Translation, cultural adaptation and psychometric properties of the Ghanaian language (Akan; Asante Twi) version of the Health Literacy Questionnaire.

BACKGROUND: Patients' competencies and resources to manage their own health, which is termed health literacy, is a necessity for better health outcomes. Thus, it is relevant to have a comprehensive health literacy measurement tool suitable for populations of interest. The Health Literacy Questionnaire (HLQ) is a tool useful for health literacy assessment covering nine dimensions/scales of health literacy. The HLQ has been translated and validated in diverse contexts but has so far not been assessed in any country in sub-Saharan Africa. We sought to translate this tool into the most common language used in Ghana and assess its validity. METHODS: We carried out a cross-sectional study using the HLQ concurrently with an assessment of a malaria programme for caregivers with children under 5 years. The HLQ was translated using a systematic translation procedure. We analysed the psychometric properties of the HLQ based on data collected by face-to-face interview of 1234 caregivers. The analysis covered tests on difficulty level of scales, composite reliability, Cronbach's alpha and confirmatory factor analysis (CFA). RESULTS: Cognitive testing showed that some words were ambiguous, which led to minor rewording of the questionnaire. A nine-factor CFA model was fitted to the 44 question items with no cross-loadings or correlated residuals allowed. Given the very restricted nature of the model, the fit was quite satisfactory: χ2 DWLS (866 df) = 17,177.58, p < 0.000, CFI = 0.971, TLI = 0.969, RMSEA = 0.126 and SRMR = 0.107. Composite reliability and Cronbach's alpha were > 0.65 for all scales except Cronbach's alpha for scale 9, 'Understanding health information well enough to know what to do' (0.57). The mean differences between most demographic groups among health literacy scales were statistically significant. CONCLUSION: The Akan-Twi version of HLQ proved relevant in our description of the health literacy levels among the caregivers in our study. This validated tool will be useful to conduct health literacy needs assessments to guide policies addressing such needs. Further work is needed to validate this tool for use in Ghana and similar contexts.

Childhood mortality, intra-household bargaining power and fertility preferences among women in Ghana.

BACKGROUND: Continuing population growth could be detrimental for social and economic wellbeing. Understanding the factors that influence family planning decisions will be important for policy. This paper examines the effect of childhood mortality and women's bargaining power on family planning decisions. METHODS: Data was from the 2014 Ghana Demographic and Health Survey (DHS). A sample of 3313 women in their reproductive age were included in this study. We created variables on women's exposure to and experience of child mortality risks. Three different indicators of women's bargaining power in the household were also used. Probit models were estimated in accordance with the nature of the dependent variable. RESULTS: Results from the probit models suggest that child mortality has a positive association with higher fertility preference. Also, child mortality risks and woman's bargaining power play important roles in a woman's fertility choices in Ghana. Women with higher bargaining power were likely to prefer fewer children in the face of child mortality risks, compared to women with lower bargaining power. CONCLUSION: In addition to public sensitization campaigns on the dangers of high fertility and use of contraceptives, the findings of this study emphasize the need to focus on reducing child mortality and improving women bargaining power in developing countries.

Health, Social, and Economic Variables Associated with Depression Among Older People in Low and Middle Income Countries: World Health Organization Study on Global AGEing and Adult Health.

OBJECTIVE: Although depression among older people is an important public health problem worldwide, systematic studies evaluating its prevalence and determinants in low and middle income countries (LMICs) are sparse. The biopsychosocial model of depression and prevailing socioeconomic hardships for older people in LMICs have provided the impetus to determine the prevalence of geriatric depression; to study its associations with health, social, and economic variables; and to investigate socioeconomic inequalities in depression prevalence in LMICs. METHODS: The authors accessed the World Health Organization Study on Global AGEing and Adult Health Wave 1 data that studied nationally representative samples from six large LMICs (N = 14,877). A computerized algorithm derived depression diagnoses. The authors assessed hypothesized associations using survey multivariate logistic regression models for each LMIC and pooled their risk estimates by meta-analyses and investigated related socioeconomic inequalities using concentration indices. RESULTS: Cross-national prevalence of geriatric depression was 4.7% (95% CI: 1.9%-11.9%). Female gender, illiteracy, poverty, indebtedness, past informal-sector occupation, bereavement, angina, and stroke had significant positive associations, whereas pension support and health insurance showed significant negative associations with geriatric depression. Pro-poor inequality of geriatric depression were documented in five LMICs. CONCLUSIONS: Socioeconomic factors and related inequalities may predispose, precipitate, or perpetuate depression amongolder people in LMICs. Relative absence of health safety net places socioeconomically disadvantaged older people in LMICs at risk. The need for population-based public health interventions and policies to prevent and to manage geriatric depression effectively in LMICs cannot be overemphasized.

Progress in the utilization of antenatal and delivery care services in Bangladesh: where does the equity gap lie?

BACKGROUND: Universal access to health care services does not automatically guarantee equity in the health system. In the post Millennium Development Goals (MDGs) era, the progress towards universal access to maternal health care services in a developing country, like Bangladesh requires an evaluation in terms of equity lens. This study, therefore, analysed the trend in inequity and identified the equity gap in the utilization of antenatal care (ANC) and delivery care services in Bangladesh between 2004 and 2011. METHODS: The data of this study came from the Bangladesh Demographic and Health Survey. We employed rate ratio, concentration curve and concentration index to examine the trend in inequity of ANC and delivery care services. We also used logistic regression models to analyse the relationship between socioeconomic factors and maternal health care services. RESULTS: The concentration index for 4+ ANC visits dropped from 0.42 in 2004 to 0.31 in 2011 with a greater decline in urban area. There was almost no change in the concentration index for ANC services from medically trained providers during this period. We also found a decreasing trend in inequity in the utilization of both health facility delivery and skilled birth assistance but this trend was again more pronounced in urban area compared to rural area. The concentration index for C-section delivery decreased by about 33 % over 2004-2011 with a similar rate in both urban and rural areas. Women from the richest households were about 3 times more likely to have 4+ ANC visits, delivery at a health facility and skilled birth assistance compared to women from the poorest households. Women's and their husbands' education were significantly associated with greater use of maternal health care services. In addition, women's exposure to mass media, their involvement in microcredit programs and autonomy in healthcare decision-making appeared as significant predictors of using some of these health care services. CONCLUSIONS: Bangladesh faces not only a persistent pro-rich inequity but also a significant rural-urban equity gap in the uptake of maternal health care services. An equity perspective in policy interventions is much needed to ensure safe motherhood and childbirth in Bangladesh.

Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem?

BACKGROUND: Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources. METHODS: The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified. RESULTS: Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS. CONCLUSION: Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.

Association between gender inequality index and child mortality rates: a cross-national study of 138 countries.

BACKGROUND: Gender inequality weakens maternal health and harms children through many direct and indirect pathways. Allied biological disadvantage and psychosocial adversities challenge the survival of children of both genders. United Nations Development Programme (UNDP) has recently developed a Gender Inequality Index to measure the multidimensional nature of gender inequality. The global impact of Gender Inequality Index on the child mortality rates remains uncertain. METHODS: We employed an ecological study to investigate the association between child mortality rates and Gender Inequality Indices of 138 countries for which UNDP has published the Gender Inequality Index. Data on child mortality rates and on potential confounders, such as, per capita gross domestic product and immunization coverage, were obtained from the official World Health Organization and World Bank sources. We employed multivariate non-parametric robust regression models to study the relationship between these variables. RESULTS: Women in low and middle income countries (LMICs) suffer significantly more gender inequality (p < 0.001). Gender Inequality Index (GII) was positively associated with neonatal (ß = 53.85; 95% CI 41.61-64.09), infant (ß = 70.28; 95% CI 51.93-88.64) and under five mortality rates (ß = 68.14; 95% CI 49.71-86.58), after adjusting for the effects of potential confounders (p < 0.001). CONCLUSIONS: We have documented statistically significant positive associations between GII and child mortality rates. Our results suggest that the initiatives to curtail child mortality rates should extend beyond medical interventions and should prioritize women's rights and autonomy. We discuss major pathways connecting gender inequality and child mortality. We present the socio-economic problems, which sustain higher gender inequality and child mortality in LMICs. We further discuss the potential solutions pertinent to LMICs. Dissipating gender barriers and focusing on social well-being of women may augment the survival of children of both genders.

Malaria care seeking behavior of individuals in Ghana under the NHIS: Are we back to the use of informal care?

BACKGROUND: Malaria is Ghana's most endemic disease; occurring across most parts of the country with a significant impact on individuals and the health system as whole. Treatment seeking for malaria care takes various forms. The National Health Insurance Scheme (NHIS) was introduced in 2004 to promote access to health services to mitigate the negative impact of the user fee regime. Ten years on, national coverage is less than 40% of the total population and patients continue to make direct payments for health services. This paper analyses the care-seeking behaviour of households for treatment of malaria in Ghana under the NHI policy. METHOD: Using a cross-sectional survey of household data collected from three districts in Ghana covering the 3 ecological zones namely the coastal, forest and savannah, a multinomial logit model is estimated. The sample consists of 365 adults and children reporting being ill with malaria in the last four weeks prior to the study. RESULTS: Out of the total, 58% were insured and 71% of them sought care from a formal health facility. Among the insured, 15% chose informal care compared to 48% among the uninsured. The results from the multinomial logit estimations show that health insurance and travel time to health facility are significant determinants of health care demand. The results show that the insured are 6 times more likely to choose regional/district hospitals: 5 times more likely to choose health centres/clinics and 7 times more likely to choose private hospitals/clinics over informal care when compared with the uninsured. Individual characteristics such as age, education and wealth status were significant determinants of health care provider choice for specific categories of health facilities. CONCLUSION: Overall, for malaria care the uninsured are more likely to choose informal care compared to the insured for the treatment of malaria.

Does the National Health Insurance Scheme provide financial protection to households in Ghana?

BACKGROUND: Excessive healthcare payments can impede access to health services and also disrupt the welfare of households with no financial protection. Health insurance is expected to offer financial protection against health shocks. Ghana began the implementation of its National Health Insurance Scheme (NHIS) in 2004. The NHIS is aimed at removing the financial barrier to healthcare by limiting direct out-of-pocket health expenditures (OOPHE). The study examines the effect of the NHIS on OOPHE and how it protects households against catastrophic health expenditures. METHODS: Data was obtained from a cross-sectional representative household survey involving 2,430 households from three districts across Ghana. All OOPHE associated with treatment seeking for reported illness in the household in the last 4 weeks preceding the survey were analysed and compared between insured and uninsured persons. The incidence and intensity of catastrophic health expenditures (CHE) among households were measured by the catastrophic health payment method. The relative effect of NHIS on the incidence of CHE in the household was estimated by multiple logistic regression analysis. RESULTS: About 36% of households reported at least one illness during the 4 weeks period. Insured patients had significantly lower direct OOPHE for out-patient and in-patient care compared to the uninsured. On financial protection, the incidence of CHE was lower among insured households (2.9%) compared to the partially insured (3.7%) and the uninsured (4.0%) at the 40% threshold. The incidence of CHE was however significantly lower among fully insured households (6.0%) which sought healthcare from NHIS accredited health facilities compared to the partially insured (10.1%) and the uninsured households (23.2%). The likelihood of a household incurring CHE was 4.2 times less likely for fully insured and 2.9 times less likely for partially insured households relative to being uninsured. The NHIS has however not completely eliminated OOPHE for the insured and their households. CONCLUSION: The NHIS has significant effect in reducing OOPHE and offers financial protection against CHE for insured individuals and their households though they still made some out-of-pocket payments. Efforts should aim at eliminating OOPHE for the insured if the objective for establishing the NHIS is to be achieved.

Household perceptions towards a redistributive policy across health insurance funds in Tanzania.

BACKGROUND: The Tanzanian health insurance system comprises multiple health insurance funds targeting different population groups but which operate in parallel, with no mechanisms for redistribution across the funds. Establishing such redistributive mechanisms requires public support, which is grounded on the level of solidarity within the country. The aim of this paper is to analyse the perceptions of CHF, NHIF and non-member households towards cross-subsidisation of the poor as an indication of the level of solidarity and acceptance of redistributive mechanisms. METHODS: This study analyses data collected from a survey of 695 households relating to perceptions of household heads towards cross-subsidisation of the poor to enable them to access health services. Kruskal-Wallis test is used to compare perceptions by membership status. Generalized ordinal logistic regression models are used to identify factors associated with support for cross-subsidisation of the poor. RESULTS: Compared to CHF and NHIF households, non-member households expressed the highest support for subsidised CHF membership for the poor. The odds of expressing support for subsidised CHF membership are higher for NHIF households and non-member households, households that are wealthier, whose household heads have lower education levels, and have sick members. The majority of households support a partial rather than fully subsidised CHF membership for the poor and there were no significant differences by membership status. The odds of expressing willingness to contribute towards subsidised CHF membership are higher for households that are wealthier, with young household heads and have confidence in scheme management. CONCLUSION: The majority may support a redistributive policy, but there are indications that this support and willingness to contribute to its achievement are influenced by the perceived benefits, amount of subsidy considered, and trust in scheme management. These present important issues for consideration when designing redistributive policies.

Quality of uncomplicated malaria case management in Ghana among insured and uninsured patients.

INTRODUCTION: The National Health Insurance Act, 2003 (Act 650) established the National Health Insurance Scheme (NHIS) in Ghana with the aim of increasing access to health care and improving the quality of basic health care services for all citizens. The main objective is to assess the effect of health insurance on the quality of case management for patients with uncomplicated malaria, ascertaining any significant differences in treatment between insured and non-insured patients. METHOD: A structured questionnaire was used to collect data from 523 respondents diagnosed with malaria and prescribed malaria drugs from public and private health facilities in 3 districts across Ghana's three ecological zones. Collected information included initial examinations performed on patients (temperature, weight, age, blood pressure and pulse); observations of malaria symptoms by trained staff, laboratory tests conducted and type of drugs prescribed. Insurance status of patients, age, gender, education level and occupation were asked in the interviews. RESULTS: Of the 523 patients interviewed, only 40 (8%) were uninsured. Routine recording of the patients' age, weight, and temperature was high in all the facilities. In general, assessments needed to identify suspected malaria were low in all the facilities with hot body/fever and headache ranking the highest and convulsion ranking the lowest. Parasitological assessments in all the facilities were also very low. All patients interviewed were prescribed ACTs which is in adherence to the drug of choice for malaria treatment in Ghana. However, there were no significant differences in the quality of malaria treatment given to the uninsured and insured patients. CONCLUSION: Adherence to the standard protocol of malaria treatment is low. This is especially the case for parasitological confirmation of all suspected malaria patients before treatment with an antimalarial as currently recommended for the effective management of malaria in the country. The results show that about 16 percent of total sample were parasitologically tested. Effective management of the disease demands proper diagnosis and treatment and therefore facilities need to be adequately supplied with RDTs or be equipped with well functioning laboratories to provide adequate testing.

Health care seeking behaviour and utilisation in a multiple health insurance system: does insurance affiliation matter?

BACKGROUND: Many countries striving to achieve universal health insurance coverage have done so by means of multiple health insurance funds covering different population groups. However, existence of multiple health insurance funds may also cause variation in access to health care, due to the differential revenue raising capacities and benefit packages offered by the various funds resulting in inequity and inefficiency within the health system. This paper examines how the existence of multiple health insurance funds affects health care seeking behaviour and utilisation among members of the Community Health Fund, the National Health Insurance Fund and non-members in two districts in Tanzania. METHODS: Using household survey data collected in 2011 with a sample of 3290 individuals, the study uses a multinomial logit model to examine the influence of predisposing, enabling and need characteristics on the probability of seeking care and choice of provider. RESULTS: Generally, health insurance is found to increase the probability of seeking care and reduce delays. However, the probability, timing of seeking care and choice of provider varies across the CHF and NHIF members. CONCLUSIONS: Reducing fragmentation is necessary to provide opportunities for redistribution and to promote equity in utilisation of health services. Improvement in the delivery of services is crucial for achievement of improved access and financial protection and for increased enrolment into the CHF, which is essential for broadening redistribution and cross-subsidisation to promote equity.

Cost and burden of informal caregiving of dependent older people in a rural Indian community.

BACKGROUND: Lack of state supported care services begets the informal caregiving by family members as the mainstay of care provided to the dependent older people in many Low and Middle Income Countries (LMICs), including India. Little is known about the time spent on caregiving, its cost and the burden experienced by these informal caregivers. We aimed to estimate the costs of informal caregiving and to evaluate the nature as well as correlates of caregivers' burden in a rural Indian community. METHODS: We assessed 1000 people aged above 65 years, among whom 85 were dependent. We assessed their socioeconomic profiles, disability, health status and health expenditures. Their caregivers' socio-demographic profiles, mental health, and the time spent on caregiving were assessed using standard instruments. Caregiver's burden was evaluated using Zarit Burden Scale. We valued the annual informal caregiving costs using proxy good method. We employed appropriate non-parametric multivariate statistics to evaluate the correlates of caregivers' burden. RESULTS: Average time spent on informal caregiving was 38.6 (95% CI 35.3-41.9) hours/week. Estimated annual cost of informal caregiving using proxy good method was 119,210 US$ in this rural community. Mean total score of Zarit burden scale, measuring caregivers' burden, was 17.9 (95% CI 15.6-20.2). Prevalence of depression among the caregivers was 10.6% (95% CI 4.1-17.1%). Cerebrovascular disease, Parkinson's disease, higher disability, insomnia and incontinence of the dependent older people as well as the time spent on helping Activities of Daily Living and on supervision increased caregiver's burden significantly. CONCLUSIONS: Cost and burden of informal caregiving are high in this rural Indian community. Many correlates of burden, experienced by caregivers, are modifiable. We discuss potential strategies to reduce this burden in LMICs. Need for support to informal caregivers and for management of dependent older people with chronic disabling diseases by multidisciplinary community teams are highlighted.

Correlates of out-of-pocket and catastrophic health expenditures in Tanzania: results from a national household survey.

BACKGROUND: Inequality in health services access and utilization are influenced by out-of-pocket health expenditures in many low and middle-income countries (LMICs). Various antecedents such as social factors, poor health and economic factors are proposed to direct the choice of health care service use and incurring out-of-pocket payments. We investigated the association of these factors with out-of-pocket health expenditures among the adult and older population in the United Republic of Tanzania. We also investigated the prevalence and associated determinants contributing to household catastrophic health expenditures. METHODS: We accessed the data of a multistage stratified random sample of 7279 adult participants, aged between 18 and 59 years, as well as 1018 participants aged above 60 years, from the first round of the Tanzania National Panel survey. We employed multiple generalized linear and logistic regression models to evaluate the correlates of out-of-pocket as well as catastrophic health expenditures, accounting for the complex sample design effects. RESULTS: Increasing age, female gender, obesity and functional disability increased the adults' out-of-pocket health expenditures significantly, while functional disability and visits to traditional healers increased the out-of-pocket health expenditures in older participants. Adult participants, who lacked formal education or worked as manual laborers earned significantly less (p < 0.001) and spent less on health (p < 0.001), despite having higher levels of disability. Large household size, household head's occupation as a manual laborer, household member with chronic illness, domestic violence against women and traditional healer's visits were significantly associated with high catastrophic health expenditures. CONCLUSION: We observed that the prevalence of inequalities in socioeconomic factors played a significant role in determining the nature of both out-of-pocket and catastrophic health expenditures. We propose that investment in social welfare programs and strengthening the social security mechanisms could reduce the financial burden in United Republic of Tanzania.

Healthcare provider cost of antimicrobial resistance in two teaching hospitals in Ghana.

Understanding the healthcare provider costs of antimicrobial resistance (AMR) in lower-middle-income countries would motivate healthcare facilities to prioritize reducing the AMR burden. This study evaluates the extra length of stay and the associated healthcare provider costs due to AMR to estimate the potential economic benefits of AMR prevention strategies. We combined data from a parallel cohort study with administrative data from the participating hospitals. The parallel cohort study prospectively matched a cohort of patients with bloodstream infections caused by third-generation cephalosporin-resistant enterobacteria and methicillin-resistant Staphylococcus aureus (AMR cohort) with two control arms: patients infected with similar susceptible bacteria and a cohort of uninfected controls. Data collection took place from June to December 2021. We calculated the cost using aggregated micro-costing and step-down costing approaches and converted costs into purchasing power parity in international US dollars, adjusting for surviving patients, bacterial species and cost centres. We found that the AMR cohort spent a mean of 4.2 extra days (95% CI: 3.7-4.7) at Hospital 1 and 5.5 extra days (95% CI: 5.1-5.9) at Hospital 2 compared with the susceptible cohort. This corresponds to an estimated mean extra cost of $823 (95% CI: 812-863) and $946 (95% CI: US$929-US$964) per admission, respectively. For both hospitals, the estimated mean annual extra cost attributable to AMR was approximately US$650 000. The cost varies by organism and type of resistance expressed. The result calls for prioritization of interventions to mitigate the spread of AMR in Ghana.

Health literacy and household financial loss on malaria treatment for children under five in Ghana: a patients' perspective.

BACKGROUND: Inadequate health literacy increases medical costs and leads to poor health outcomes. However, there is a paucity of empirical evidence of such associations in sub-Saharan Africa. This study investigates how the household cost of malaria in children under five in Ghana varies based on different levels of health literacy. METHODS: A cross-sectional survey involving 1270 caregivers of children under five was conducted. The survey included health literacy questionnaire and several pieces of sociodemographic and behavioural variables. RESULTS: We created seven caregiver health literacy profiles by scoring nine dimensions. The mean total cost for managing malaria among respondents was US$20.29 per episode. The total household cost for caregivers with high health literacy (Profile 1) (US$24.77) was higher than all other profiles, with the lowest cost (US$17.93) among the low health literacy profile (Profile 6). Compared with Profile 4, caregivers with high health literacy (Profile 1) spent more on managing malaria in children, while those with the lowest health literacy (Profile 7) spent less. CONCLUSION: The current study presents a snapshot of malaria treatment costs, and argues that low health literacy may lead to increased costs due to possible reinfections from delayed healthcare use. There is a need for longitudinal studies to understand causal relationship between health literacy and household expenses on malaria treatment to inform policy development and interventions. LAY SUMMARY: This study explores the impact of caregiver health literacy levels on the cost of managing malaria incidents in children under five in Ghana. High health-literate caregivers incurred the highest total household cost at US$24.77, with US$17.93 incurred by lower health-literate caregivers per malaria episode.

Knowledge, attitudes and practices regarding antimicrobial use and resistance among healthcare seekers in two tertiary hospitals in Ghana: a quasi-experimental study.

OBJECTIVE: To evaluate knowledge of antimicrobial resistance (AMR), to study how the judgement of health value (HVJ) and economic value (EVJ) affects antibiotic use, and to understand if access to information on AMR implications may influence perceived AMR mitigation strategies. DESIGN: A quasi-experimental study with interviews performed before and after an intervention where hospital staff collected data and provided one group of participants with information about the health and economic implications of antibiotic use and resistance compared with a control group not receiving the intervention. SETTING: Korle-Bu and Komfo Anokye Teaching Hospitals, Ghana. PARTICIPANTS: Adult patients aged 18 years and older seeking outpatient care. MAIN OUTCOME MEASURES: We measured three outcomes: (1) level of knowledge of the health and economic implications of AMR; (2) HVJ and EVJ behaviours influencing antibiotic use and (3) differences in perceived AMR mitigation strategy between participants exposed and not exposed to the intervention. RESULTS: Most participants had a general knowledge of the health and economic implications of antibiotic use and AMR. Nonetheless, a sizeable proportion disagreed or disagreed to some extent that AMR may lead to reduced productivity/indirect costs (71% (95% CI 66% to 76%)), increased provider costs (87% (95% CI 84% to 91%)) and costs for carers of AMR patients/societal costs (59% (95% CI 53% to 64%)). Both HVJ-driven and EVJ-driven behaviours influenced antibiotic use, but the latter was a better predictor (reliability coefficient >0.87). Compared with the unexposed group, participants exposed to the intervention were more likely to recommend restrictive access to antibiotics (p<0.01) and pay slightly more for a health treatment strategy to reduce their risk of AMR (p<0.01). CONCLUSION: There is a knowledge gap about antibiotic use and the implications of AMR. Access to AMR information at the point of care could be a successful way to mitigate the prevalence and implications of AMR.

Attributable Patient Cost of Antimicrobial Resistance: A Prospective Parallel Cohort Study in Two Public Teaching Hospitals in Ghana.

OBJECTIVE: The aim of this study was to evaluate the attributable patient cost of antimicrobial resistance (AMR) in Ghana to provide empirical evidence to make a case for improved AMR preventive strategies in hospitals and the general population. METHODS: A prospective parallel cohort design in which participants were enrolled at the time of hospital admission and remained until 30 days after the diagnosis of bacteraemia or discharge from the hospital/death. Patients were matched on age group (± 5 years the age of AMR patients), treatment ward, sex, and bacteraemia type. The AMR cohort included all inpatients with a positive blood culture of Escherichia coli or Klebsiella spp., resistant to third-generation cephalosporins (3GC), or methicillin-resistant Staphylococcus aureus (MRSA). We matched the AMR cohort (n = 404) with two control arms, i.e., patients with the same bacterial infections susceptible to 3GC or S. aureus that was methicillin-susceptible (susceptible cohort; n = 152), and uninfected patients (uninfected cohort; n = 404). Settings were Korle-Bu and Komfo Anokye Teaching Hospitals, Ghana. The outcome measures were the length of hospital stay (LOS) and the associated patient costs. Outcomes were evaluated from the patient perspective. RESULTS: From a total of 5752 blood cultures screened, 1836 participants had growth in blood culture, of which, based on our inclusion criteria, 426 were enrolled into the AMR cohort; however, only 404 completed the follow-up and were matched with participants in the two control cohorts. Patients in the AMR cohort stayed approximately 5 more days (95% confidence interval [CI] 4.0-6.0) and 8 more days (95% CI 7.2-8.6) compared with the susceptible and uninfected cohorts, respectively. The mean extra patient cost due to AMR relative to the susceptible cohort was US$1300 (95% CI 1018-1370), of which about 30% resulted from productivity loss due to presenteeism and absenteeism from work. Overall, the estimated annual patient cost due to AMR translates to about US$1 million and US$1.4 million when compared with the susceptible and uninfected cohorts, respectively. CONCLUSION: We have shown that AMR is associated with a significant excess LOS and patient costs in Ghana using prospective data from two public tertiary hospitals. This calls for infection prevention and control strategies aimed at mitigating the prevalence of AMR.

Cost-effectiveness analysis of alcohol handrub for the prevention of neonatal bloodstream infections: Evidence from HAI-Ghana study.

Published evidence of the cost-effectiveness of alcohol-based handrub (ABH) for the prevention of neonatal bloodstream infections (BSI) is limited in sub-Saharan Africa. Therefore, this study evaluates the cost-effectiveness of a multimodal hand hygiene involving alcohol-based hand rub (ABH) for the prevention of neonatal BSI in a neonatal intensive care unit (NICU) setting in Ghana using data from HAI-Ghana study. Design was a before and after intervention study using economic evaluation model to assess the cost-effectiveness of a multimodal hand hygiene strategy involving alcohol-based hand rub plus soap and water compared to existing practice of using only soap and water. We measured effect and cost by subtracting outcomes without the intervention from outcomes with the intervention. The primary outcome measure is the number of neonatal BSI episode averted with the intervention and the consequent cost savings from patient and provider perspectives. The before and after intervention studies lasted four months each, spanning October 2017 to January 2018 and December 2018 to March 2019, respectively. The analysis shows that the ABH program was effective in reducing patient cost of neonatal BSI by 41.7% and BSI-attributable hospital cost by 48.5%. Further, neonatal BSI-attributable deaths and extra length of hospital stay (LOS) decreased by 73% and 50% respectively. Also, the post-intervention assessment revealed the ABH program contributed to 16% decline in the incidence of neonatal BSI at the NICU. The intervention is a simple and adaptable strategy with cost-saving potential when carefully scaled up across the country. Though the cost of the intervention may be more relative to using just soap and water for hand hygiene, the outcome is a good reason for investment into the intervention to reduce the incidence of neonatal BSI and the associated costs from patient and providers' perspectives.

Cost-effectiveness analysis of an active 30-day surgical site infection surveillance at a tertiary hospital in Ghana: evidence from HAI-Ghana study.

OBJECTIVE: To assess the cost-effectiveness of an active 30-day surgical site infection (SSI) surveillance mechanism at a referral teaching hospital in Ghana using data from healthcare-associated infection Ghana (HAI-Ghana) study. DESIGN: Before and during intervention study using economic evaluation model to assess the cost-effectiveness of an active 30-day SSI surveillance at a teaching hospital. The intervention involves daily inspection of surgical wound area for 30-day postsurgery with quarterly feedback provided to surgeons. Discharged patients were followed up by phone call on postoperative days 3, 15 and 30 using a recommended surgical wound healing postdischarge questionnaire. SETTING: Korle-Bu Teaching Hospital (KBTH), Ghana. PARTICIPANTS: All prospective patients who underwent surgical procedures at the general surgical unit of the KBTH. MAIN OUTCOME MEASURES: The primary outcome measures were the avoidable SSI morbidity risk and the associated costs from patient and provider perspectives. We also reported three indicators of SSI severity, that is, length of hospital stay (LOS), number of outpatient visits and laboratory tests. The analysis was performed in STATA V.14 and Microsoft Excel. RESULTS: Before-intervention SSI risk was 13.9% (62/446) as opposed to during-intervention 8.4% (49/582), equivalent to a risk difference of 5.5% (95% CI 5.3 to 5.9). SSI mortality risk decreased by 33.3% during the intervention while SSI-attributable LOS decreased by 32.6%. Furthermore, the mean SSI-attributable patient direct and indirect medical cost declined by 12.1% during intervention while the hospital costs reduced by 19.1%. The intervention led to an estimated incremental cost-effectiveness ratio of US$4196 savings per SSI episode avoided. At a national scale, this could be equivalent to a US$60 162 248 cost advantage annually. CONCLUSION: The intervention is a simple, cost-effective, sustainable and adaptable strategy that may interest policymakers and health institutions interested in reducing SSI.

Costs of shoulder disorders in Denmark: a nationwide cost-of-illness study investigating 617,334 patients and matched controls.

ABSTRACT: Shoulder disorders are very common musculoskeletal conditions. Few studies have focused on the costs associated with shoulder disorders, and the economic burden has never been established in a nationwide cost-of-illness study. We aimed to evaluate the healthcare costs and costs of productivity loss (sick leave) and to evaluate if costs were higher for specific subgroups. Using national Danish registers, we identified individuals with shoulder disorders (subacromial pain, stiffness, fracture, or dislocation) diagnosed between 2005 and 2017 and controls matched on age and gender without shoulder disorders. Health care usage, sick leave, and related costs were estimated. During the 13-year inclusion period, 617,334 unique individuals were identified and the incidence rate was 1215 per 100,000 person-years in 2017. The expected additional societal costs were €1.21 billion annually. The mean additional total costs for the 6-year period were €11,334 (11,014-11,654) for individuals aged ≥65 years and €25,771 (25,531-26,012) for individuals aged <65 years. For individuals in the working age, the costs of sick leave accounted for approximately 70% of the total costs. Individuals aged ≥65 years had healthcare costs that were twice as high as individuals aged <65 years. Additionally, the 20% of cases accruing the highest costs accounted for 66% of the total costs. In conclusion, incidence rates of shoulder disorders were high and costs of sick leave accounted for a large proportion of total costs associated with illness in working age people. Furthermore, a minority of patients accounted for a substantial share of the total costs.