Economic and social determinants of health care utilization during the first wave of COVID-19 pandemic among adults in Ghana: a population-based cross-sectional study.

BACKGROUND: The COVID-19 pandemic had socioeconomic effects in Africa. This study assessed the social and economic determinants of healthcare utilization during the first wave of COVID-19 among adults in Ghana. METHODS: Information about individuals residing in Ghana was derived from a survey conducted across multiple countries, aiming to evaluate the impact of the COVID-19 pandemic on the mental health and overall well-being of adults aged 18 and above. The dependent variable for the study was healthcare utilization (categorized as low or high). The independent variables were economic (such as financial loss, job loss, diminished wages, investment/retirement setbacks, and non-refunded travel cancellations) and social (including food scarcity, loss of financial support sources, housing instability, challenges affording food, clothing, shelter, electricity, utilities, and increased caregiving responsibilities for partners) determinants of health. A multinomial logistic regression was conducted to identify factors associated with healthcare utilization after adjusting for confounders (age, gender, access to medical insurance, COVID-19 status, educational background, employment, and marital status of the participants). RESULTS: The analysis included 364 responses. Individuals who encountered a loss of financial support (AOR: 9.58; 95% CI: 3.44-26.73; p < 0.001), a decrease or loss of wages (AOR: 7.44, 95% CI: 3.05-18.16, p < 0.001), experienced investment or retirement setbacks (AOR: 10.69, 95% CI: 2.60-43.88, p = 0.001), and expressed concerns about potential food shortages (AOR: 6.85, 95% CI: 2.49-18.84, p < 0.001) exhibited significantly higher odds of low healthcare utilization during the initial phase of the pandemic. Contrastingly, participants facing challenges in paying for basic needs demonstrated lower odds of low healthcare utilization compared to those who found it easy to cover basic expenses (AOR: 0.19, 95% CI: 0.06-0.67, p = 0.001). CONCLUSION: Economic and social factors were associated with low healthcare utilization in Ghana during the first wave of the pandemic. Investment or retirement loss and financial support loss during the pandemic had the largest effect on healthcare utilization. Further research is needed to understand the connection between concerns about food shortages, welfare losses during pandemics and healthcare utilization during pandemics in Ghana.

A multi-country survey of the socio-demographic factors associated with adherence to COVID-19 preventive measures during the first wave of the COVID-19 pandemic.

BACKGROUND: Health behaviours are influenced by individual characteristics including age, gender, education and economic level. This study aimed to assess the associations between individual-level determinants and adherence to COVID-19 preventive measures. METHODS: We performed secondary analyses of international data collected using an online survey during the first wave of the COVID-19 pandemic between June and December 2020. The dependent variables were self-reported adherence to COVID-19 preventive measures (wearing of face masks, frequent washing/sanitizing of hands, physical distancing, working remotely). The independent variables were age, sex at birth (female vs male), having a chronic disease related elevated risk for severe COVID-19 (none/little, might be at increased risk, at increased risk), educational level completed (no formal education, primary, secondary vs college/university) and employment status (retiree, students, not employed vs employed). Four multivariate logistic regression analyses were conducted to determine the associations between the dependent variables and independent variables. Interaction terms with country-income level were tested in regressions to explore its moderating effect. RESULTS: Out of 16,866 respondents, 12,634 (74.9%) wore masks or face coverings, 12,336 (73.1%) washed or sanitized their hands frequently, 11,464 (68.0%) reported adherence to physical distancing and 5,646 (33.5%) worked remotely. In adjusted analyses, increased age, college/university education, employment, and having risks for severe COVID-19 were associated with significantly higher odds of adhering to COVID-19 preventive measures. Retirees and students had lower odds of adhering to COVID-19 prevention measures than employed individuals. Males had significantly lower odds of wearing face masks (AOR: 0.901), frequent washing/sanitizing hands (AOR: 0.774) and working remotely (AOR: 0.875) compared to females. Country-income level generally moderated the above relationships such that the associations disappeared in lower income countries. CONCLUSION: The study findings suggest that the individual socio-demographic factors-age, sex, employment status, education status and having a chronic disease - influence adherence to COVID-19 preventive measures. Findings further reiterate the need for health education and health promotion campaigns on preventive health measures to focus on subpopulations, such as younger males, students and retirees, that require targeted or unique messaging.

A multi-country survey on access to healthcare and treatment services among individuals with critical medical care needs during the first wave of the pandemic.

BACKGROUND: Healthcare services were significantly interrupted during the early phase of the COVID-19 pandemic. The aim of the present study was to determine the associations between sociodemographic factors and healthcare access during the first wave of the COVID-19 pandemic among individuals with critical care needs. METHODS: This was a secondary analysis of the data of 5,156 participants recruited from 152 countries during the first wave of the COVID-19 pandemic. The dependent variables were self-reported difficulty of access to health care, challenges with obtaining medication, and the use of alternative medical services. The independent variables were age at last birthday; sex at birth, level of education, employment status and the macro-social vulnerability status. The confounding variable was the country income level. Three multivariable logistic regression analyses were conducted to determine the associations between the dependent variables and the independent variables after adjusting for the confounder. RESULTS: Difficulty accessing health care services and obtaining medications was experienced by 1922 (37.3%) and 3746 (72.7%) participants respectively. Also, 1433 (27.8%) used alternative medical care. Retirees (AOR:1.59), unemployed (AOR:1.198), people living with HIV (AOR:2.36) and at increased risk of COVID-19 (AOR:2.10), people who used drugs (AOR:1.83) and transacted sex (AOR:1.971) had significantly higher odds for reporting difficulty with access to health care. Males (AOR:1.23), respondents with secondary level of education (AOR:1.39), retirees (AOR:2.19), unemployed (AOR:1.47), people living with HIV (AOR:2.46), people who used drugs (AOR:1.79), transacted sex (AOR:2.71) and those who might be (AOR: 1.66) and were at (AOR: 2.3) increased risk of severe COVID-19 had significantly higher odds for reporting difficulty with access to medications. People who used drugs (AOR:2.093) transacted sex (AOR:1.639), who might be (AOR: 1.211) and were at (AOR: 1.511) increased risk of severe COVID-19, and who had difficulty accessing usual healthcare (AOR: 9.047) and obtaining medications (AOR:2.16) had significantly higher odds of reporting alternative medical care use. People living with HIV (AOR:0.562) had significantly lower odds of using alternative medical care. CONCLUSION: We identified populations who had challenges with access to healthcare and obtaining medications used alternative medical care except for people living with HIV. Priority attention should be given to alternative medical care use during future health pandemics.

A multi-country study of the associations between HIV vulnerability status, perception of COVID-19 related stigma and post-traumatic stress symptoms during the first wave of the pandemic.

BACKGROUND: This study investigated the associations between COVID-19 related stigma and post-traumatic stress symptoms (PTSS); and the associations between PTSS and COVID-19 related stigma, HIV status, COVID-19 status and key HIV population status. METHODS: This was a secondary analysis of data of 12,355 study participants generated through an online survey that recruited adults from 152 countries between July and December 2020. The dependent variables were COVID-19-related stigma and PTSS. The independent variables were HIV status (positive/negative), transaction sex (yes/no), use of psychoactive drugs (yes/no), and vulnerability status (transaction sex workers, people who use psychoactive drugs, living with HIV, and COVID-19 status). The confounding variables were age, sex at birth (male/female), level of education, sexual minority individuals (yes/no) and country income level. Multivariable logistic regression analyses were conducted to determine associations between the dependent and independent variables after adjusting for confounders. RESULTS: There were 835 (6.8%) participants who experienced COVID-19 related stigma during the pandemic and 3,824 (31.0%) participants reported PTSS. Respondents who were living with HIV (AOR: 1.979; 95%CI: 1.522-2.573), tested positive for COVID-19 (AOR: 3.369; 95%CI: 2.692-4.217), engaged in transactional sex (AOR: 1.428; 95%CI: 1.060-1.922) and used psychoactive drugs (AOR: 1.364; 95%CI: 1.053-1.767) had significantly higher odds of experiencing COVID-19 related stigma. Individuals with vulnerability status (AOR:4.610; 95%CI: 1.590-13.368) and who experienced COVID-19 related stigma (AOR: 2.218; 95%CI: 1.920-2.561) had significantly higher odds of PTSS. CONCLUSION: Individuals with vulnerability status may be at increased risk for COVID-19 related stigma. Key and vulnerable populations who were living with HIV and who experienced stigma may be at a higher risk of experiencing PTSS. Populations at risk for PTSS should be routinely screened and provided adequate support when they contract COVID-19 to reduce the risk for poor mental health during COVID-19 outbreaks and during future health crisis with similar magnitude as the COVID-19 pandemic.

Mapping age- and sex-specific HIV prevalence in adults in sub-Saharan Africa, 2000-2018.

BACKGROUND: Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) is still among the leading causes of disease burden and mortality in sub-Saharan Africa (SSA), and the world is not on track to meet targets set for ending the epidemic by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Sustainable Development Goals (SDGs). Precise HIV burden information is critical for effective geographic and epidemiological targeting of prevention and treatment interventions. Age- and sex-specific HIV prevalence estimates are widely available at the national level, and region-wide local estimates were recently published for adults overall. We add further dimensionality to previous analyses by estimating HIV prevalence at local scales, stratified into sex-specific 5-year age groups for adults ages 15-59 years across SSA. METHODS: We analyzed data from 91 seroprevalence surveys and sentinel surveillance among antenatal care clinic (ANC) attendees using model-based geostatistical methods to produce estimates of HIV prevalence across 43 countries in SSA, from years 2000 to 2018, at a 5 × 5-km resolution and presented among second administrative level (typically districts or counties) units. RESULTS: We found substantial variation in HIV prevalence across localities, ages, and sexes that have been masked in earlier analyses. Within-country variation in prevalence in 2018 was a median 3.5 times greater across ages and sexes, compared to for all adults combined. We note large within-district prevalence differences between age groups: for men, 50% of districts displayed at least a 14-fold difference between age groups with the highest and lowest prevalence, and at least a 9-fold difference for women. Prevalence trends also varied over time; between 2000 and 2018, 70% of all districts saw a reduction in prevalence greater than five percentage points in at least one sex and age group. Meanwhile, over 30% of all districts saw at least a five percentage point prevalence increase in one or more sex and age group. CONCLUSIONS: As the HIV epidemic persists and evolves in SSA, geographic and demographic shifts in prevention and treatment efforts are necessary. These estimates offer epidemiologically informative detail to better guide more targeted interventions, vital for combating HIV in SSA.

Differences in COVID-19 Preventive Behavior and Food Insecurity by HIV Status in Nigeria.

The aim of the study was to assess if there were significant differences in the adoption of COVID-19 risk preventive behaviors and experience of food insecurity by people living with and without HIV in Nigeria. This was a cross-sectional study that recruited a convenience sample of 4471 (20.5% HIV positive) adults in Nigeria. Binary logistic regression analysis was conducted to test the associations between the explanatory variable (HIV positive and non-positive status) and the outcome variables-COVID-19 related behavior changes (physical distancing, isolation/quarantine, working remotely) and food insecurity (hungry but did not eat, cut the size of meals/skip meals) controlling for age, sex at birth, COVID-19 status, and medical status of respondents. Significantly fewer people living with HIV (PLWH) reported a positive COVID-19 test result; and had lower odds of practicing COVID-19 risk preventive behaviors. In comparison with those living without HIV, PLWH had higher odds of cutting meal sizes as a food security measure (AOR: 3.18; 95% CI 2.60-3.88) and lower odds of being hungry and not eating (AOR: 0.24; 95% CI 0.20-0.30). In conclusion, associations between HIV status, COVID-19 preventive behaviors and food security are highly complex and warrant further in-depth to unravel the incongruities identified.

Associations between COVID-19 testing status, non-communicable diseases and HIV status among residents of sub-Saharan Africa during the first wave of the pandemic.

BACKGROUND: This study determined if non-communicable disease status, HIV status, COVID-19 status and co-habiting were associated with COVID-19 test status in sub-Saharan Africa. METHODS: Data of 5945 respondents age 18-years-old and above from 31 countries in sub-Saharan Africa collected through an online survey conducted between June and December 2020, were extracted. The dependent variable was COVID-19 status (testing positive for COVID-19 and having symptoms of COVID-19 but not getting tested). The independent variables were non-communicable disease status (hypertension, diabetes, cancer, heart conditions, respiratory conditions, depression), HIV positive status, COVID-19 status (knowing a close friend who tested positive for COVID-19 and someone who died from COVID-19) and co-habiting (yes/no). Two binary logistic regression models developed to determine associations between the dependent and independent variables were adjusted for age, sex, employment, sub region and educational status. RESULTS: Having a close friend who tested positive for COVID-19 (AOR:6.747), knowing someone who died from COVID-19 infection (AOR:1.732), and living with other people (AOR:1.512) were significantly associated with higher odds of testing positive for COVID-19 infection, while living with HIV was associated with significantly lower odds of testing positive for COVID-19 infection (AOR:0.284). Also, respondents with respiratory conditions (AOR:2.487), self-reported depression (AOR:1.901), those who had a close friend who tested positive for COVID-19 infection (AOR:2.562) and who knew someone who died from COVID-19 infection (AOR:1.811) had significantly higher odds of having symptoms of COVID-19 infection but not getting tested. CONCLUSION: Non-communicable diseases seem not to increase the risk for COVID-19 positive test while cohabiting seems to reduce this risk. The likelihood that those who know someone who tested positive to or who died from COVID-19 not getting tested when symptomatic suggests there is poor contact tracing in the region. People with respiratory conditions and depression need support to get tested for COVID-19.

Factors associated with COVID-19 pandemic induced post-traumatic stress symptoms among adults living with and without HIV in Nigeria: a cross-sectional study.

BACKGROUND: Nigeria is a country with high risk for traumatic incidences, now aggravated by the COVID-19 pandemic. This study aimed to identify differences in COVID-19 related post-traumatic stress symptoms (PTSS) among people living and not living with HIV; to assess whether PTSS were associated with COVID-19 pandemic-related anger, loneliness, social isolation, and social support; and to determine the association between PTSS and use of COVID-19 prevention strategies. METHODS: The data of the 3761 respondents for this analysis was extracted from a cross-sectional online survey that collected information about mental health and wellness from a convenience sample of adults, 18 years and above, in Nigeria from July to December 2020. Information was collected on the study's dependent variable (PTSS), independent variables (self-reported COVID-19, HIV status, use of COVID-19 prevention strategies, perception of social isolation, access to emotional support, feelings of anger and loneliness), and potential confounder (age, sex at birth, employment status). A binary logistic regression model tested the associations between independent and dependent variables. RESULTS: Nearly half (47.5%) of the respondents had PTSS. People who had symptoms but were not tested (AOR = 2.20), felt socially isolated (AOR = 1.16), angry (AOR = 2.64), or lonely (AOR = 2.19) had significantly greater odds of reporting PTSS (p < 0.001). People living with HIV (AOR = 0.39), those who wore masks (AOR = 0.62) and those who had emotional support (AOR = 0.63), had lower odds of reporting PTSS (p < .05). CONCLUSION: The present study identified some multifaceted relationships between post-traumatic stress, HIV status, facemask use, anger, loneliness, social isolation, and access to emotional support during this protracted COVID-19 pandemic. These findings have implications for the future health of those affected, particularly for individuals living in Nigeria. Public health education should be incorporated in programs targeting prevention and prompt diagnosis and treatment for post-traumatic stress disorder at the community level.

Is self-reported depression, HIV status, COVID-19 health risk profile and SARS-CoV-2 exposure associated with difficulty in adhering to COVID-19 prevention measures among residents in West Africa?

BACKGROUND: The aim of this study was to determine whether self-reported depression, coronavirus disease of 2019 (COVID-19) health risk profile, HIV status, and SARS-CoV-2 exposure were associated with the use of COVID-19 prevention measures. METHODS: This survey collected data electronically between June 29 and December 31, 2020 from a convenient sample of 5050 adults 18 years and above living in 12 West African countries. The dependent variables were: social distancing, working remotely, difficulty obtaining face masks and difficulty washing hands often. The independent variables were self-reported depression, having a health risk for COVID-19 (high, moderate and little/no risk), living with HIV and COVID-19 status (SARS-CoV-2 positive tests, having COVID-19 symptoms but not getting tested, having a close friend who tested positive for SARS-CoV-2 and knowing someone who died from COVID-19). Four binary logistic regression models were developed to model the associations between the dependent and independent variables, adjusting for socio-demographic variables (age, gender, educational status, employment status and living status). RESULTS: There were 2412 (47.8%) male participants and the mean (standard deviation) age was 36.94 (11.47) years. Respondents who reported depression had higher odds of working remotely (AOR: 1.341), and having difficulty obtaining face masks (AOR: 1.923;) and washing hands often (AOR: 1.263). People living with HIV had significantly lower odds of having difficulty washing hands often (AOR: 0.483). Respondents with moderate health risk for COVID-19 had significantly higher odds of social distancing (AOR: 1.144) and those with high health risk had difficulty obtaining face masks (AOR: 1.910). Respondents who had a close friend who tested positive for SARS-CoV-2 (AOR: 1.132) and knew someone who died of COVID-19 (AOR: 1.094) had significantly higher odds of social distancing. Those who tested positive for SARS-CoV-2 had significantly lower odds of social distancing (AOR: 0.629) and working remotely (AOR: 0.713). Those who had symptoms of COVID-19 but did not get tested had significantly lower odds of social distancing (AOR: 0.783) but significantly higher odds of working remotely (AOR: 1.277). CONCLUSIONS: The study signifies a disparity in the access to and use of COVID-19 preventative measures that is allied to the health and COVID-19 status of residents in West Africa. Present findings point to risk compensation behaviours in explaining this outcome.

Health system barriers influencing timely breast cancer diagnosis and treatment among women in low and middle-income Asian countries: evidence from a mixed-methods systematic review.

BACKGROUND: Globally, breast cancer is the most common cancer type and the leading cause of cancer mortality among women in developing countries. A high prevalence of late breast cancer diagnosis and treatment has been reported predominantly in Low- and Middle-Income Countries (LMICs), including those in Asia. Thus, this study utilized a mixed-methods systematic review to synthesize the health system barriers influencing timely breast cancer diagnosis and treatment among women in Asian countries. METHODS: We systematically searched five electronic databases for studies published in English from 2012 to 2022 on health system barriers that influence timely breast cancer diagnosis and treatment among women in Asian countries. The review was conducted per the methodology for systematic reviews and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, while health system barriers were extracted and classified based on the World Health Organization (WHO)'s Health Systems Framework. The mixed-methods appraisal tool was used to assess the methodological quality of the included studies. RESULTS: Twenty-six studies were included in this review. Fifteen studies were quantitative, nine studies were qualitative, and two studies used a mixed-methods approach. These studies were conducted across ten countries in Asia. This review identified health systems barriers that influence timely breast cancer diagnosis and treatment. The factors were categorized under the following: (1) delivery of health services (2) health workforce (3) financing for health (4) health information system and (5) essential medicines and technology. Delivery of health care (low quality of health care) was the most occurring barrier followed by the health workforce (unavailability of physicians), whilst health information systems were identified as the least barrier. CONCLUSION: This study concluded that health system factors such as geographical accessibility to treatment, misdiagnosis, and long waiting times at health facilities were major barriers to early breast cancer diagnosis and treatment among Asian women in LMICs. Eliminating these barriers will require deliberate health system strengthening, such as improving training for the health workforce and establishing more healthcare facilities.

Leveraging e-Learning technology to enhance pre-service training for healthcare trainees in Ghana: evidence from a pilot project and pointers to policy reforms.

BACKGROUND: E-Learning solutions are increasingly being advocated to augment existing traditional teaching and learning efforts in health training institutions. Unfortunately, these emerging technologies rarely focus on health sciences education within the context of public universities, hence the need for this study. This project evaluated experiences of healthcare trainees with a pilot e-Learning project (SMART e-Learning project) initiated in one of Ghana's public universities in 2017. The study used a mixed methods cross-sectional approach among 363 healthcare trainees. Data collection was between 17th October, 2019 to 3rd December, 2019. Data was analysed descriptively and test for variable differences done using Pearson Chi-square and Fisher's Exact for categorical variables. Wilcoxon Mann-Whitney test was used to test for differences in the Likert scale items. Additionally, rotated varimax factor analysis was performed for the health trainees' rated satisfaction factors. RESULTS: Out of 446 respondents who consented to participate in the study, 363 responses were complete and valid, representing a response rate of 81 %. Most frequently used e-learning facilities by healthcare trainees were: writing interim assessments (IAs) (82 %) while the least used function was live chating with faculty (5 %). Challenges associated with the e-learning pilot project were: limited workspace in the pilot computer laboratory (33 %), slow internet/intranet speed (29 %) and limited capacity of teaching and ICT staff to support users (28 %). CONCLUSIONS: There is the need to engage relevant stakeholders at the University, ministries of health and education through policy dialogues to develop statutory e-Learning guidelines for health educational institutions of higher learning to complement existing traditional teaching and learning approaches.

Self-reported breast and cervical cancer screening practices among women in Ghana: predictive factors and reproductive health policy implications from the WHO study on global AGEing and adult health.

BACKGROUND: Breast and cervical cancers constitute the two leading causes of cancer deaths among women in Ghana. This study examined breast and cervical screening practices among adult and older women in Ghana. METHODS: Data from a population-based cross-sectional study with a sample of 2749 women were analyzed from the study on global AGEing and adult health conducted in Ghana between 2007 and 2008. Binary and multivariable ordinal logistic regression analyses were performed to assess the association between socio-demographic factors, breast and cervical screening practices. RESULTS: We found that 12.0 and 3.4% of adult women had ever had pelvic screening and mammography respectively. Also, 12.0% of adult women had either one of the screenings while only 1.8% had both screening practices. Age, ever schooled, ethnicity, income quantile, father's education, mother's employment and chronic disease status were associated with the uptake of both screening practices. CONCLUSION: Nationwide cancer awareness campaigns and education should target women to improve health seeking behaviours regarding cancer screening, diagnosis and treatment. Incorporating cancer screening as a benefit package under the National Health Insurance Scheme can reduce financial barriers for breast and cervical screening.

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.

Adherence to standard nursing protocols on nasogastric tube feeding in a secondary referral hospital in Ghana: comparing self-ratings by professional and auxiliary nurses.

BACKGROUND: Data on nurses' adherence to standard protocol on nasogastric (NG) tube feeding remain scanty in Ghana even though patients in critical medical conditions are routinely managed using this procedure. This study explored self-rated adherence to standard protocols on NG tube feeding among professional and auxiliary nurses and the perceived barriers impeding compliance to these standard protocols. METHODS: This is a descriptive analytical cross-sectional study among professional (n = 89) and auxiliary (n = 24) nurses in a major referral hospital in one of the ten administrative regions in Ghana. Four-point Likert scale was used to ascertain the level of adherence to standard guidelines on nasogastric tube, ranging from 4 "Very large extent" to 1 "Very little extent". Wilcoxon Mann-Whitney test and univariate ordered logistic regression tests (proportional odds models) were performed to determine the odds of higher self-ratings among professional and auxiliary nurses. RESULTS: Overall, the odds of higher self-ratings on adherence to standard nursing protocols on NG tube feeding was higher among auxiliary nurses than professional nurses (OR = 2.76, p = 0.031) after adjusting for age, gender, education and years of work experience. Key barriers to adherence to standard protocols on NG tube feeding were: limited opportunities for in-service trainings and insufficiency of NG tube feeding protocols on the wards. CONCLUSION: There is the need for more routine in-service trainings for nursing staff to update their knowledge on NG tube feeding. Hospital management should also make current nursing protocols available to nurses to guide their practice alongside routine onsite supervision of nurses.

International note: Analysis of risk and protective factors for risky sexual behaviours among school-aged adolescents.

This study examined the prevalence and associated factors of risky sexual behaviours among 1648 school-going adolescents using the 2012 Ghana Global School-based Student Health Survey. Our findings showed 33.5% of the participants had ever had sex 32.5% had multiple sexual partners and only 26.2% reported using condom during their last sexual intercourse. Being male, older age, anxiety, loneliness, suicidal ideation, being bullied, food insecurity (hunger), current alcohol and marijuana use were significant risk factors for being sexually experienced, multiple partners, but not condom use. Parental knowledge of activity was a significant protective factor against adolescents' sexual experience. These findings underscore the need to develop school-based interventions that would help reduce risky sexual behaviours among school-going adolescents.

Stakeholders' views on maternity care shortcomings in rural Ghana: An ethnographic study among women, providers, public, and quasiprivate policy sector actors.

Access to skilled provider and emergency obstetric care is not universal across all districts in Ghana. The lived experiences of 3 stakeholder groups on maternity care shortcomings in 3 rural Ghanaian districts are examined in this study. We applied an ethnographic study approach where field data were collected between March to May 2015 in 3 rural districts of northern Ghana. Data were collected among women with recent births experiences (n = 90), health care providers (n = 16), and policy actors (n = 6). Transcripts were read through to identify similar and divergent stakeholders' views. Significant expressions and experiences of stakeholders on maternity care shortcomings were extracted and evaluated to define key themes. Four themes emerged: social/community factors, payments for health care, facility level factors, and policy level factors. The results show that traditional women's roles divest time for maternity care. Poor transport arrangements, insufficient health workforce, health funding gaps, insurance reimbursements delays, and catastrophic health expenditures on travel and drugs are attested as major barriers across all stakeholder groups in all districts studied. The discussion of the study findings suggests it is important to ascertain the scale of informal payments and their impacts on health access. Investments in health workforce and reliable ambulatory service systems could help address poor referral difficulties in rural areas of the country. Social support for community initiatives that pool funds could provide extra resources and relieve cost access-related challenges for using maternity care in rural settings in Ghana.

Context-specific Factors and Contraceptive Use: A Mixed Method Study among Women, Men and Health Providers in a Rural Ghanaian District.

Suitable options for improving women's access to effective, safe and context-specific contraceptive methods must be explored to curtail rising unmet needs for contraceptive use in rural Ghana. The study aimed to outline context-specific factors associated with contraceptive use, access on demand and future use intentions among women in one district of Ghana. Using mixed method approach, quantitative data (n=720) was collected among women aged 18-28. Focus group discussions and in-depth interviews were also conducted among women (n=30) aged 18-49 and men (n=10) respectively. IDIs were conducted among 3 midwives. Women who received focused counseling on contraceptive use were twice likely to have ever used (OR=2 95% CI 1.163-3.467) or be current users (OR=2, 95% CI 1.146-4.010) of contraceptives. Male partner support can drive cultural sensitivities towards accepting use of contraception (OR=34.5, CI% 19.01-64.22). Covert use is still preferred by most in the study. Services delivered on good provider-relational grounds and convenient clinic hours encourage contraceptive use among women. Male targeting for improving contraceptive service use must first identify context-specific preferences of the woman, since covert use is highly valued. Ascertaining the prevalence of covert use and how community systems can address this for improved contraceptive uptake is further recommended.

Focused maternity care in Ghana: results of a cluster analysis.

BACKGROUND: Ghana missed out in attaining Millennium Development Goal 5 in 2015. The provision of adequate prenatal and postnatal care remains problematic, with poor evidence on women's views on met and unmet maternity care needs across all regions in Ghana. This paper examines maternal care utilization in Ghana by applying WHO indicators for focused maternal care utilization. METHODS: Two-step cluster analysis segregated women into groups based on the components of the maternity care used. Using cluster membership variables as dependent variables, we applied multinomial and binary regression to examine associations of care use with individual, household and regional characteristics. RESULTS: We identified three patterns of care use: adequate, less and least adquate care. The presence of a female and skilled provider is an indicator of adequate care. Women in Volta, Upper West, Northern and Western regions received less adequate care compared with other regions. Supply-related factors (drugs availability, distance/transport, health insurance ownership, rural residence) were associated with adequacy of care. The lack of female autonomy, widowed/divorced women, age and parity were associated with less adequate care. Care patterns were distinctively associated with the quality of health care support (skilled and female attendant) instead of with the number of visits made to the facility. Across regions and within rural settings, disparities exist, often compounded by supply-related factors. CONCLUSIONS: Efforts to address skilled workforce shortages, greater accountability for quality and equity, improving women motivation for care seeking and active participation are important for maternity care in Ghana.

Unmet reproductive health needs among women in some West African countries: a systematic review of outcome measures and determinants.

BACKGROUND: Identifying relevant measures of women's reproductive health needs is critical to improve women's chances of service utilization. The study aims to systematically review and analyze the adequacy of outcome measures and determinants applied in previous studies for assessing women reproductive health needs across West Africa. METHODS: Evidence on outcomes and determinants of unmet reproductive health needs among women of childbearing age in diverse multicultural, religious, and ethnic settings in West African countries was systematically reviewed. The review included recent English language publications (from January 2009 - March 2014). Clinical studies particularly on obstetric care services and reproductive services in relation to HIV/AIDS were excluded. We acknowledge the possibility to have excluded non-English publications and yet-to-be-published articles related to the study aim and objectives. Outcomes and determinants were assessed and defined at three main levels; contraceptive use, obstetric care, and antenatal care utilization. RESULTS: Results show increasing unmet need for women's reproductive health needs. Socio-cultural norms and practices resulting in discontinuation of service use, economic constraints, travel distance to access services and low education levels of women were found to be key predictors of service utilization for contraception, antenatal and obstetric care services. Outcome measures were mainly assessed based on service utilization, satisfaction, cost, and quality of services available as core measures across the three levels assessed in this review. CONCLUSIONS: Evidence from this review indicates that currently applied measures of women's reproductive health needs might be inadequate in attaining best maternal outcomes since they appear rather broad. More support and research for developing and advancing context-related measures may help to improve women's maternal health.