Medication adherence and blood pressure control: A preliminary assessment of the role of health insurance in Nigeria and Ghana.

Objectives: This study sought to assess the current impact of health insurance coverage on medication adherence and blood pressure control of patients being managed for hypertension in Ghana and Nigeria. Methods: The study was a prospective study among 109 patients with hypertension in two health facilities with similar population dynamics in Ghana and Nigeria. Patients were systematically selected, categorized as having health insurance coverage or not, and followed up monthly for 6 months. The outcome variables (medication adherence and blood pressure control) were then measured and compared at 6 months. Analysis was done using Stata with level of significance set at p ⩽ 0.05. Results: There was a 90% insurance coverage among participants from Ghana compared to 15% from Nigeria. National Health Insurance Authority enrolees in both countries had better blood pressure control and medication adherence compared to non-enrolees (adjusted odds ratio = 2.6 and 4.5, respectively). Conclusion: National Health Insurance Authority enrolment was found to be poor among respondents in Nigeria compared to Ghana. Enrolment into the National health financing schemes in both countries led to better blood pressure control and medication adherence among patients with hypertension at primary health facilities. There is therefore the need for system strengthening to improve their sustainability.

Attitudes towards abortion and decision-making capacity of pregnant adolescents: perspectives of medicine, midwifery and law students in Accra, Ghana.

Objectives: Because medical, midwifery and law students in Ghana constitute the next generation of health care and legal practitioners, this study aimed to evaluate their attitudes towards abortion and their perceptions of the decision-making capacity of pregnant adolescents.Methods: We conducted a cross-sectional survey among 340 medical, midwifery and law students. A pretested and validated questionnaire was used to collect relevant data on respondents' sociodemographic characteristics, attitudes towards abortion and the perceived capacity and rationality of pregnant adolescents' decisions. The χ2 test of independency and Fischer's exact test were used where appropriate.Results: We retained 331 completed questionnaires for analysis. Respondents' mean age was 21.0 ± 2.9 years and the majority (95.5%) were of the Christian faith. Women made up 77.9% (n = 258) of the sample. Most students (70.1%) were strongly in favour of abortion if it was for health reasons. More than three-quarters (78.0%) of the students strongly disagreed on the use of abortion for the purposes of sex selection. Most respondents (89.0%) were not in favour of legislation to make abortion available on request for pregnant adolescents, with medical students expressing a more negative attitude compared with law and midwifery students (p < 0.001). Over half of the midwifery students (52.6%) believed that adolescents should have full decision-making capacity regarding their pregnancy outcome, compared with law and medical students (p < 0.001).Conclusion: Tensions between adolescent reproductive autonomy, the accepted culture of third party involvement (parents and partners), and the current abortion law may require keen reflection if an improvement in access to safe abortion services is envisioned.

Old age and depression in Ghana: assessing and addressing diagnosis and treatment gaps.

Background: There is limited evidence about the prevalence of depression among older people in sub-Saharan Africa, about access to treatment or the potential efficacy of community-based interventions.Objective: Using nationally representative data from the WHO SAGE survey, we examine the prevalence of and factors associated with depression among people aged 50 and over in Ghana. Compare self-reported diagnosis and a symptom algorithm to assess treatment gaps and factors associated with the size of gap. Assess the feasibility of a small community-based intervention specifically for older people.Method: Prevalence and treatment data were taken from the WHO SAGE 2007 survey in Ghana, including 4,725 people aged 50 or over. Outcomes of interest were self-reported depression and diagnosis of depression derived from a symptom-based algorithm. The data were subjected to bivariate and multivariate analysis. In parallel, a pilot intervention was conducted with 35 older people, which included screening by a trained psychiatrist and follow-up group sessions of psychotherapy.Results: The symptomatic algorithm reported an overall rate of 9.2 per cent for the study population, with associations with female sex and older age. The treatment gap for these cases was found to be 83.0 per cent. The implementation of the pilot study was perceived as effective and replicable by stakeholders and there was some evidence of enhanced outcomes for people with mild depression.Conclusions: Large numbers of older people in Ghana experience depression, but very few have access to treatment. There is an urgent need to develop and validate community-based services for older people experiencing this condition.

Using Mobile Health to Support Clinical Decision-Making to Improve Maternal and Neonatal Health Outcomes in Ghana: Insights of Frontline Health Worker Information Needs.

BACKGROUND: Developing and maintaining resilient health systems in low-resource settings like Ghana requires innovative approaches that adapt technology to context to improve health outcomes. One such innovation was a mobile health (mHealth) clinical decision-making support system (mCDMSS) that utilized text messaging (short message service, SMS) of standard emergency maternal and neonatal protocols via an unstructured supplementary service data (USSD) on request of the health care providers. This mCDMSS was implemented in a cluster randomized controlled trial (CRCT) in the Eastern Region of Ghana. OBJECTIVE: This study aimed to analyze the pattern of requests made to the USSD by health workers (HWs). We assessed the relationship between requests made to the USSD and types of maternal and neonatal morbidities reported in health facilities (HFs). METHODS: For clusters in the intervention arm of the CRCT, all requests to the USSD during the 18-month intervention period were extracted from a remote server, and maternal and neonatal health outcomes of interest were obtained from the District Health Information System of Ghana. Chi-square and Fisher exact tests were used to compare the proportion and type of requests made to the USSD by cluster, facility type, and location; whether phones accessing the intervention were shared facility phones or individual-use phones (type-of-phone); or whether protocols were accessed during the day or at night (time-of-day). Trends in requests made were analyzed over 3 6-month periods. The relationship between requests made and the number of cases reported in HFs was assessed using Spearman correlation. RESULTS: In total, 5329 requests from 72 (97%) participating HFs were made to the intervention. The average number of requests made per cluster was 667. Requests declined from the first to the third 6-month period (44.96% [2396/5329], 39.82% [2122/5329], and 15.22% [811/5329], respectively). Maternal conditions accounted for the majority of requests made (66.35% [3536/5329]). The most frequently accessed maternal conditions were postpartum hemorrhage (25.23% [892/3536]), other conditions (17.82% [630/3536]), and hypertension (16.49% [583/3536]), whereas the most frequently accessed neonatal conditions were prematurity (20.08% [360/1793]), sepsis (15.45% [277/1793]), and resuscitation (13.78% [247/1793]). Requests made to the mCDMSS varied significantly by cluster, type of request (maternal or neonatal), facility type and its location, type-of-phone, and time-of-day at 6-month interval (P<.001 for each variable). Trends in maternal and neonatal requests showed varying significance over each 6-month interval. Only asphyxia and sepsis cases showed significant correlations with the number of requests made (r=0.44 and r=0.79; P<.001 and P=.03, respectively). CONCLUSIONS: There were variations in the pattern of requests made to the mCDMSS over time. Detailed information regarding the use of the mCDMSS provides insight into the information needs of HWs for decision-making and an opportunity to focus support for HW training and ultimately improved maternal and neonatal health.

Blood pressure patterns and body mass index status in pregnancy: An assessment among women reporting for antenatal care at the Korle-Bu Teaching hospital, Ghana.

BACKGROUND: Maternal obesity in pregnancy has been linked with increased risk of pregnancy induced hypertension (PIH). In some tertiary referral hospitals in Ghana, PIH is the leading cause of institutional maternal mortality. OBJECTIVE: To evaluate blood pressure changes during pregnancy amongst different body mass index (BMI) groups and how this relates to the risk of developing PIH. METHODS: Women who had a dating ultrasound before 20 weeks gestation and registering for antenatal care at the Korle-Bu Teaching Hospital in Accra, between February and December 2013 and met the inclusion criteria were recruited into a cohort study. BMI was assessed at baseline. Blood pressure measurements were taken at (±2) 24, 28 and 36 weeks. Primary outcome measure of interest during follow-up was a diagnosis of PIH at these points. BP changes during follow up at the three points were measured. Descriptive analysis of baseline factors was carried out and compared for the BMI groups. Relative risk (RR) of PIH was estimated at 95% confidence interval. RESULTS: Mean (SD) age for the 361 women was 30.9 (4.8) years. Incidence of PIH amongst the cohort was 10.5% (95% CI: 7.45% - 14.45%) and 40.4% and 33.0% of them were overweight and obese respectively at baseline. Pregnant women who were obese at baseline had a three-fold increased risk of PIH compared to those with normal BMI [RR = 3.01 (1.06-8.52), p = 0.04]. CONCLUSION: Obese women have a significantly increased risk of PIH. Women should be screened at booking for obesity status. Antenatal protocols should have interventions for prevention or early detection of obesity and management of obesity to improve outcomes.

Predictors of skilled attendance at delivery among antenatal clinic attendants in Ghana: a cross-sectional study of population data.

OBJECTIVE: To identify demographic, maternal and community predictors of skilled attendance at delivery among women who attend antenatal clinic at least once during their pregnancy in Ghana. DESIGN: A cross-sectional study using the 2008 Ghana Demographic and Health Survey (DHS) data. We used frequencies for descriptive analysis, χ(2) test for associations and logistic regression to identify significant predictors. Predictive models were built with estimation of area under the receiver operating characteristic curves (AUC). SETTING: Ghana. PARTICIPANTS: A total of 2041 women who had a live birth in the 5 years preceding the survey, and attended an antenatal clinic having a skilled provider, at least once, during the pregnancy. OUTCOME: Skilled attendance at delivery. RESULTS: Overall, 60.5% (1235/2041) of women in our study sample reported skilled attendance at delivery. Significant positive associations existed between skilled attendance at delivery and the variables such as maternal educational level, wealth status class, ever use of contraception, previous pregnancy complications and health insurance coverage (p<0.001). Significant predictors of skilled attendance were wealth status class, residency, previous delivery complication, health insurance coverage and religion in a model with AUC (95% CI) of 0.85 (0.83 to 0.88). CONCLUSIONS: Women less likely to have skilled attendance at delivery can be identified during antenatal care by using data on wealth status class, health insurance coverage, residence, history of previous birth complications and religion, and targeted with interventions to improve skilled attendance at delivery.