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.

Health insurance coverage among women of reproductive age in rural Ghana: policy and equity implications.

BACKGROUND: Globally, health insurance has been identified as a key component of healthcare financing. The implementation of health insurance policies in low and middle-income countries has led to a significant increase in access to healthcare services in these countries. This study assessed health insurance coverage and its associated factors among women of reproductive age living in rural Ghana. METHODS: This study used a nationally representative data from the 2017/2018 Ghana Multiple Indicator Cluster Survey (GMICS) and included 7340 rural women aged 15-49 years. Bivariate and multivariable logistic regression models were developed to assess the association between the explanatory and the outcome variable. Statistical significance was considered at p = 0.05. RESULTS: The overall prevalence of health insurance coverage among rural women in Ghana was 51.9%. Women with secondary (aOR = 1.72, 95% CI: 1.38-2.14) and higher education (aOR = 4.57, 95% CI: 2.66-7.84) were more likely to have health insurance coverage than those who had no formal education. Women who frequently listened to radio (aOR = 1.146, 95% CI: 1.01-1.30) were more likely to have health insurance coverage than those who did not. Women who had a child (aOR = 1.81, 95% CI: 1.50-2.17), two children (aOR = 1.59, 95% CI: 1.27-1.98), three children (aOR = 1.41, 95% CI: 1.10-1.80), and five children (aOR = 1.36, 95% CI: 1.03-1.79) were more likely to have health insurance coverage than those who had not given birth. Women who were pregnant (aOR = 3.52, 95% CI: 2.83-4.38) at the time of the survey, and women within the richest households (aOR = 3.89, 95% CI: 2.97-5.10) were more likely to have health insurance coverage compared to their other counterparts. Women in the Volta region (aOR = 1.36, 95% CI: 1.02-1.81), Brong Ahafo region (aOR = 2.82, 95% CI: 2.20-3.60), Northern region (aOR = 1.32, 95% CI: 1.02-1.70), Upper East region (aOR = 2.13, 95% CI: 1.63-2.80) and Upper West region (aOR = 1.56, 95% CI: 1.20-2.03) were more likely to have health insurance coverage than those in the Western region. CONCLUSION: Although more than half of women were covered by health insurance, a significant percentage of them were uninsured, highlighting the need for prompt policy actions to improve coverage levels for insurance. It was found that educational level, listening to radio, parity, pregnancy status, wealth quintile, and region of residence were factors associated with health insurance coverage. We recommend better targeting and prioritization of vulnerability in rural areas and initiate policies that improve literacy and community participation for insurance programs. Further studies to establish health policy measures and context specific barriers using experimental designs for health insurance enrolments are required.

Cost of childbirth in Upper West Region of Ghana: a cross-sectional study.

BACKGROUND: Out-of-pocket payment (OOPP) is reported to be a major barrier to seeking maternal health care especially among the poor and can expose households to a risk of catastrophic expenditure and impoverishment.This study examined the OOPPs women made during childbirth in the Upper West region of Ghana. METHODS: We carried out a cross-sectional study and interviewed women who gave birth between January 2013 and December 2017. Data on socio-demographic characteristics, place of childbirth, as well as direct cost (medical and non-medical) were collected from respondents. The costs of childbirth were estimated from the patient perspective. Logistics regression was used to assess the factors associated with catastrophic payments cost. All analyses were done using STATA 16.0. RESULTS: Out of the 574 women interviewed, about 71% (406/574) reported OOPPs on their childbirth. The overall average direct medical and non-medical expenditure women made on childbirth was USD 7.5. Cost of drugs (USD 8.0) and informal payments (UDD 5.7) were the main cost drivers for medical and non-medical costs respectively. Women who were enrolled into the National Health Insurance Scheme (NHIS) spent a little less (USD 7.5) than the uninsured women (USD 7.9). Also, household childbirth expenditure increased from primary health facilities level (community-based health planning and services compound = USD7.2; health centre = USD 6.0) to secondary health facilities level (hospital = USD11.0); while home childbirth was USD 4.8. Overall, at a 10% threshold, 21% of the respondents incurred catastrophic health expenditure. Regression analysis showed that place of childbirth and household wealth were statistically significant factors associated with catastrophic payment. CONCLUSIONS: The costs of childbirth were considerably high with a fifth of households spending more than one-tenth of their monthly income on childbirth and therefore faced the risk of catastrophic payments and impoverishment. Given the positive effect of NHIS on cost of childbirth, there is a need to intensify efforts to improve enrolment to reduce direct medical costs as well as sensitization and monitoring to reduce informal payment. Also, the identified factors that influence cost of childbirth should be considered in strategies to reduce cost of childbirth.

"Our Work, Our Health, No One's Concern": Domestic Waste Collectors' Perceptions of Occupational Safety and Self-Reported Health Issues in an Urban Town in Ghana.

Domestic waste collectors face major public health hazards that result in injuries and morbidity globally. This study explored domestic waste collectors' perceptions of occupational safety and self-reported health issues in a city in Ghana using a phenomenological qualitative research design. In-depth interviews and focus group discussions were held with 64 domestic waste collectors from two waste companies. The transcribed data were imported into NVivo 11.0 software (QSR International, Burlington, MA, USA) for coding, and a content analysis was applied to analyze all the transcribed data using the processes of induction and deduction. The consensual views from the domestic waste collectors showed the waste-company employers' non-interest in the domestic waste collectors' occupational safety and health. Poor communication from employers to domestic waste collectors and huge workloads were identified as the causes of the poor implementation of occupational safety practices, which exposed the domestic waste collectors to occupational health hazards. The domestic waste collectors reported that they suffered from occupational injuries, psychosocial disorders, work-related stress, and frequent burnout. The domestic waste collectors adopted coping strategies, such as self-medication, to deal with these occupational hazards, since most of them were not covered by guaranteed health insurance. In addition, the study revealed the non-compliance and non-enforcement of occupational health and safety policies by the employers to guide health and safety training and practices among the domestic waste collectors. In conclusion, the findings suggest that DWCs are exposed to occupational safety and health hazards in their work. Waste-company employers should extend welfare benefits to DWCs, such as health insurance and social security benefits, to ensure their security, health, and well-being. The findings could inform the design of intervention programs and policies to guide training and practices for domestic waste collectors.

Sub-national variations in general service readiness of primary health care facilities in Ghana: Health policy and equity implications towards the attainment of Universal Health Coverage.

BACKGROUND: Service availability and readiness are critical for the delivery of quality and essential health care services. In Ghana, there is paucity of literature that describes general service readiness (GSR) of primary health care (PHC) facilities within the national context. This study therefore assessed the GSR of PHC facilities in Ghana to provide evidence to inform heath policy and drive action towards reducing health inequities. METHODS: We analysed data from 140 Service Delivery Points (SDPs) that were part of the Performance Monitoring and Accountability 2020 survey (PMA2020). GSR was computed using the Service Availability and Readiness Assessment (SARA) manual based on four out of five components. Descriptive statistics were computed for both continuous and categorical variables. A multivariable binary logistic regression model was fitted to assess predictors of scoring above the mean GSR. Analyses were performed using Stata version 16.0. Significance level was set at p<0.05. RESULTS: The average GSR index of SDPs in this study was 83.4%. Specifically, the mean GSR of hospitals was 92.8%, whereas health centres/clinics and CHPS compounds scored 78.0% and 64.3% respectively. The least average scores were observed in the essential medicines and standard precautions for infection prevention categories. We found significant sub-national, urban-rural and facility-related disparities in GSR. Compared to the Greater Accra Region, SDPs in the Eastern, Western, Upper East and Upper West Regions had significantly reduced odds of scoring above the overall GSR. Majority of SDPs with GSR below the average were from rural areas. CONCLUSION: Overall, GSR among SDPs is appreciable as compared to other settings. The study highlights the existence of regional, urban-rural and facility-related differences in GSR of SDPs. The reality of health inequities has crucial policy implications which need to be addressed urgently to fast-track progress towards the achievement of the SDGs and UHC targets by 2030.

Breastfeeding and weaning practices among mothers in Ghana: A population-based cross-sectional study.

BACKGROUND: Children need good nutrition to develop proper immune mechanisms and psychosocial maturity, but malnutrition can affect their ability to realize this. Apart from the national demographic and health survey, which is carried out every 5 years, there have not been enough documented studies on child breastfeeding and weaning practices of caregivers in the Volta Region. We, therefore, examined child breastfeeding and weaning practices of mothers in the Volta Region of Ghana. METHODS: A sub-national survey method was adopted and a semi-structured questionnaire was used to collect data from 396 mothers and their children. Descriptive and inferential statistics comprising frequency, percentage, chi-square, and logistic regression were employed in analysing the data. We defined exclusive breastfeeding as given only breast milk to an infant from a mother or a wet nurse for six months of life except drops or syrups consisting of vitamins, minerals, supplements, or medicines on medical advice, and prolonged breastfeeding as breastfeeding up to 24 months of age. RESULTS: The prevalence of exclusive breastfeeding (EBF) was 43.7%. Mothers constituting 61.1% started breastfeeding within an hour of giving birth. In addition to breast milk, 5.1% gave fluids to their children on the first day of birth. About 66.4% started complementary feeding at 6 months, 22.0% breastfed for 24 months or beyond, while 40.4% fed their children on-demand. Child's age (AOR: 0.23, 95% CI:0.12-0.43, p<0.0001), prolonged breastfeeding (AOR: 0.41, 95%CI: 0.12-0.87, p = 0.001), mother's religion (AOR: 3.92, 95%CI: 1.23-12.61, p = 0.021), feeding practices counselled on (AOR: 1.72, 95%CI: 1.96-3.09, p = 0.023), mother ever heard about EBF (AOR: 0.43, 95%CI: 1.45-2.41, p = 0.039), child being fed from the bottle with a nipple (AOR: 1.53, 95%CI: 1.94-2.48, p = 0.003), and age at which complementary feeding was started (AOR: 17.43, 95%CI: 3.47-87.55, p = 0.008) were statistically associated with EBF. CONCLUSION: Breastfeeding education has been ongoing for decades, yet there are still gaps in the breastfeeding practices of mothers. To accelerate progress towards attainment of the sustainable development goal 3 of ensuring healthy lives and promoting well-being for all at all ages by the year 2030, we recommend innovative policies that include extensive public education to improve upon the breastfeeding and weaning practices of mothers.

Prevalence and predictors of depression, anxiety, and stress among adults in Ghana: A community-based cross-sectional study.

INTRODUCTION: Over the past two decades, there have been several global interventions including the Sustainable Development Goals (SDGs), aimed at improving health outcomes. Despite efforts by countries to achieve the SDG targets, mental health challenges remain major public health concerns globally. We examined the prevalence and predictors of depression, anxiety, and stress as well as the comorbidities of these mental health issues among adults. MATERIALS AND METHODS: This was a community-based cross-sectional study conducted among 2456 adults in four districts of the Volta Region of Ghana using data from the UHAS-Yonsei University Partnership Project. We analysed the data using frequency, percentage, mean, standard deviation, correlation, and binary logistic regression. RESULTS: Overall, 51.8% of the participants had at least one of the mental health issues examined. The prevalence of a mental health issue was 25.2%, 53.3%, and 9.7% for depression, anxiety, and stress respectively. Participants constituting 8.3% experienced all three mental health issues as comorbidities. Participants' level of formal education and income significantly predicted depression, anxiety, and stress respectively at the multivariable level. Adults with a tertiary level of education were, for instance, 68% (AOR = 0.32, 95%CI = 0.15-0.66), 65% (AOR = 0.35, 95%CI = 0.17-0.73), and 50% (AOR = 0.50, 95%CI = 0.33-0.76) less likely to experience depression, anxiety, and stress, respectively compared with those who had no formal education. CONCLUSION: The majority of our study participants either experienced depression, anxiety, or stress. There were quite high comorbidities of the mental health issues among the adult population. To accelerate progress towards the achievement of SDG 3.4 target of promoting mental health and wellbeing for all by the year 2030, there is a need for effective implementation of the country's 2012 Mental Health Act which makes provisions for the establishment of a Mental Health Fund. This could improve the financial circumstances of indigenes as income has been realised in the present study as an important factor influencing depression, anxiety, and stress among the adult population.

Factors Associated with Financial Security, Food Security and Quality of Daily Lives of Residents in Nigeria during the First Wave of the COVID-19 Pandemic.

An online survey was conducted to identify factors associated with financial insecurity, food insecurity and poor quality of daily lives of adults in Nigeria during the first wave of the COVID-19 pandemic. The associations between the outcome (experience of financial loss, changes in food intake and impact of the pandemic on daily lives) and the explanatory (age, sex, education level, anxiety, depression, HIV status) variables were determined using logistic regression analysis. Of the 4439 respondents, 2487 (56.0%) were financially insecure, 907 (20.4%) decreased food intake and 4029 (90.8%) had their daily life negatively impacted. Males (AOR:0.84), people who felt depressed (AOR:0.62) and people living with HIV -PLHIV- (AOR:0.70) had significantly lower odds of financial insecurity. Older respondents (AOR:1.01) had significantly higher odds of financial insecurity. Those depressed (AOR:0.62) and PLHIV (AOR:0.55) had significantly lower odds of reporting decreased food intake. Respondents who felt anxious (AOR:0.07), depressed (AOR: 0.48) and who were PLHIV (AOR:0.68) had significantly lower odds of reporting a negative impact of the pandemic on their daily lives. We concluded the study findings may reflect a complex relationship between financial insecurity, food insecurity, poor quality of life, mental health, and socioeconomic status of adults living in Nigeria during the COVID-19 pandemic.

The shared experiences of insured members and the uninsured in health care access and utilization under Ghana's national health insurance scheme: Evidence from the Hohoe Municipality.

BACKGROUND: The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003 to remove financial barriers and to promote equitable access to health care services. Post implementation has been characterized by increases in access and utilization of services among the insured. The uninsured have been less likely to utilize services due to unaffordability of health care costs. In this study, we explored the experiences of the insured members of the NHIS, the uninsured and health professionals in accessing and utilizing health care services under the NHIS in the Hohoe Municipality of Ghana. METHODS: Qualitative in-depth interviews were held with twenty-five NHIS insured, twenty-five uninsured, and five health care professionals, who were randomly sampled from the Hohoe Municipality to collect data for this study. Data was analyzed using thematic analysis. RESULTS: Participants identified both enablers or motivating factors and barriers to health care services of the insured and uninsured. The major factors motivating members to access and use health care services were illness severity and symptom persistence. On the other hand, barriers identified included perceived poor service quality and lack of health insurance among the insured and uninsured respectively. Other barriers participants identified included financial constraints, poor attitudes of service providers, and prolonged waiting time. However, the level of care received were reportedly about the same among the insured and uninsured with access to quality health care much dependent on ability to pay, which favors the rich and thereby creating inequity in accessing the needed quality care services. CONCLUSION: The implication of the financial barriers to health care access identified is that the poor and uninsured still suffer from health care access challenges, which questions the efficiency and core goal of the NHIS in removing financial barrier to health care access. This has the potential of undermining Ghana's ability to meet the Sustainable Development Goal 3.8 of universal health coverage by the year 2030.

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.

Women's knowledge and its associated factors regarding optimum utilisation of antenatal care in rural Ghana: A cross-sectional study.

INTRODUCTION: Improving maternal health is a global public health challenge especially in sub-Saharan Africa. The optimum utilisation of antenatal care (ANC) by pregnant women is known to improve maternal health outcomes. Maternal morbidity and mortality rates in Ghana remain unacceptably high, particularly in rural settings where skilled delivery care often times is disproportionally low. This study assessed factors associated with optimum utilisation of antenatal care in rural Ghana. METHODS: A cross-sectional design was applied to collect data among eligible participants between October 2018 and January 2019. A total of 322 women who gave birth and attended the postnatal clinic were recruited for the study. Consecutive sampling was employed in recruiting participants. The associations between the dependent variables (ANC service utilisation and knowledge of ANC) and independent variables (socio-demographic characteristics) were examined using ordinary least squares logistic regression at 95% confidence interval in STATA version 14.0. RESULTS: Of the 322 participants, 69.0% reported utilising at least four or more times ANC services. Determinants of women attending ANC for four or more times was significantly associated with age [OR = 4.36 (95%CI: 2.16-8.80), p<0.001], educational level [OR = 10.18 (95%CI: 3.86-26.87), p<0.001], and insured with National Health Insurance Scheme [OR = 3.42 (95%CI: 1.72-6.82), p<0.001]. Not married [OR = 0.65 (0.39-1.09), p = 0.011] or divorced [OR = 0.33 (95%CI: 0.13-0.83), p = 0.019] was negatively associated with utilisation of four or more ANC services. The majority (79.0%) of the participants had a good level of knowledge regarding antenatal care. CONCLUSION: Although the majority of women in this study had good knowledge of ANC services, a significant number of them did not complete the recommended number of ANC visits for at least four times during a normal pregnancy. Awareness and further education to reproductive-age women on the significant role adequate ANC attendance plays in advancing health and well-being require further investments, particularly among rural women in Ghana.

Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care.

BACKGROUND: In 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017. METHODS: This exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed. RESULTS: Negative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns. CONCLUSION: Health-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme.

Towards Resilient Health Systems in Sub-Saharan Africa: A Systematic Review of the English Language Literature on Health Workforce, Surveillance, and Health Governance Issues for Health Systems Strengthening.

BACKGROUND: Meeting health security capacity in sub-Saharan Africa will require strengthening existing health systems to prevent, detect, and respond to any threats to health. The purpose of this review was to examine the literature on health workforce, surveillance, and health governance issues for health systemsstrengthening. METHODS: We searched PubMed, Science Direct, Cochrane library, CINAHL, Web of Science, EMBASE, EBSCO, Google scholar, and the WHO depository library databases for English-language publications between January 2007 and February 2017. Electronic searches for selected articles were supplemented by manual reference screening. The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Out of 1,548 citations retrieved from the electronic searches, 31 articles were included in the review. Any country health system that trains a cadre of health professionals on the job, reduces health workforce attrition levels, and builds local capacity for health care workers to apply innovative mHealth technologies improves health sector performance. Building novel surveillance systems can improve clinical care and improve health system preparedness for health threats. Effective governance processes build strong partnerships for health and create accountability mechanisms for responding to health emergencies. CONCLUSIONS: Overall, policy shifts in African countries' health systems that prioritize training a cadre of willing and able workforce, invest in robust and cost-effective surveillance capacity, and create financial accountability and good governance are vital in health strengthening efforts.

Predictors of Health Care Service Quality among Women Insured Under Ghana's National Health Insurance Scheme.

BACKGROUND: Insured women in Ghana are more likely to use maternity care services than their uninsured counterparts. To improve service quality among insured women in Ghana, better understanding of the factors that predict quality standards of primary health care services is essential. OBJECTIVE: To examine predictors of health care service quality among insured women under the National Health Insurance Scheme (NHIS) in Ghana. METHODS: Data from the 2014 Ghana Demographic Health Survey was analysed. Cluster analysis was applied to construct a dependent variable; service care quality. Socio-demographic/background characteristics were used as independent variables. Descriptive and inferential analyses were performed followed by multiple regression to predict service quality among the insured population of women aged 15-49 years. SPSS version 21 was used during the clustering while STATA version 14 was used to perform the inferential and regression analyses. FINDINGS: Overall, geographical region of respondents was significant to expressions of insured service quality (χ2=495.4, p ≤ 0.001). Literacy levels were significant at χ2=69.232 and p ≤ 0.001 for service quality. On place of residence, the estimation show urban residency was more positively correlated with indicating quality ratings of health services compared to rural residency (χ2=70.29, p ≤ 0.001). Highest educational level had the highest predictive influence with a coefficient of 0.15. CONCLUSIONS: A more supportive health insurance system approach that shifts towards introducing valued-based care models for patients, insurers and health care providers could be supportive in improving quality standards among insured population groups 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.