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

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

A cluster randomized controlled trial to assess the impact of the 'Caring for Providers to Improve Patient Experience' intervention on person-centered maternity care in Kenya and Ghana: Study Protocol.

Background: Poor person-centered maternal care (PCMC) contributes to high maternal mortality and morbidity, directly and indirectly, through lack of, delayed, inadequate, unnecessary, or harmful care. While evidence on poor PCMC prevalence, as well as inequities, expanded in the last decade, there is still a significant gap in evidence-based interventions to address PCMC. We describe the protocol for a trial to test the effectiveness of the "Caring for Providers to Improve Patient Experience" (CPIPE) intervention, which includes five strategies for provider behavior change, targeting provider stress and bias as intermediate factors to improve PCMC and to address inequities. Methods: The trial will assess the effect of CPIPE on PCMC, as well as on intermediate and distal outcomes, using a two-arm cluster randomized controlled trial in 40 health facilities in Migori and Homa Bay Counties in Kenya and Upper East and Northeast Regions in Ghana. Twenty facilities in each country will be randomized to 10 intervention and 10 control sites. The primary intervention targets are all healthcare workers who provide maternal health services. The intervention impact will also be assessed first among providers, and then among women who give birth in health facilities. The primary outcome is PCMC measured with the PCMC scale, via multiple cross-sectional surveys of mothers who gave birth in the preceding 12 weeks in study facilities at baseline (prior to the intervention), midline (6 months after intervention start), and endline (12 months post-baseline) (N = 2000 across both countries at each time point). Additionally, 400 providers in the study facilities across both countries will be followed longitudinally at baseline, midline, and endline, to assess intermediate outcomes. The trial incorporates a mixed-methods design; survey data alongside in-depth interviews (IDIs) with healthcare facility leaders, providers, and mothers to qualitatively explore factors influencing the outcomes. Finally, we will collect process and cost data to assess intervention fidelity and cost-effectiveness. Discussion: This trial will be the first to rigorously assess an intervention to improve PCMC that addresses both provider stress and bias and will advance the evidence base for interventions to improve PCMC and contribute to equity in maternal and neonatal health.

Person-centred care (PCC) research in Ghana: a scoping review protocol.

INTRODUCTION: Person-centred care (PCC) is provision of care that is respectful of and responsive to individual patient preferences, needs and values, and ensures that patient values guide all clinical decisions. While there is a large body of evidence on the benefits of PCC in high-income countries, little research exists on PCC in Ghana and Sub-Saharan Africa at large. Most studies on PCC have focused on maternity care as part of the global movement of respectful maternity care. The few studies on patient experiences and health system responsiveness beyond maternal health also highlight gaps in patient experience and satisfaction as well as discrimination in health facilities, which leads to the most vulnerable having the poorest experiences. The protocol for this scoping review aims to systematically map the extent of literature focused on PCC in Ghana by identifying patient expectations and preferences, barriers and facilitators, and interventions. METHODS AND ANALYSIS: The protocol will be guided by the Arksey and O'Malley methodological framework and recommendations by Levac et al. A comprehensive search strategy will be used to search for published articles in PubMed, EMBASE, Web of Science and the African Journals Online from their inception to August 2022. Grey literature and reference lists of included studies will also be searched. Two independent reviewers will perform the literature search, eligibility assessments and study selection. Any disagreements will be resolved through discussion with a third reviewer. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for the scoping reviews will be used to outline the study selection process. Extracted data from the included articles will be synthesised and reported under key concepts derived from the outcomes of the scoping review. ETHICS AND DISSEMINATION: This scoping review does not require ethical approval. The findings will be disseminated through publications and conference presentations. SCOPING REVIEW REGISTRATION: OSF Registration DOI 10.17605/OSF.IO/ZMDH9.

Sociodemographic and Behavioral Factors Associated With Hypertension and Depression in 4 Rural Communities in Northern Ghana: A Cross-Sectional Study.

OBJECTIVES: The prevalences of hypertension and depression in sub-Saharan Africa are substantial and rising, despite limited data on their sociodemographic and behavioral risk factors and their interactions. We undertook a cross-sectional study in 4 communities in the Upper East Region of Ghana to identify persons with hypertension and depression in the setting of a pilot intervention training local nurses and health volunteers to manage these conditions. METHODS: We quantified hypertension and depression prevalence across key sociodemographic factors (age, sex, occupation, education, religion, ethnicity, and community) and behavioral factors (tobacco use, alcohol use, and physical activity) and tested for association by multivariable logistic regression. RESULTS: Hypertension prevalence was higher in older persons (7.6% among 35- to 50-year-olds vs 16.4% among 51- to 70-year-olds) and among those reporting alcohol use (18.9% vs 8.5% between users and nonusers). In multivariable models, only older age (AOR 2.39 [1.02, 5.85]) and residence in the community of Wuru (AOR 7.60 [1.81, 32.96]) were independently associated with hypertension, and residence in Wuru (AOR 23.58 [7.75-78.25]) or Navio (AOR 7.41 [2.30-24.74]) was the only factor independently associated with depression. CONCLUSIONS: We report a high prevalence of both diseases overall and in select communities, a trend that requires further research to inform targeted chronic disease interventions.

Exploring infant and young child-feeding practices among mothers of well-nourished children in northern Ghana: An INPreP substudy.

This study investigated infant and young child-feeding (IYCF) practices among mothers of well-nourished children in northern Ghana. This was a qualitative study where in-depth individual interviews were conducted with participants. The interviews were audio recorded, transcribed, and QSR Nvivo software version 11 was used to organize the data before thematic analysis. It was observed that mothers of well-nourished children were likely to adhere to breastfeeding guidelines and also practice appropriate complementary feeding. Furthermore, these mothers mostly had some form of support from their husbands and mother-in-laws in feeding their infants. While adoption and adherence to appropriate IYCF practices contribute to improved nutrition outcomes in children, social support systems are needed to sustain the practice.

Promoting a global culture of respectful maternity care.

Respectful maternity care (RMC) - a fundamental human right for all women - prioritizes autonomy and rights of pregnant and birthing women throughout the entire childbirth journey. Despite increasing acknowledgment of the importance of RMC for optimal maternal and new-born outcomes, women often experience disrespectful and abusive practices during pregnancy and childbirth. This Editorial points to the need for development of international guidelines for the implementation of RMC programs globally.

Impact of kinship support on child mortality in the Upper East Region of Ghana: assessing the Grandmother Hypothesis.

BACKGROUND: The grandmother is an important kin member whose contribution to childcare and survival has been recognized in the literature, hence the Grandmother Hypothesis. This article examines the effect of the presence of a grandmother on child mortality. METHODS: Data were obtained from the Navrongo Health and Demographic Surveillance System, located in the Upper East Region of Ghana. Children born between January 1999 and December 2018 were included in the analysis. Person-months lived for each child were generated. The multilevel Poisson regression technique was employed to investigate the effect of a grandmother on child survival. RESULTS: In all, 57 116 children were included in the analysis, of which 7% died before age 5 y. Person-months were generated for the children, which produced 2.7 million records, with about 487 800 person-years. After controlling for confounders, results showed that children in households with paternal grandmothers are 11% less likely to die compared with those without paternal grandmothers. However, when other confounders were taken into accounts, the beneficial effect of maternal grandmothers disappeared. CONCLUSIONS: We conclude that the presence of grandmothers improves child survival, thus sustaining the Grandmother Hypothesis. The experiences of these grandmothers should be tapped to improve child survival, particularly in rural areas.

Community Barriers, Enablers, and Normative Embedding of Second Year of Life Vaccination in Ghana: A Qualitative Study.

INTRODUCTION: Coverage rates for second year of life (2YL) vaccination still lag behind infant vaccination in most settings. We conducted a qualitative baseline study of community barriers and enablers to acceptance of 2YL vaccines in Ghana 4 years after introducing the second dose of the measles-containing vaccine. METHODS: We conducted 26 focus group discussions in 2016 with men and women caregivers from mixed urban, peri-urban, and rural areas, as well as pastoralists, using semistructured topic guides based on the Health Belief Model theory. We conducted a thematic analysis of the discussion using NVivo software. We use Normalization Process Theory to contextualize results as a snapshot of a dynamic process of community adaptation to change to a well-established routine immunization schedule following 2YL introduction. RESULTS: Routine immunization for infants enjoys resilient demand, grounded in strong community norms despite surprisingly low levels of vaccine literacy. Despite best practices like integration with the established 18-month "weighing visit," demand for 2YL vaccination is still conditional on individual awareness and competition for limited maternal time, household resources, and other health concerns. An embedded norm that children should be fully vaccinated by 12 months originally sustained Expanded Programme for Immunization goals but now discouraged some caregivers from seeking vaccines for children perceived to be "too old" to vaccinate. Caregivers cited greater costs and inconvenience of taking older, heavier children in for vaccination and anticipated criticism from both community members and health care providers for coming "too late." CONCLUSION: Closing the 2YL vaccination coverage gap will ultimately require modifying embedded norms among caregivers and health care providers alike. Time is necessary but not sufficient to reach this goal. Progress can be accelerated by increasing the level of community and institutional engagement and adapting services where possible to minimize added costs to caregivers of vaccinating older children.

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.

Provider implicit and explicit bias in person-centered maternity care: a cross-sectional study with maternity providers in Northern Ghana.

BACKGROUND: Person-centered maternity care (PCMC) has become a priority in the global health discourse on quality of care due to the high prevalence of disrespectful and lack of responsive care during facility-based childbirth. Although PCMC is generally sub-optimal, there are significant disparities. On average, women of low socioeconomic status (SES) tend to receive poorer PCMC than women of higher SES. Yet few studies have explored factors underlying these inequities. In this study, we examined provider implicit and explicit biases that could lead to inequitable PCMC based on SES. METHODS: Data are from a cross-sectional survey with 150 providers recruited from 19 health facilities in the Upper East region of Ghana from October 2020 to January 2021. Explicit SES bias was assessed using situationally-specific vignettes (low SES and high SES characteristics) on providers' perceptions of women's expectations, attitudes, and behaviors. Implicit SES bias was assessed using an Implicit Association Test (IAT) that measures associations between women's SES characteristics and providers' perceptions of women as 'difficult' or 'good'. Analysis included descriptive statistics, mixed-model ANOVA, and bivariate and multivariate linear regression. RESULTS: The average explicit bias score was 18.1 out of 28 (SD = 3.60) for the low SES woman vignette and 16.9 out of 28 (SD = 3.15) for the high SES woman vignette (p < 0.001), suggesting stronger negative explicit bias towards the lower SES woman. These biases manifested in higher agreement to statements such as the low SES woman in the vignette is not likely to expect providers to introduce themselves and is not likely to understand explanations. The average IAT score was 0.71 (SD = 0.43), indicating a significant bias in associating positive characteristics with high SES women and negative characteristics with low SES women. Providers with higher education had significantly lower explicit bias scores on the low SES vignette than those with less education. Providers in private facilities had higher IAT scores than those in government hospitals. CONCLUSIONS: The findings provide evidence of both implicit and explicit SES bias among maternity providers. These biases need to be addressed in interventions to achieve equity in PCMC and to improve PCMC for all women.

How different incentives influence reported motivation and perceptions of performance in Ghanaian community-based health planning and services zones.

BACKGROUND: Maternal mortality is still a burden worldwide, and Ghana's maternal and child mortalities are still high. Incentive schemes have been effective in improving health workers' performance thereby reducing maternal and child deaths. The efficiency of public health services in most developing countries has been linked to the provision of incentives. Thus, financial packages for Community Health Volunteers (CHVs) serve as enablers for them to be focused and committed to their work. However, the poor performance of CHVs is still a challenge in health service delivery in many developing countries. Although the reasons for these persistent problems are understood, we need to find out how to implement what works in the face of political will and financial constraints. This study assesses how different incentives influence reported motivation and perceptions of performance in Community-based Health Planning and Services Program (CHPS) zones in the Upper East region. METHODS: A quasi-experimental study design with post-intervention measurement was used. Performance-based interventions were implemented for 1 year in the Upper East region. The different interventions were rolled out in 55 of 120 CHPS zones. The 55 CHPS zones were randomly assigned to four groups: three groups of 14 CHPS zones with the last group containing 13 CHPS zones. Several alternative types of financial and non-financial incentives as well as their sustainability were explored. The financial incentive was a small monthly performance-based Stipend. The non-financial incentives were: Community recognition; paying for National Health Insurance Scheme (NHIS) premiums and fees for CHV, one spouse, and up to two children below 18 years, and; quarterly performance-based Awards for best-performing CHVs. The four groups represent the four different incentive schemes. We conducted 31 In-depth interviews (IDIs) and 31 Focus Group Discussions (FGDs) with health professionals and community members. RESULTS: Community members and the CHVs wanted the stipend as the first incentive but requested that it be increased from the current level. The Community Health Officers (CHOs) prioritized the Awards over the Stipend because they felt it was too small to generate the required motivation in the CHVs. The second incentive was the National Health Insurance Scheme (NHIS) registration. Community recognition was also considered by health professionals as effective in motiving CHVs and work support inputs and CHVs training helped in improving output. The various incentives have helped increase health education and facilitated the work of the volunteers leading to increased outputs: Household visits and Antenatal Care and Postnatal Care coverage improved. The incentives have also influenced the initiative of volunteers. Work support inputs were also regarded as motivators by CHVs, but the challenges with the incentives included the size of the stipend and delays in disbursement. CONCLUSION: Incentives are effective in motivating CHVs to improve their performance, thereby improving access to and use of health services by community members. The Stipend, NHIS, Community recognition and Awards, and the work support inputs all appeared to be effective in improving CHVs' performance and outcomes. Therefore, if health professionals implement these financial and non-financial incentives, it could bring a positive impact on health service delivery and use. Also, building the capacities of CHVs and providing them with the necessary inputs could improve output.

Community perspectives on cardiovascular disease control in rural Ghana: A qualitative study.

BACKGROUND: Cardiovascular disease (CVD) prevalence is high in Ghana-but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors. METHODS: We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes. RESULTS: CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital. CONCLUSIONS: CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors-in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD-including its behavioral and mental health causes-in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise.

'Joy, not sorrow': Men's perspectives on gender, violence, and cash transfers targeted to women in northern Ghana.

Evidence indicates that cash transfers can decrease intimate partner violence (IPV) against women, although most research has focused on women's perspectives and experiences, with less attention to men. We analyzed data from four focus group discussions with male partners of women who participated in the Ghana Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program. We elicited men's perceptions of poverty, relationship dynamics, IPV and cash transfers targeted to their wives using thematic analysis. Men largely viewed the effects of the cash transfer as positive - they felt decreased provider role strain when women used the cash to cover household expenses such as food and school fees. Men also indicated that they felt respected when women used the cash to cover sudden expenses, such as funeral costs, thus preventing the need to borrow from community members and exposing their inability to fulfill provider roles. These feelings of relief and respect helped improve men's overall wellbeing, their marital relationships and reduced the potential for IPV. Despite these positive results, men revealed that they still expected to be informed and consulted about the transfer and its expenditure, and felt disrespected when women did not do so, thus heightening the potential for household conflict. Further research and innovation in programming is needed to integrate gender transformative strategies into cash transfer programs, explicitly aimed at changing gender norms to enhance and sustain beneficial impacts on gender relations and IPV.

Individual and situational predictors of psychological and physiological stress and burnout among maternity providers in Northern Ghana.

BACKGROUND: Maternity providers, including nurses, midwives, physicians, are at significant risk for stress and burnout due to the nature of care provision in maternal and child health settings. Yet, the empirical evidence on stress and burnout among maternity providers in sub-Saharan Africa is scarce. Therefore, the purpose of our study was to (1) assess levels of stress and burnout among maternity providers and support staff in Ghana, and (2) identify individual and situational factors associated with maternity provider stress, burnout, and physiology. METHOD: Using a purposive sampling technique, we recruited 150 maternity providers from 19 high delivery health facilities within the 15 districts of the Upper East region (UER) of Ghana into a cross-sectional study. Participants completed Cohen's Perceived Stress Scale, the Shirom-Melamed Burnout scale, and sociodemographic, health-, and work-related items. Participants' heart rate variability (HRV) and hair cortisol levels were assessed for stress-related physiologic responses. We computed bivariate and multivariate linear regression models to examine factors associated with stress and burnout. RESULT: Most participants were experiencing moderate to high stress (58.0%) and burnout (65.8%). Each unit increase in overcommitment to work was associated with 0.62 higher perceived stress scores (ß = 0.62, 95% CI: 0.22, 1.02) and 0.15 higher burnout scores. On average, those who had experienced disrespect from colleagues in the last year had higher perceived stress scores compared to those who had not experienced disrespect (ß = 1.77, 95% CI: 0.50, 3.04); and those who had experienced disrespect from patients in the last year had higher cortisol levels than those who had not (ß = 0.52, 95% CI: 0.11, 0.93). Those who work for more than 5 days also had higher cortisol levels, on average, compared to those who worked fewer days a week. CONCLUSION: We found high levels of stress and burnout among maternity providers in Northern Ghana, underscoring the need for interventions to manage the effects of stress and burnout on maternity providers' wellbeing, quality of care, and patient outcomes. Healthcare management teams should assist providers in reducing their overcommitment by hiring more staff, given its strong link to stress and burnout. Additionally, facilitating a respectful workplace culture could also help reduce stress and burnout among maternity providers.

Optimising reporting of adverse events following immunisation by healthcare workers in Ghana: A qualitative study in four regions.

INTRODUCTION: Despite the emphasis on reporting of Adverse Events Following Immunisation (AEFIs) during didactic training sessions, especially prior to new vaccine introductions, it remains low in Ghana. We explored the factors underlying the under-reporting of AEFI by healthcare workers (HCWs) to provide guidance on appropriate interventions to increase reporting. METHODS: We conducted an exploratory descriptive in-depth study of the factors contributing to low reporting of AEFI among HCWs in four regions in Ghana. Key informant interviews (KII) were held with purposively selected individuals that are relevant to the AEFI reporting process at the district, regional, and national levels. We used KII guides to conduct in-depth interviews and used NVivo 10 qualitative software to analyse the data. Themes on factors influencing AEFI reporting were derived inductively from the data, and illustrative quotes from respondents were used to support the narratives. RESULTS: We conducted 116 KIIs with the health managers, regulators and frontline HCWs and found that lack of information on reportable AEFIs and reporting structures, misunderstanding of reportable AEFIs, heavy workload, cost of reporting AEFIs, fear of blame by supervisors, lack of motivation, and inadequate feedback as factors responsible for underreporting of AEFIs. Respondents suggested that capacity building for frontline HCWs, effective supervision, the provision of motivation and feedback, simplification of reporting procedures, incentives for integrating AEFI reporting into routine monitoring and reporting, standardization of reporting procedures across regions, and developing appropriate interventions to address the fear of personal consequences would help improve AEFI reporting. CONCLUSION: From the perspectives of a broad range of key informants at all levels of the vaccine safety system, we found multiple factors (both structural and behavioural), that may impact HCW reporting of AEFI in Ghana. Improvements in line with the suggestions are necessary for increased AEFI reporting in Ghana.

Breast cancer screening pathways in Ghana: applying an exploratory single case study methodology with cross-case analysis.

Background: Breast cancer is steadily increasing in Ghana, with the majority of Ghanaians only seeking care in the advanced stage of the disease. Furthermore, structured breast cancer control strategies are mostly non-existent. This study aimed to examine breast cancer and breast screening pathways in a tertiary healthcare facility within the Kumasi metropolis. Method: We used a single exploratory case-study design to purposefully select one healthcare facility as a case with embedded sub-units of analysis (patients, first-degree relatives of patients, and clinicians) to address the study's aim. In-depth interview was used to generate evidence from 35 participants. Applying Miles and Huberman's thematic strategy, a cross-case analysis was conducted using Morse's analytical framework. Results: Five (5) main themes emerged from the data: description of breast cancer, breast health education in Ghana, breast screening practices among women, the state of breast screening and barriers to breast screening uptake and lastly, the way forward. Malignancy of the breast was described as common, especially among young women who commonly present with advanced disease with poor prognostic outcomes. There were reports of limited breast cancer awareness and knowledge among women. Comparatively, urban educated women were noted to be relatively knowledgeable and more proactive about breast cancer than the less-privileged women in rural communities. Self and clinical-breast examination practices were reported as unusual habits for Ghanaian women. Several provider-related factors, lack of screening facilities, and attitude of women were highlighted as barriers to breast screening practices. Education among health professionals and interventions to promote opportunistic and organized breast screening were cited as the way forward for breast cancer control and early detection in Ghana. Conclusion: This is a confirmatory result of a stark burden of breast cancer in Ghana, inferring a need to address the deficiencies around breast cancer and early detection practices.

Compliance to HIV testing and counseling guidelines at antenatal care clinics in the Kassena-Nankana districts of northern Ghana: A qualitative study.

BACKGROUND: Utilization of antenatal care services in Ghana has substantially increased over the years, but the rates of mother-to-child transmission of HIV is still high. The high burden of HIV among pregnant women has serious implications for mother-to-child transmission. The main objective of this study was to assess the compliance of HIV testing and counseling provided at antenatal care clinics in two rural districts in northern Ghana by comparing reported practices to the national guidelines. METHODS: This study was a descriptive qualitative study conducted in the Kassena-Nankana Districts of northern Ghana. In-depth interviews were conducted with 10 midwives, 10 mothers, and 2 public health nurses who were recruited through purposive and snowball sampling. All interviews were audio recorded, transcribed into English, and imported into NVivo 12.0 software for open, axial, and selective coding. RESULTS: The findings indicate that not all pregnant women were informed prior to testing nor informed of their test results. Many mothers indicated that pre-test counseling is limited although the midwives claimed to provide it. Post-test counseling is primarily given to those who test positive, and several midwives agreed that there is no need to counsel HIV-negative women. Perceptions of the lack of confidentiality and privacy were pervasive among mothers despite the emphasis placed on its importance by the midwives. There were conflicting reports on whether HIV testing during antenatal care is voluntary or compulsory. The challenges with HIV testing and counseling that were mentioned by midwives include lack of adequate infrastructure, language barriers, and insufficient training. CONCLUSIONS: HIV testing and counseling provided at antenatal care is not uniform across all health facilities and does not strictly adhere to national guidelines. Future interventions that focus on standardization, monitoring, privacy, and capacity building are likely to prove valuable in ensuring quality services are provided.

Social and demographic correlates of cardiovascular mortality in the Kassena-Nankana districts of Ghana: a verbal post-mortem analysis.

BACKGROUND: The burden of cardiovascular disease (CVD) in Ghana is rising, but details on its epidemiology are scarce. We sought to quantify mortality due to CVD in two districts in rural Ghana using verbal post-mortem (VPM) data. METHODS: We conducted a proportional sub-hazards analysis of 10 232 deaths in the Kassena-Nankana East and West districts from 2005 to 2012, to determine adult mortality attributed to CVD over time. We stratified results by age, gender and socio-economic status (SES), and compared CVD mortality among SES and gender strata over time. A competing risk model estimated the cumulative effect of eliminating CVD from the area. RESULTS: From 2005 to 2012, CVD mortality more than doubled overall, from 0.51 deaths for every 1000 person-years in 2005 to 1.08 per 1000 person-years in 2012. Mortality peaked in 2008 at 1.23 deaths per 1000 person-years. Increases were comparable in men (2.0) and women (2.3), but greater among the poorest residents (3.3) than the richest (1.3), and among persons aged 55-69 years (2.1) than those aged ≥70 years (1.8). By 2012, male and female CVD mortality was highest in middle-SES persons. We project that eliminating CVD would increase the number of individuals reaching age 73 years from 35% to 40%, adding 1.6 years of life expectancy. CONCLUSIONS: The burden of CVD on overall mortality in the Upper East Region is substantial and markedly increasing. CVD mortality has especially increased in lower-income persons and persons in middle age. Further initiatives for the surveillance and control of CVD in these vulnerable populations are needed.

'Poverty can break a home': Exploring mechanisms linking cash plus programming and intimate partner violence in Ghana.

A growing body of research in West Africa and globally shows that cash transfers can decrease intimate partner violence (IPV). The purpose of this study was to explore how the government of Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 program, an unconditional cash transfer plus health insurance premium waiver targeted at pregnant women and women with young children, influenced IPV experiences. Existing program theory hypothesizes three pathways through which cash transfers influence IPV, including: 1) increased economic security and emotional wellbeing; 2) reduced intra-household conflict; and 3) increased women's empowerment. Informed by this theory, we conducted qualitative in-depth interviews with women in northern Ghana (n = 30) who were or had been beneficiaries of LEAP 1000 and had reported declines in IPV in an earlier impact evaluation. We used narrative and thematic analytic techniques to examine these pathways in the context of gender norms and household dynamics, as well as a fourth potential pathway focused on interactions with healthcare providers. Overall, the most prominent narrative was that poverty is the main determinant of physical IPV and that by reducing poverty, LEAP 1000 reduced conflict and violence in households and communities and improved emotional wellbeing. Participant narratives also supported pathways of reduced intra-household conflict and increased empowerment, as well as interplay between these three pathways. However, participants also reflected that cash transfers did not fundamentally change gender norms or reduce gender-role strain in a context of ongoing economic insecurity, which could limit the gender transformative potential and sustainability of IPV reductions. Finally, while health insurance increased access to healthcare, local norms, shame, fear, and minimal provider screening deterred IPV disclosure to healthcare providers. Additional research is needed to explore interplay between pathways of impact across programs with different design features and implementation contexts to continue informing effective programming to maximize impact.

Constructing a Nurse-led Cardiovascular Disease Intervention in Rural Ghana: A Qualitative Analysis.

Background: Cardiovascular disease (CVD) is a growing burden in low- and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana's Upper East Region. Objective: This study sought to identify non-physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana's current primary health care structure. Methods: Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants. Findings: Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies. Conclusions: Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.