up mean = 119, p = 0.0067) and malaria tests (baseline mean = 43, follow-up mean = 380, p = 0.0174). Control facilities however performed better than intervention facilities in terms of general laboratory tests, voluntary counselling and testing, treatment of sexually transmitted infections, male child circumcisions and other minor surgical procedures. CONCLUSION: Community engagement in health has the potential of improving utilization of maternal and child health services. There is the need for multi-stakeholder dialogues on complementing existing quality improvement interventions with community engagement strategies.

Subscribers' perception of quality of services provided by Ghana's National Health Insurance Scheme - what are the correlates?

BACKGROUND: Ghana's National Health Insurance Scheme (NHIS) has witnessed an upsurge in enrollment since its inception in 2003, with over 40% of the Ghanaian population actively enrolled in the scheme. While the scheme strives to achieve universal health coverage, this quest is derailed by negative perceptions of the quality of services rendered to NHIS subscribers. This paper presents an analysis on perceptions of service quality provided to subscribers of Ghana's NHIS with emphasis on rural and urban scheme policy holders, using a nationally representative data. METHODS: The study used data from the 2014 Ghana Demographic and Health Survey. Ordered logistic regressions were estimated to identify the correlates of perceived quality of care of services rendered by the NHIS. Also, chi-square statistics were performed to test for significant differences in the proportions of subscribers in the two subsamples (rural and urban). RESULTS: Rural subscribers of the NHIS were found to identify more with better perception of quality of services provided by the NHIS than urban subscribers. Results from the chi-square statistics further indicated that rural subscribers are significantly different from urban subscribers in terms of the selected socioeconomic and demographic characteristics. In the full sample; age, out-of-pocket payment for healthcare and region of residence proved significant in explaining perceived quality of services rendered by the NHIS. Age, out-of-pocket payment for healthcare, region of residence, wealth status, and access to media were found to be significant predictors of perceived quality of services provided to both rural and urban subscribers of the NHIS. The significance of these variables varied among men and women in rural and urban areas. CONCLUSION: Different factors affect the perception of quality of services provided to rural and urban subscribers of Ghana's NHIS. Health financing policies geared toward improving the NHIS-related services in rural and urban areas should be varied.

Respiratory and non-respiratory symptoms associated with pesticide management practices among farmers in Ghana's most important vegetable hub.

The data presented here are from the Offinso North District Farm Health Study (ONFAHS), a population-based cross-sectional study among vegetable farmers in Ghana. The paper addresses knowledge, pesticide handling practices, and protective measures related to pesticide use by self-reported symptoms for 310 adult farmers who completed a comprehensive questionnaire on pesticide management practices and health. In addition, an inventory was prepared using information supplied by pesticide sellers/dealers in this district. We report that cough and wheezing (but not breathlessness) are positively associated with stirring pesticide preparations with bare hands/drinking water while mixing/applying pesticides, and stirring pesticide preparations with bare hands/drinking water/smoking cigarettes while mixing/applying pesticides. There is a significant exposure-response association between the number of precautionary measures practiced while handling pesticides and cough and wheezing but not with breathlessness. We also found unsafe practices to be associated with sexual dysfunction, nervousness, and lack of concentration. The results also suggest a negative association between practice of any precautionary measure when mixing/applying pesticides and sexual dysfunction, nervousness, and lack of concentration. We found that in spite of the fact that farmers have adequate knowledge about the environment and health effects of pesticides, several unhygienic practices are in widespread use, indicating that knowledge is not necessarily always translated in action. Further action is necessary to promote the safe use of pesticides and to replace existing poor management practices among these and other farmers in Ghana.

Determinants of cigarette smoking and smoking intensity among adult males in Ghana.

BACKGROUND: In spite of the adverse health and financial implications of smoking, it still remains one of the leading causes of preventable diseases and deaths in the world. Key to discouraging the habit of smoking is knowledge of the drivers of smoking. In Ghana, though smoking behaviours are relatively more associated with adult males than youth and adolescents, studies on smoking behaviours of adult males are scant. This study, therefore, investigates the determinants of cigarette smoking and smoking intensity among adult males in Ghana. METHODS: Data were obtained from the most recent Ghana Demographic and Health Survey (DHS) conducted in 2014. Based on the 2014 GDHS, a negative binomial-logit hurdle model was estimated to explore the socioeconomic and demographic characteristics associated with cigarette consumption and smoking intensity among adult males in Ghana. To ensure robustness, separate estimations were performed for the respective logit and negative binomial models used in the two-part model. RESULTS: We find that men in lower socioeconomic category (poor and low education) have a higher likelihood to smoke. Also, age proved significant in explaining smoking behaviors in Ghana. Moreover, religion and region of residence are reported to affect cigarette consumption decision. Furthermore, we find that among the men who smoke, those between the ages of 44 and 60 years and have attained approximately primary education have a higher likelihood to smoke greater quantities of cigarette daily. Also, the smokers who reside in the Upper East and Upper West regions are reported to smoke more intensely than their counterparts in the Greater Accra region. CONCLUSION: Since smoking remains one of the major causes of diseases and deaths the world over, the current study provides recent empirical evidence based on a nationally representative sample for public health policies geared towards smoking reduction and ultimately cessation. This study suggests that public policies that promote higher educational attainment and improved incomes (wealth) are crucial in smoking reduction and cessation in Ghana.

Correlates of Early Sexual Debut Among Sexually Active Youth in Ghana.

Using the 2014 Ghana Demographic and Health Survey, this study explores the correlates of early sexual debut among 2,746 (males = 670 and females = 2,076) sexually active youth aged 15 to 24 years in Ghana. The results indicate that males aged 15 to 19 years (odds ratio [ OR] = 8.84, p < .001) and who had basic education ( OR = 3.17, p < .001) were significantly more likely to initiate sexual debut early. Urban males who had used modern contraceptive ( OR = 0.35, p < .001) were significantly less likely to initiate early sexual debut. Meanwhile, females aged 15 to 19 years ( OR = 4.26, p < .001); who had used modern contraceptive ( OR = 1.99, p < .001); with no formal ( OR = 2.90, p < .001) or basic ( OR = 3.12, p < .001) education; with partial access to media ( OR = 1.58, p < .01); and from the Akans ( OR = 1.73, p < .001), Ewes ( OR = 1.92, p < .001), and other ethnic groups ( OR = 1.63, p < .001) were significantly more likely to initiate early sexual debut. However, employed females living in rural areas ( OR = 0.70, p < .01) and those with average ( OR = 0.54, p < .01) or rich ( OR = 0.51, p < .01) household living in urban areas were significantly less likely to initiate early sexual debut. Interventions and policies targeting those living in both rural and urban areas are therefore needed for adolescent males and females in their early teens before they start engaging in sexual intercourse.

Health insurance and quality of care: Comparing perceptions of quality between insured and uninsured patients in Ghana's hospitals.

BACKGROUND: The introduction of health insurance in Ghana in 2003 has resulted in a tremendous increase in utilization of health services. However, concerns are being raised about the quality of patient care. Some of the concerns include long waiting times, verbal abuse of patients by health care providers, inadequate physical examination by doctors and discrimination of insured patients. The study compares perceptions of quality of care between insured and uninsured out-patients in selected hospitals in Ghana to determine whether there is any unequal treatment between insured and uninsured patients in terms of quality of care, as empirical and anecdotal evidence seem to suggest. METHODS: A cross-sectional survey of 818 out-patients was conducted in 17 general hospitals from three regions of Ghana. These are the Upper East, Brong Ahafo and Central Regions. Convenience sampling was employed to select the patients in exit interviews. Descriptive statistics, including frequency distributions, means and standard deviations, were used to describe socio-economic and demographic characteristics of respondents. Factor analysis was used to determine distinct quality of care constructs; t-test statistic was used to test for differences in quality perceptions between the insured and uninsured patients; and regression analysis was used to test the association between health insurance and quality of care. RESULTS: Overall, there was no significant difference in perceptions of quality between insured and uninsured patients. However, there was a significant difference between insured and uninsured patients in respect of financial access to care. The major quality of care concern affecting all patients was the problem of inadequate resources, especially lack of doctors, lack of drugs and other basic supplies and equipment to work with. CONCLUSIONS: It was concluded that generally, insured and uninsured patients are not treated unequally, contrary to prevailing anecdotal and empirical evidence. On the contrary, quality of care is a concern of both insured and uninsured patients.

Associations between pesticide use and respiratory symptoms: A cross-sectional study in Southern Ghana.

BACKGROUND: Indiscriminate use of pesticides is a common practice amongst farmers in Low and Middle Income Countries (LMIC) across the globe. However, there is little evidence defining whether pesticide use is associated with respiratory symptoms. OBJECTIVES: This cross-sectional study was conducted with 300 vegetable farmers in southern Ghana (Akumadan). Data on pesticide use was collected with an interviewed-administered questionnaire. The concentration of seven organochlorine pesticides and 3 pyrethroid pesticides was assayed in urine collected from a sub-population of 100 vegetable farmers by a gas chromatograph equipped with an electron capture detector (GC-ECD). RESULTS: A statistically significant exposure-response relationship of years per day spent mixing/applying fumigant with wheezing [30-60 days/year: prevalence ratio (PR)=1.80 (95% CI 1.30, 2.50); >60days/year: 3.25 (1.70-6.33), p for trend=0.003] and hours per day spent mixing/applying fumigant with wheezing [1-2h/day: 1.20 (1.02-1.41), 3-5h/day: 1.45 (1.05-1.99), >5h/day: 1.74 (1.07-2.81), p for trend=0.0225]; days per year spent mixing/applying fungicide with wheezing [30-60 days/year: 2.04 (1.31-3.17); >60days/year: 4.16 (1.72-10.08), p for trend=0.0017] and h per day spent mixing/applying fungicide with phlegm production [1-2h/day: 1.25 (1.05-1.47), 3-5h/day: 1.55 (1.11-2.17), >5h/day: 1.93 (1.17-3.19), p for trend=0.0028] and with wheezing [1-2h/day: 1.10 (1.00-1.50), 3-5h/day: 1.20 (1.11-1.72), >5h/day: 1.32 (1.09-2.53), p for trend=0.0088]; h per day spent mixing/applying insecticide with phlegm production [1-2h/day: 1.23 (1.09-1.62), 3-5h/day: 1.51 (1.20-2.58), >5h/day: 1.85 (1.31-4.15), p for trend=0.0387] and wheezing [1-2h/day: 1.22 (1.02-1.46), 3-5h/day: 1.49 (1.04-2.12), >5h/day: 1.81 (1.07-3.08), p for trend=0.0185] were observed. Statistically significant exposure-response association was also observed for a combination of activities that exposes farmers to pesticide with all 3 respiratory symptoms. Furthermore, significant exposure-response associations for 3 organochlorine insecticides: beta-HCH, heptachlor and endosulfan sulfate were noted. CONCLUSIONS: In conclusion, vegetable farmers in Ghana may be at increased risk for respiratory symptoms as a result of exposure to pesticides.

Perspectives of frontline health workers on Ghana's National Health Insurance Scheme before and after community engagement interventions.

BACKGROUND: Barely a decade after introduction of Ghana's National Health Insurance Scheme (NHIS), significant successes have been recorded in universal access to basic healthcare services. However, sustainability of the scheme is increasingly threatened by concerns on quality of health service delivery in NHIS-accredited health facilities coupled with stakeholders' discontentment with the operational and administrative challenges confronting the NHIS. The study sought to ascertain whether or not Systematic Community Engagement (SCE) interventions have a significant effect on frontline health workers' perspectives on the NHIS and its impact on quality health service delivery. METHODS: The study is a randomized cluster trial involving clinical and non-clinical frontline health workers (n = 234) interviewed at baseline and follow-up in the Greater Accra and Western regions of Ghana. Individual respondents were chosen from within each intervention and control groupings. Difference-in-difference estimations and propensity score matching were performed to determine impact of SCE on staff perceptions of the NHIS. The main outcome measure of interest was staff perception of the NHIS based on eight (8) factor-analyzed quality service parameters. RESULTS: Staff interviewed in intervention facilities appeared to perceive the NHIS more positively in terms of its impact on "availability and quality of drugs (p < 0.05)" and "workload on health staff/infrastructure" than those interviewed in control facilities (p < 0.1). Delayed reimbursement of service providers remained a key concern to over 70 % of respondents in control and intervention health facilities. CONCLUSION: Community engagement in quality service assessment is a potential useful strategy towards empowering communities while promoting frontline health workers' interest, goodwill and active participation in Ghana's NHIS.

Social capital and active membership in the Ghana National Health Insurance Scheme - a mixed method study.

BACKGROUND: People's decision to enroll in a health insurance scheme is determined by socio-cultural and socio-economic factors. On request of the National health Insurance Authority (NHIA) in Ghana, our study explores the influence of social relationships on people's perceptions, behavior and decision making to enroll in the National Health Insurance Scheme. This social scheme, initiated in 2003, aims to realize accessible quality healthcare services for the entire population of Ghana. We look at relationships of trust and reciprocity between individuals in the communities (so called horizontal social capital) and between individuals and formal health institutions (called vertical social capital) in order to determine whether these two forms of social capital inhibit or facilitate enrolment of clients in the scheme. Results can support the NHIA in exploiting social capital to reach their objective and strengthen their policy and practice. METHOD: We conducted 20 individual- and seven key-informant interviews, 22 focus group discussions, two stakeholder meetings and a household survey, using a random sample of 1903 households from the catchment area of 64 primary healthcare facilities. The study took place in Greater Accra Region and Western Regions in Ghana between June 2011 and March 2012. RESULTS: While social developments and increased heterogeneity seem to reduce community solidarity in Ghana, social networks remain common in Ghana and are valued for their multiple benefits (i.e. reciprocal trust and support, information sharing, motivation, risk sharing). Trusting relations with healthcare and insurance providers are, according healthcare clients, based on providers' clear communication, attitude, devotion, encouragement and reliability of services. Active membership of the NHIS is positive associated with community trust, trust in healthcare providers and trust in the NHIS (p-values are .009, .000 and .000 respectively). CONCLUSION: Social capital can motivate clients to enroll in health insurance. Fostering social capital through improving information provision to communities and engaging community groups in health care and NHIS services can facilitate peoples' trust in these institutions and their active participation in the scheme.

Efficiency of private and public primary health facilities accredited by the National Health Insurance Authority in Ghana.

BACKGROUND: Despite improvements in a number of health outcome indicators partly due to the National Health Insurance Scheme (NHIS), Ghana is unlikely to attain all its health-related millennium development goals before the end of 2015. Inefficient use of available limited resources has been cited as a contributory factor for this predicament. This study sought to explore efficiency levels of NHIS-accredited private and public health facilities; ascertain factors that account for differences in efficiency and determine the association between quality care and efficiency levels. METHODS: The study is a cross-sectional survey of NHIS-accredited primary health facilities (n = 64) in two regions in southern Ghana. Data Envelopment Analysis was used to estimate technical efficiency of sampled health facilities while Tobit regression was employed to predict factors associated with efficiency levels. Spearman correlation test was performed to determine the association between quality care and efficiency. RESULTS: Overall, 20 out of the 64 health facilities (31 %) were optimally efficient relative to their peers. Out of the 20 efficient facilities, 10 (50 %) were Public/government owned facilities; 8 (40 %) were Private-for-profit facilities and 2 (10 %) were Private-not-for-profit/Mission facilities. Mission (Coef. = 52.1; p = 0.000) and Public (Coef. = 42.9; p = 0.002) facilities located in the Western region (predominantly rural) had higher odds of attaining the 100 % technical efficiency benchmark than those located in the Greater Accra region (largely urban). No significant association was found between technical efficiency scores of health facilities and many technical quality care proxies, except in overall quality score per the NHIS accreditation data (Coef. = -0.3158; p < 0.05) and SafeCare Essentials quality score on environmental safety for staff and patients (Coef. = -0.2764; p < 0.05) where the association was negative. CONCLUSIONS: The findings suggest some level of wastage of health resources in many healthcare facilities, especially those located in urban areas. The Ministry of Health and relevant stakeholders should undertake more effective need analysis to inform resource allocation, distribution and capacity building to promote efficient utilization of limited resources without compromising quality care standards.

An assessment of the direct and indirect costs of breast cancer treatment in leading cancer hospitals in Ghana.

BACKGROUND: In Ghana, breast cancer remains the most common cancer and the leading cause of cancer deaths among women. The cost of treating cancer is huge and poses a great challenge for patients, their families, and health care systems. While comprehensive studies have been conducted on the economic burden of cancers in developed economies such as the EU and the US, there are limited studies in Africa, and Ghana, in particular. This study quantitatively assessed Ghana's direct and indirect costs of breast cancer treatment. METHODS: Primary data were collected using a questionnaire administered to 217 breast cancer patients at the Korle-Bu and Komfo Anokye Teaching Hospitals, Ghana's two leading hospitals, and Sweden Ghana Medical Centre. Direct and indirect costs were computed using the Cost-of-Illness Approach. Quantitative analysis was done using multivariate linear regression. RESULTS: The findings showed that the breast cancer patients studied paid a median amount of Ghana cedis (GHC) 31,021.0 (IQR; 25,262.5-42,147.0), approximating USD 5,500.2 (IQR: 4,477.0-7,469.2 USD) for their treatment within one year of active treatment in 2019. About 61.9% (95% CI: 61.8-62.0%) of this cost was direct cost, while the remaining 38.1% (95% CI: 38.0-38.1%) was indirect cost. Patients who sought care from public facilities for breast cancer paid a median amount of GHC 29,606.3 (USD 5,249.3), while those who sought care from private facilities paid GHC 55,071.2 (USD 9,744.4). Findings from the multivariate linear regression indicate that being married/cohabiting, divorced/separated and having tertiary level education predicted higher cost of breast cancer treatment while patients on retirement and patients in the middle stage (Stage II) of breast cancer diagnoses were associated with lower cost of breast cancer treatment. CONCLUSIONS: The cost of breast cancer treatment poses a significant burden on patients and their families. There is a need for increased public funding for breast cancer treatment to reduce the huge economic burden its treatment poses for patients and their families.

Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries.

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

Association between health worker motivation and healthcare quality efforts in Ghana.

BACKGROUND: Ghana is one of the sub-Saharan African countries making significant progress towards universal access to quality healthcare. However, it remains a challenge to attain the 2015 targets for the health related Millennium Development Goals (MDGs) partly due to health sector human resource challenges including low staff motivation. PURPOSE: This paper addresses indicators of health worker motivation and assesses associations with quality care and patient safety in Ghana. The aim is to identify interventions at the health worker level that contribute to quality improvement in healthcare facilities. METHODS: The study is a baseline survey of health workers (n = 324) in 64 primary healthcare facilities in two regions in Ghana. Data collection involved quality care assessment using the SafeCare Essentials tool, the National Health Insurance Authority (NHIA) accreditation data and structured staff interviews on workplace motivating factors. The Spearman correlation test was conducted to test the hypothesis that the level of health worker motivation is associated with level of effort by primary healthcare facilities to improve quality care and patient safety. RESULTS: The quality care situation in health facilities was generally low, as determined by the SafeCare Essentials tool and NHIA data. The majority of facilities assessed did not have documented evidence of processes for continuous quality improvement and patient safety. Overall, staff motivation appeared low although workers in private facilities perceived better working conditions than workers in public facilities (P <0.05). Significant positive associations were found between staff satisfaction levels with working conditions and the clinic's effort towards quality improvement and patient safety (P <0.05). CONCLUSION: As part of efforts towards attainment of the health related MDGs in Ghana, more comprehensive staff motivation interventions should be integrated into quality improvement strategies especially in government-owned healthcare facilities where working conditions are perceived to be the worst.