Improved adherence to test, treat, and track (T3) malaria strategy among Over-the-Counter Medicine Sellers (OTCMS) through interventions implemented in selected rural communities of Fanteakwa North district, Ghana.

BACKGROUND: Prompt diagnosis and treatment of malaria prevents a mild case from developing into severe disease and death. Unfortunately, parasitological testing of febrile children is greater in the public and formal private sector than in the informal private sector where many patients with malaria-like symptoms first seek treatment. This study was aimed at improving implementation of the T3 policy among OTCMS using some interventions that could be scaled-up easily at the national level. METHODS: Interventions were evaluated using a two-arm, cluster randomized trial across 8 rural communities (4 clusters per arm), in two adjacent districts of Ghana. A total of 7 OTCMS in the intervention arm and 5 OTCMS in the control arm in the selected communities participated in the study. Five interventions were implemented in the intervention arm only. These were acquisition of subsidized malaria rapid diagnostic test (RDT) kits, training of OTCMS, supportive visits to OTCMS, community sensitization on malaria, and introduction of malaria surveillance tool. The primary outcome was the proportion of children under 10 years with fever or suspected to have malaria visiting OTCMS and getting tested (using RDT) before treatment. Secondary outcomes included OTCMS adherence to national malaria treatment guidelines and the recommended RDT retail price. Outcomes were measured using mystery client (an adult who pretends to be a real patient) surveys supplemented by a household survey. Proportions were compared using chi-square test or Fisher exact test. RESULTS: Following deployment of interventions, mystery client survey showed that OTCMS' adherence to malaria protocol in the intervention arm increased significantly (p < 0.05) compared to the control arm. Household surveys in the intervention arm showed that caregivers self-treating their children or visiting drug vendors significantly decreased in favour of visits to OTCMS shops for treatment (p < 0.001). End-line malaria testing rate was higher compared with the baseline rate, though not statistically significant (30.8% vs 10.5%; p = 0.1238). OTCMS in the intervention arm also adhered to the subsidized RDT retail price of GHc2.40. CONCLUSION: Interventions targeting OTCMS in rural communities have the potential of improving adherence to the T3 malaria policy and subsequently improving management of uncomplicated malaria in Ghana. TRIAL REGISTRATION: ISRCTN registry ISRCTN77836926. Registered on 4 November 2019.

COVID-19 related perception among some community members and frontline healthcare providers for NTD control in Ghana.

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) pandemic has resulted in a major breakdown of health service provision in the fight against neglected tropical diseases (NTDs). COVID-19 may impact NTDs service delivery in varied ways. As the Ghana NTD programme planned to resume MDA activities, we examined the COVID-19 related perceptions and practices among some community members and frontline health workers for NTD control activities in the country. METHODS: The study was conducted in seven communities in the Ahanta West district of Ghana. This was a qualitative study using in-depth interviews (IDI) and focus group discussions (FGDs) for data collection. Participants were purposively selected from varied backgrounds to represent both beneficiaries and service providers directly involved in NTD programme implementation. Trained and experienced qualitative data collectors conducted the FGD and IDI sessions in the local Twi language, while health worker sessions were conducted in English. Discussions were audio-recorded and transcribed directly into English. Data was analysed using an iterative process. The transcripts were pre-coded using the broad themes, entered into a computer using Microsoft Word, and then imported into the MAXQDA software for thematic content analysis to select relevant representative narratives for presentation. RESULTS: Participants were aware of the COVID-19 pandemic and referred to it appropriately as 'coronavirus', COVID-19, and often as 'the new disease'. Though many respondents could not describe the route of transmission, most of them reported that it is transmitted through touch or sharing of common items. They reported some signs/symptoms like fever, headache and difficulty breathing, and prevention methods like the use of hand sanitiser, washing of hands and sneezing appropriately. Respondents have reported that COVID-19 has negatively affected their daily lives by limiting their movements and therefore work. It also came to light that COVID-19 has also negatively affected the NTD programme implementation, especially mass drug administration (MDA) activities, leading to the postponement of the yearly MDA. The COVID-19 pandemic has negatively affected clinic attendance; people are afraid that they may be tested for COVID-19 at the clinic. CONCLUSION: COVID-19 has negatively affected the NTD programme. Education and the provision of personal protective equipment will be required to build the confidence of frontline care providers including community drug distributors and community members in order to enhance quality service and participation in future MDA activities.

Guiding placement of health facilities using multiple malaria criteria and an interactive tool.

BACKGROUND: Access to healthcare is important in controlling malaria burden and, as a result, distance or travel time to health facilities is often a significant predictor in modelling malaria prevalence. Adding new health facilities may reduce overall travel time to health facilities and may decrease malaria transmission. To help guide local decision-makers as they scale up community-based accessibility, the influence of the spatial allocation of new health facilities on malaria prevalence is evaluated in Bunkpurugu-Yunyoo district in northern Ghana. A location-allocation analysis is performed to find optimal locations of new health facilities by separately minimizing three district-wide objectives: malaria prevalence, malaria incidence, and average travel time to health facilities. METHODS: Generalized additive models was used to estimate the relationship between malaria prevalence and travel time to the nearest health facility and other geospatial covariates. The model predictions are then used to calculate the optimisation criteria for the location-allocation analysis. This analysis was performed for two scenarios: adding new health facilities to the existing ones, and a hypothetical scenario in which the community-based healthcare facilities would be allocated anew. An interactive web application was created to facilitate efficient presentation of this analysis and allow users to experiment with their choice of health facility location and optimisation criteria. RESULTS: Using malaria prevalence and travel time as optimisation criteria, two locations that would benefit from new health facilities were identified, regardless of scenarios. Due to the non-linear relationship between malaria incidence and prevalence, the optimal locations chosen based on the incidence criterion tended to be inequitable and was different from those based on the other optimisation criteria. CONCLUSIONS: This study findings underscore the importance of using multiple optimisation criteria in the decision-making process. This analysis and the interactive application can be repurposed for other regions and criteria, bridging the gap between science, models and decisions.

Factors impacting test-based management of suspected malaria among caregivers of febrile children and private medicine retailers within rural communities of Fanteakwa North District, Ghana.

BACKGROUND: Prompt diagnosis and treatment prevents a mild case of malaria from developing into severe disease and death. Unfortunately, parasitological testing of febrile children is greater in the public and formal private sector than in the informal private sector in sub-Saharan Africa. METHODS: A mixed method study was carried out to determine factors limiting test-based management of suspected malaria cases among caregivers of febrile children and Over-the-Counter medicine sellers (OTCMS) in eight rural communities in Ghana. Structured questionnaires were used to interview 254 adult caregivers. Fourteen in-depth interviews were conducted with OTCMS. The interviews were audio-recorded, transcribed verbatim, and analysed thematically. RESULTS: The most frequently sought health providers by caregivers of febrile children in descending order were Community Health-Based Planning Services (CHPS) compounds; drug vendors; and OTCMS. Malaria parasitological testing rate of febrile children was highest (94.9%) at the CHPS compound and lowest (10.5%) at the OTCMS shops. Proportion of febrile children not subjected to malaria blood test is 28.3%. Among caregivers who did not ask for malaria blood test, 15.2% reported that healthcare provider did not offer a malaria blood test; 21.7% were financially handicapped to visit the Health Centre; and 63% lacked knowledge of malaria blood test and where to get it. From OTCMS point of view, clients' inability to pay for malaria blood test, community perception that OTCMS are unqualified to perform malaria blood test, financial loss when unused RDT kits expires, clients' demand for half dose of ACT, and activities of drug peddlers are factors limiting adherence to WHO recommended policy on testing before treating uncomplicated malaria cases. CONCLUSION: The study results suggest the need to implement community friendly interventions aimed at improving test-based management of suspected malaria in febrile children. These may include educating caregivers and community members on the need to test and confirm malaria in febrile children before treating them, and supply of subsidized RDT kits to OTCMS and re-training them to provide testing services to their clients. Further studies pertaining to influence of gender roles on healthcare seeking attitude for febrile children is also suggested.

Characterizing local-scale heterogeneity of malaria risk: a case study in Bunkpurugu-Yunyoo district in northern Ghana.

BACKGROUND: Bayesian methods have been used to generate country-level and global maps of malaria prevalence. With increasing availability of detailed malaria surveillance data, these methodologies can also be used to identify fine-scale heterogeneity of malaria parasitaemia for operational prevention and control of malaria. METHODS: In this article, a Bayesian geostatistical model was applied to six malaria parasitaemia surveys conducted during rainy and dry seasons between November 2010 and 2013 to characterize the micro-scale spatial heterogeneity of malaria risk in northern Ghana. RESULTS: The geostatistical model showed substantial spatial heterogeneity, with malaria parasite prevalence varying between 19 and 90%, and revealing a northeast to southwest gradient of predicted risk. The spatial distribution of prevalence was heavily influenced by two modest urban centres, with a substantially lower prevalence in urban centres compared to rural areas. Although strong seasonal variations were observed, spatial malaria prevalence patterns did not change substantially from year to year. Furthermore, independent surveillance data suggested that the model had a relatively good predictive performance when extrapolated to a neighbouring district. CONCLUSIONS: This high variability in malaria prevalence is striking, given that this small area (approximately 30 km × 40 km) was purportedly homogeneous based on country-level spatial analysis, suggesting that fine-scale parasitaemia data might be critical to guide district-level programmatic efforts to prevent and control malaria. Extrapolations results suggest that fine-scale parasitaemia data can be useful for spatial predictions in neighbouring unsampled districts and does not have to be collected every year to aid district-level operations, helping to alleviate concerns regarding the cost of fine-scale data collection.

Understanding the gap between access and use: a qualitative study on barriers and facilitators to insecticide-treated net use in Ghana.

BACKGROUND: Mass and continuous distribution channels have significantly increased access to insecticide-treated nets (ITNs) in Ghana since 2000. Despite these gains, a large gap remains between ITN access and use. METHODS: A qualitative research study was carried out to explore the individual and contextual factors influencing ITN use among those with access in three sites in Ghana. Eighteen focus group discussions, and free listing and ranking activities were carried out with 174 participants; seven of those participants were selected for in-depth case study. Focus group discussions and case study interviews were audio-recorded, transcribed verbatim, and analysed thematically. RESULTS: ITN use, as described by study participants, was not binary; it varied throughout the night, across seasons, and over time. Heat was the most commonly cited barrier to consistent ITN use and contributed to low reported ITN use during the dry season. Barriers to ITN use throughout the year included skin irritation; lack of airflow in the sleeping space; and, in some cases, a lack of information on the connection between the use of ITNs and malaria prevention. Falling ill or losing a loved one to malaria was the most powerful motivator for consistent ITN use. Participants also discussed developing a habit of ITN use and the economic benefit of prevention over treatment as facilitating factors. Participants reported gender differences in ITN use, noting that men were more likely than women and children to stay outdoors late at night and more likely to sleep outdoors without an ITN. CONCLUSION: The study results suggest the greatest gains in ITN use among those with access could be made by promoting consistent use throughout the year among occasional and seasonal users. Opportunities for improving communication messages, such as increasing the time ITNs are aired before first use, as well as structural approaches to enhance the usability of ITNs in challenging contexts, such as promoting solutions for outdoor ITN use, were identified from this work. The information from this study can be used to inform social and behaviour change messaging and innovative approaches to closing the ITN use gap in Ghana.

Prevalence of asymptomatic malaria parasitaemia following mass testing and treatment in Pakro sub-district of Ghana.

BACKGROUND: Global efforts to scale-up malaria control interventions are gaining steam. These include the use of Long-Lasting Insecticide Nets, Indoor Residual Spraying, Intermittent Preventive Treatment and Test, Treat and Track. Despite these, the drive for malaria elimination is far from being realistic in endemic communities in Africa. This is partly due to the fact that asymptomatic parasite carriage, not specifically targeted by most interventions, remains the bedrock that fuels transmission. This has led to mass testing, treatment and tracking (MTTT) as an alternative strategy to target asymptomatic individuals. We report the impact of MTTT on the prevalence of asymptomatic malaria parasitaemia over a one-year period in Ghana, hypothesizing that implementing MTTT could reduce the rate of asymptomatic parasitaemia. METHODS: A population of about 5000 individuals in seven communities in the Pakro sub-district of Ghana participated in this study. A register was developed for each community following a census. MTTT engaged trained community-based health volunteers who conducted house-to-house testing using RDTs every 4 months and treated positive cases with Artemisinin-based Combination Therapy. Between interventions, community-based management of malaria was implemented for symptomatic cases. RESULTS: MTTT Coverage was 98.8% in July 2017 and 79.3% in July 2018. Of those tested, asymptomatic infection with malaria parasites reduced from 36.3% (1795/4941) in July 2017 to 32.9% (1303/3966) in July 2018 (p = 0.001). Prevalence of asymptomatic parasitaemia among children under 15 years declined from 52.6% (1043/1984) in July 2017 to 47.5% (820/1728) in July 2018 (p = 0.002). Implementing MTTT significantly reduced asymptomatic parasitaemia by 24% from July 2017 to July 2018 after adjusting for age, ITN use and axillary temperature (OR = 0.76, CI = 0.67, 0.85 p ≤ 0.001). CONCLUSION: This study has demonstrated that implementing MTTT is feasible and could reduce the prevalence of asymptomatic malaria parasitaemia in children under 15 years of age. Furthermore, the use of community-based health volunteers could ensure high coverage at lower cost of implementation. TRIAL REGISTRATION: NCT04167566, Date 14/11/2019. Retrospective registration.

Challenges and perceptions of implementing mass testing, treatment and tracking in malaria control: a qualitative study in Pakro sub-district of Ghana.

BACKGROUND: Malaria remains endemic in Ghana despite several interventions. Studies have demonstrated very high levels of asymptomatic malaria parasitaemia in both under-five and school-age children. Mass testing, treatment and tracking (MTTT) of malaria in communities is being proposed for implementation with the argument that it can reduce parasite load, amplify gains from the other control interventions and consequently lead to elimination. However, challenges associated with implementing MTTT such as feasibility, levels of coverage to be achieved for effectiveness, community perceptions and cost implications need to be clearly understood. This qualitative study was therefore conducted in an area with on-going MTTT to assess community and health workers' perceptions about feasibility of scale-up and effectiveness to guide scale-up decisions. METHODS: This qualitative study employed purposive sampling to select the study participants. Ten focus group discussions (FGDs) were conducted in seven communities; eight with community members (n = 80) and two with health workers (n = 14). In addition, two in-depth interviews (IDI) were conducted, one with a Physician Assistant and another with a Laboratory Technician at the health facility. All interviews were recorded, transcribed, translated and analyzed using QSR NVivo 12. RESULTS: Both health workers and community members expressed positive perceptions about the feasibility of implementation and effectiveness of MTTT as an intervention that could reduce the burden of malaria in the community. MTTT implementation was perceived to have increased sensitisation about malaria, reduced the incidence of malaria, reduced household expenditure on malaria and alleviated the need to travel long distances for healthcare. Key challenges to implementation were doubts about the expertise of trained Community-Based Health Volunteers (CBHVs) to diagnose and treat malaria appropriately, side effects of Artemisinin-based Combination Therapies (ACTs) and misconceptions that CBHVs could infect children with epilepsy. CONCLUSION: The study demonstrated that MTTT was perceived to be effective in reducing malaria incidence and related hospital visits in participating communities. MTTT was deemed useful in breaking financial and geographical barriers to accessing healthcare. The interventions were feasible and acceptable to community members, despite observed challenges to implementation such as concerns about CBHVs' knowledge and skills and reduced revenue from internally generated funds (IGF) of the health facility.

Detecting local risk factors for residual malaria in northern Ghana using Bayesian model averaging.

BACKGROUND: There is a need for comprehensive evaluations of the underlying local factors that contribute to residual malaria in sub-Saharan Africa. However, it is difficult to compare the wide array of demographic, socio-economic, and environmental variables associated with malaria transmission using standard statistical approaches while accounting for seasonal differences and nonlinear relationships. This article uses a Bayesian model averaging (BMA) approach for identifying and comparing potential risk and protective factors associated with residual malaria. RESULTS: The relative influence of a comprehensive set of demographic, socio-economic, environmental, and malaria intervention variables on malaria prevalence were modelled using BMA for variable selection. Data were collected in Bunkpurugu-Yunyoo, a rural district in northeast Ghana that experiences holoendemic seasonal malaria transmission, over six biannual surveys from 2010 to 2013. A total of 10,022 children between the ages 6 to 59 months were used in the analysis. Multiple models were developed to identify important risk and protective factors, accounting for seasonal patterns and nonlinear relationships. These models revealed pronounced nonlinear associations between malaria risk and distance from the nearest urban centre and health facility. Furthermore, the association between malaria risk and age and some ethnic groups was significantly different in the rainy and dry seasons. BMA outperformed other commonly used regression approaches in out-of-sample predictive ability using a season-to-season validation approach. CONCLUSIONS: This modelling framework offers an alternative approach to disease risk factor analysis that generates interpretable models, can reveal complex, nonlinear relationships, incorporates uncertainty in model selection, and produces accurate predictions. Certain modelling applications, such as designing targeted local interventions, require more sophisticated statistical methods which are capable of handling a wide range of relevant data while maintaining interpretability and predictive performance, and directly characterize uncertainty. To this end, BMA represents a valuable tool for constructing more informative models for understanding risk factors for malaria, as well as other vector-borne and environmentally mediated diseases.

Community perspectives on persistent transmission of lymphatic filariasis in three hotspot districts in Ghana after 15 rounds of mass drug administration: a qualitative assessment.

BACKGROUND: The Global Program for the Elimination of Lymphatic Filariasis (GPELF) started operation in 2000 and aimed at eliminating the disease by the year 2020, following 5-6 rounds of effective annual Mass Drug Administration (MDA). The MDA programme took off in Ghana in 2001 and has interrupted transmission in many areas while it has persisted in some areas after 10 or more rounds of MDA. This study was to appreciate community members' perspectives on MDA after over 15 years of implementation. Findings will inform strategies to mobilise community members to participate fully in MDA to enhance the disease elimination process. METHODS: This was a qualitative study, employing key-informant in-depth-interviews. Respondents were selected based on their recognition by community members as opinion leaders and persons who were knowledgeable about the topic of interest in the community. A snowball sampling technique was used to select respondents. RESULTS: Respondents were well informed about the MDA with most of them saying, it has been implemented for over 12 years. They were aware that the MDA was for the treatment/control of LF (elephantiasis). It came to light that MDA compliance was affected by five related barriers. These are; Medication, Personal, Health system, Disease and Social structure related barriers. Adverse effects of the drugs and the fact that many people perceived that they were not susceptibility to the infection have grossly affected the ingestion of the drugs. CONCLUSION: There is a need for community mobilization and promotional activities to explain the expected adverse reactions associated with the drugs to the people. Also the importance of why every qualified person in the community must comply with MDA must be emphasized.

Twelve-month longitudinal parasitological assessment of lymphatic filariasis-positive individuals: impact of a biannual treatment with ivermectin and albendazole.

OBJECTIVE: Mass drug administration (MDA) for the control of lymphatic filariasis (LF), in Ghana, started in the year 2000. While this had great success in many implementation units, there remain areas with persistent transmission, after more than 10 years of treatment. A closer examination of the parasite populations could help understand the reasons for persistent infections and formulate appropriate strategies to control LF in these areas of persistent transmission. MATERIALS AND METHODS: In a longitudinal study, we assessed the prevalence of microfilaraemia (mf) in two communities with 12 years of MDA in Ghana. In baseline surveys 6 months after the National MDA in 2014, 370 consenting individuals were tested for antigenaemia using immunochromatographic test (ICT) cards and had their mf count determined through night blood surveys. 48 ICT positives, of whom, 17 were positive for mf, were treated with 400 µg/kg ivermectin + 400 mg albendazole and subsequently followed for parasitological assessment at 3-month intervals for 1 year. This overlapped with the National MDA in 2015. RESULTS: There was a 68% parasite clearance 3 months after treatment. The pre-treatment mf count differed significantly from the post-treatment mf counts at 3 months (P = 0.0023), 6 months (P = 0.0051), 9 months (P = 0.0113) and 12 months (P = 0.0008). CONCLUSION: In these settings with persistent LF transmission, twice-yearly treatment may help accelerate LF elimination. Further large-scale evaluations are required to ascertain these findings.

Willingness to pay for small solar powered bed net fans: results of a Becker-DeGroot-Marschak auction in Ghana.

BACKGROUND AND METHODS: Long-lasting insecticidal nets (LLINs) are one of the main interventions recommended by the World Health Organization for malaria vector control. LLINs are ineffective if they are not being used. Subsequent to the completion of a cluster randomized cross over trial conducted in rural Greater Accra where participants were provided with the 'Bɔkɔɔ System'-a set of solar powered net fan and light consoles with a solar panel and battery-or alternative household water filters, all trial participants were invited to participate in a Becker-DeGroot-Marschak auction to determine the mean willingness to pay (WTP) for the fan and light consoles and to estimate the demand curve for the units. RESULTS, DISCUSSION AND CONCLUSIONS: Results demonstraed a mean WTP of approximately 55 Cedis (~13 USD). Demand results suggested that at a price which would support full manufacturing cost recovery, a majority of households in the area would be willing to purchase at least one such unit.

The effect of small solar powered 'Bͻkͻͻ' net fans on mosquito net use: results from a randomized controlled cross-over trial in southern Ghana.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are ineffective malaria transmission prevention tools if they are unused. Discomfort due to heat is the most commonly reported reason for not using nets, but this problem is largely unaddressed. With increasing rural electrification and the dropping price of solar power, fans could improve comfort inside nets and be affordable to populations in malaria endemic areas. Here, results are presented from a pilot randomized controlled cross-over study testing the effect of fans on LLIN use. METHODS: Eighty-three households from two rural communities in Greater Accra, Ghana, randomized into three groups, participated in a 10-month cross-over trial. After a screening survey to identify eligible households, all households received new LLINs. BÍ»kͻͻ net fan systems (one fan per member) were given to households in Group 1 and water filters were given to households in Group 2. At mid-point, Group 1 and 2 crossed over interventions. Households in Group 1 and 2 participated in fortnightly surveys on households' practices related to nets, fans and water filters, while households in Group 3 were surveyed only at screening, mid-point and study end. Entomological and weather data were collected throughout the study. Analysis took both 'per protocol' (PP) and 'intention to treat' (ITT) approaches. The mid- and end-point survey data from Group 1 and 2 were analysed using Firth logistic regressions. Fortnightly survey data from all groups were analysed using logistic regressions with random effects. RESULTS: Provision of fans to households appeared to increase net use in this study. Although the increase in net use explained by fans was not significant in the primary analyses (ITT odds ratio 3.24, p > 0.01; PP odds ratio = 1.17, p > 0.01), it was significant in secondary PP analysis (odds ratio = 1.95, p < 0.01). Net use was high at screening and even higher after provision of new LLINs and with follow up. Fan use was 90-100% depending on the fortnightly visit. CONCLUSIONS: This pilot study could not provide definitive evidence that fans increase net use. A larger study with additional statistical power is needed to assess this association across communities with diverse environmental and socio-demographic characteristics.

Understanding resilience of female adolescents towards teenage pregnancy: a cross-sectional survey in Dar es Salaam, Tanzania.

BACKGROUND: In Tanzania, teenage pregnancy rates are still high despite the efforts being made to reduce them. Not enough is known about how adolescents experience and cope with sexuality and teenage pregnancy. Over the past few decades, most studies have focused on vulnerability and risk among youth. The concept of 'reproductive resilience' is a new way of looking at teenage pregnancy. It shifts the perspective from a deficit-based to a strength-based approach. The study presented here aimed to identify factors that could contribute to strengthening the reproductive resilience of girls in Dar es Salaam, Tanzania. METHODS: Using a cross-sectional cluster sampling approach, 750 female adolescents aged 15-19 years were interviewed about how they mobilize resources to avoid or deal with teenage pregnancy. The main focus of the study was to examine how social capital (relations with significant others), economic capital (command over economic resources), cultural capital (personal dispositions and habits), and symbolic capital (recognition and prestige) contribute to the development of adolescent competencies for avoiding or dealing with teenage pregnancy and childbirth. RESULTS: A cumulative competence scale was developed to assess reproductive resilience. The cumulative score was computed based on 10 competence indicators that refer to the re- and pro-active mobilization of resources. About half of the women who had never been pregnant fell into the category, 'high competence' (50.9%), meaning they could get the information and support needed to avoid pregnancies. Among pregnant women and young mothers, most were categorized as 'high competence' (70.5%) and stated that they know how to avoid or deal with health problems that might affect them or their babies, and could get the information and support required to do so. Cultural capital, in particular, contributed to the competence of never-pregnant girls [OR = 1.80, 95% CI = 1.06 to 3.07, p = 0.029], pregnant adolescents and young mothers [OR = 3.33, 95% CI = 1.15 to 9.60, p = 0.026]. CONCLUSIONS: The reproductive resilience framework provides new insights into the reproductive health realities of adolescent girls from a strength-based perspective. While acknowledging that teenage pregnancy has serious negative implications for many female adolescents, the findings presented here highlight the importance of considering girls' capacities to prevent or deal with teenage pregnancy.

SOCIAL CAPITAL AND ADOLESCENT GIRLS' RESILIENCE TO TEENAGE PREGNANCY IN BEGORO, GHANA.

This study focuses on how older adolescent girls access and utilize social capital to develop resilience against teenage pregnancy in Begoro, Ghana. A survey of 419 non-pregnant girls aged 15-19 years, selected using a multi-stage cluster sampling technique, was conducted in 2012. Qualitative data were gathered through in-depth interviews with ten girls purposively selected from the survey respondents. Parents, relatives, teachers and religious groups were found to be important sources of social capital for the non-pregnant girls in developing resilience against teenage pregnancy. In addition, resilient girls tended to rely on multiple sources of social capital. It is recommended that stakeholders and policymakers in Ghana ensure that these significant sources of social capital in adolescent girls' sexual experience are equipped with the right information to help girls decrease the risk of teenage pregnancy.

Perceptions on the effect of small electric fans on comfort inside bed nets in southern Ghana: a qualitative study.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are known to be highly effective in reducing malaria transmission, morbidity and mortality. However, among those owning an LLIN, use rates are often suboptimal. A reported barrier to bed net use is discomfort due to heat. This qualitative study was part of a larger evaluation conducted in communities without electricity in rural Ghana to assess whether 0.8 W solar powered net fans can increase net use. METHODS: Twenty-three key informant interviews with household heads in the study communities in Shai-Osudoku District, southern Ghana, were conducted from July to August 2015. The purpose of the interviews was to obtain insight into perceptions of participants about the net fan system in relation to LLIN use. RESULTS: While all study participants reported using LLINs, with mosquito nuisance prevention as the prime motivation, heat was also mentioned as a key barrier to net use. Respondents appreciated the net fans because they improved comfort inside bed nets. The LED light on the fan stand became the main source of light at night and positively influenced the perception of the intervention as a whole. CONCLUSION: The general acceptance of the net fan system by the study participants highlights the potential of the intervention to improve comfort inside mosquito nets. This, therefore, has a potential to increase bed net use in areas with low access to electricity.

Molecular epidemiology of Mycobacterium africanum in Ghana.

BACKGROUND: Mycobacterium africanum comprises two phylogenetic lineages within the M. tuberculosis complex (MTBC) and is an important cause of human tuberculosis (TB) in West Africa. The reasons for this geographic restriction of M. africanum remain unclear. Here, we performed a prospective study to explore associations between the characteristics of TB patients and the MTBC lineages circulating in Ghana. METHOD: We genotyped 1,211 MTBC isolates recovered from pulmonary TB patients recruited between 2012 and 2014 using single nucleotide polymorphism typing and spoligotyping. Associations between patient and pathogen variables were assessed using univariate and multivariate logistic regression. RESULTS: Of the 1,211 MTBC isolates analysed, 71.9 % (871) belonged to Lineage 4; 12.6 % (152) to Lineage 5 (also known as M. africanum West-Africa 1), 9.2 % (112) to Lineage 6 (also known as M. africanum West-Africa 2) and 0.6 % (7) to Mycobacterium bovis. Univariate analysis revealed that Lineage 6 strains were less likely to be isoniazid resistant compared to other strains (odds ratio = 0.25, 95 % confidence interval (CI): 0.05-0.77, P < 0.01). Multivariate analysis showed that Lineage 5 was significantly more common in patients from the Ewe ethnic group (adjusted odds ratio (adjOR): 2.79; 95 % CI: 1.47-5.29, P < 0.001) and Lineage 6 more likely to be found among HIV-co-infected TB patients (adjOR = 2.2; 95 % confidence interval (CI: 1.32-3.7, P < 0.001). CONCLUSION: Our findings confirm the importance of M. africanum in Ghana and highlight the need to differentiate between Lineage 5 and Lineage 6, as these lineages differ in associated patient variables.

Socio-cultural and economic factors influencing adolescents' resilience against the threat of teenage pregnancy: a cross-sectional survey in Accra, Ghana.

BACKGROUND: Adolescent pregnancy exposes female adolescents to medical, social and economic risks. In Ghana, adolescent mothers are more likely to experience complications during pregnancy and delivery as compared to older mothers. This study examined the competencies of adolescent girls to either proactively prevent teenage pregnancy or reactively cope effectively with it. METHODS: A cross-sectional survey approach was used to interview 820 adolescent girls aged 15-19 years in Accra, Ghana. The main focus of the study was to examine how social capital (various kinds of valued relations with significant others), economic capital (command over economic resources, mainly cash and assets), cultural capital (personal dispositions and habits; knowledge and tradition stored in material forms and institutionalized) and symbolic capital (honour, recognition and prestige) contribute to the development of competencies of adolescents to deal with the threat of teenage pregnancy and childbirth. RESULTS: Out of 820 adolescents interviewed, 128 (16%) were pregnant or mothers. Adolescents in both groups (62% never pregnant girls and 68% pregnant/young mothers) have access to social support, especially from their parents. Parents are taking the place of aunts and grandmothers in providing sexual education to their adolescent girls due to changing social structures where extended families no longer reside together in most cases. More (79%) pregnant girls and young mothers compared to never pregnant girls (38%) have access to economic support (P = <0.001). Access to social, economic and cultural capitals was associated with high competence to either prevent or deal with pregnancy among adolescent girls. CONCLUSION: Findings showed that adolescent girls, especially those that get pregnant should not be viewed as weak and vulnerable because many of them have developed competencies to cope with pregnancy and childbirth effectively. Thus, focusing on developing the competencies of girls to access social, economic and cultural capitals may be an effective way of tackling the threat of teenage pregnancy than focusing only on their vulnerability and associated risks.

Impact of Cowpea-Based Food Containing Fish Meal Served With Vitamin C-Rich Drink on Iron Stores and Hemoglobin Concentrations in Ghanaian Schoolchildren in a Malaria Endemic Area.

BACKGROUND: Nutritional anemia is a public health problem among Ghanaian schoolchildren. There is need to employ dietary modification strategies to solve this problem through school and household feeding programs. OBJECTIVE: To evaluate the effectiveness of cowpea-based food containing fish meal served with vitamin C-rich drink to improve iron stores and hemoglobin concentrations in Ghanaian schoolchildren. METHODS: The study involved cross-sectional baseline and nutrition intervention phases. There were 150 participants of age 6 to 12 years. They were randomly assigned to 3 groups, fish meal -vitamin C (n = 50), vitamin C (n = 50), and control (n = 50), and given different cowpea-based diets for a 6-month period. Height and weight measurements were done according to the standard procedures, dietary data were obtained by 24-hour recall and food frequency questionnaire, hemoglobin concentrations were determined by Hemocue Hemoglobinometer, and serum ferritin and complement-reactive protein (CRP) were determined by enzyme-linked immunosorbent assay. Participants' blood samples were examined for malaria parasitemia and stools for helminthes using Giemsa stain and Kato-Katz techniques, respectively. RESULTS: Mean ferritin concentration was not significantly different among groups. End line mean or change in hemoglobin concentrations between fish meal-vitamin C group (128.4 ± 7.2/8.3 ± 10.6 g/L) and control (123.1 ± 6.6/4.2 ± 10.4 g/L) were different, P < .05. Change in prevalence of anemia in fish meal-vitamin C group (19.5%) was different compared to those of vitamin C group (9.3%) and the control (12.2%). Levels of malaria parasitemia and high CRP among study participants at baseline and end line were 58% and 80% then 55% and 79%, respectively. Level of hookworm infestation was 13%. CONCLUSION: Cowpea-based food containing 3% fish meal and served with vitamin C-rich drink improved hemoglobin concentration and minimized the prevalence of anemia among the study participants.

The use of social media among adolescents in Dar es Salaam and Mtwara, Tanzania.

Social media form part of the rapid worldwide digital development that is re-shaping the life of many young people. While the use of social media by youths is increasingly researched in the North, studies about youth in the South are missing. It therefore remains unclear how social media can be included in interventions that aim at informing young people in many countries of the global South about sexual and reproductive health. This paper presents findings of a mixed-methods study of young people's user behaviour on the internet and specifically of social media as a platform for sexual health promotion in Tanzania. The study used questionnaires with 60 adolescents and in-depth interviews with eight students aged 15 to 19 years in Dar es Salaam, and in Mtwara, Southern Tanzania. Findings show that youth in Dar es Salaam and Mtwara access the internet mainly through mobile phones. Facebook is by far the most popular internet site. Adolescents highlighted their interest in reproductive and sexual health messages and updates being delivered through humorous posts, links and clips, as well as by youth role models like music stars and actors that are entertaining and reflect up-to-date trends of modern youth culture.