Measuring intersectional HIV, sexual diversity, and gender non-conformity stigma among healthcare workers in Ghana: scale validation and correlates of stigma.

BACKGROUND: Men who have sex with men (MSM) are at heightened risk for HIV acquisition, yet they may delay or avoid HIV testing due to intersectional stigma experienced at the healthcare facility (HCF). Few validated scales exist to measure intersectional stigma, particularly amongst HCF staff. We developed the Healthcare Facility Staff Intersectional Stigma Scale (HCF-ISS) and assessed factors associated with stigma in Ghana. METHODS: We analyzed baseline data from HCF staff involved in a study testing a multi-level intervention to reduce intersectional stigma experienced by MSM. Data are from eight HCFs in Ghana (HCF Staff n = 200). The HCF-ISS assesses attitudes and beliefs towards same-sex relationships, people living with HIV (PLWH) and gender non-conformity. Exploratory factor analysis assessed HCF-ISS construct validity and Cronbach's alphas assessed the reliability of the scale. Multivariable regression analyses assessed factors associated with intersectional stigma. RESULTS: Factor analysis suggested an 18-item 3-factor scale including: Comfort with Intersectional Identities in the Workplace (6 items, Cronbach's alpha = 0.71); Beliefs about Gender and Sexuality Norms (7 items, Cronbach's alpha = 0.72); and Beliefs about PLWH (5 items, Cronbach's alpha = 0.68). Having recent clients who engage in same-gender sex was associated with greater comfort with intersectional identities but more stigmatizing beliefs about PLWH. Greater religiosity was associated with stigmatizing beliefs. Infection control training was associated with less stigma towards PLWH and greater comfort with intersectional identities. CONCLUSIONS: Achieving the goal of ending AIDS by 2030 requires eliminating barriers that undermine access to HIV prevention and treatment for MSM, including HCF intersectional stigma. The HCF-ISS provides a measurement tool to support intersectional stigma-reduction interventions.

Determinants of induced abortion among women of reproductive age: evidence from the 2013 and 2019 Sierra Leone Demographic and Health Survey.

BACKGROUND: Worldwide, pregnancy termination due to unintended pregnancy is crucial in maternal health, particularly in settings where abortion laws are restrictive. Presently, there is a paucity of literature on determinants of induced abortion among women of reproductive age in Sierra Leone. The study findings could be used to improve the country's maternal mortality indices and inform health programs and reproductive health policies geared toward tackling induced abortion. METHODS: We analyzed secondary data from the 2013 and 2019 Sierra Leone Demographic and Health Surveys. The surveys were nationally representative, with weighted samples comprising 16,658 (2013) and 15,574 (2019) women of reproductive age. Descriptive statistics, including frequencies and percentages, were computed, while Chi-square and Binomial Logistics Regression were employed to identify correlates of induced abortion. RESULTS: The results showed that a minority (9%) of the participants had induced abortion in both surveys. Abortion was significantly associated with age, marital status, employment status, education, parity, and frequency of listening to the radio and watching television (p < 0.05). For instance, women aged 45-49 years (AOR = 7.91; 95% CI: 5.76-10.87), married women (AOR = 2.52; 95% CI: 1.95-3.26), and working women (AOR = 1.65; 95% CI: 1.45-1.87) had a higher likelihood of induced abortion compared to their counterparts. Moreover, women with primary education (AOR = 1.27; 95% CI:1.11-1.46) and those who watch television once a week (AOR = 1.29; 95% CI: 1.11-1.49) were more likely to terminate a pregnancy. Women with six or more children (AOR = 0.40; 95% CI: 0.31-0.52) were less likely to terminate a pregnancy compared to those with no child. CONCLUSION: The study revealed that a minority of the women had induced abortions. The prevalence of induced abortion did not change over time. Induced abortion was influenced by age, marital status, employment status, education, parity, and exposure to mass media. Therefore, policies and programs to reduce unwanted pregnancies should focus on increasing access to modern contraceptives among women of lower socio-economic status.

Multi-level manifestations of sexual stigma among men with same-gender sexual experience in Ghana.

Sexual stigma and discrimination toward men who have same-gender sexual experiences are present across the globe. In Ghana, same-gender sexual desires and relationships are stigmatized, and the stigma is sanctioned through both social and legal processes. Such stigma negatively influences health and other material and social aspects of daily life for men who have sex with men (MSM). However, there is evidence that stigma at the interpersonal level can intersect with stigma that may be operating simultaneously at other levels. Few studies provide a comprehensive qualitative assessment of the multi-level sexual stigma derived from the direct narratives of men with same-gender sexual experience. To help fill this gap on sexual stigma, we qualitatively investigated [1] what was the range of sexual stigma manifestations, and [2] how sexual stigma manifestations were distributed across socioecological levels in a sample of Ghanaian MSM. From March to September 2020, we conducted eight focus group discussions (FGDs) with MSM about their experiences with stigma from Accra and Kumasi, Ghana. Data from the FGDs were subjected to qualitative content analysis. We identified a range of eight manifestations of sexual stigma: (1) gossiping and outing; (2) verbal abuse and intrusive questioning; (3) non-verbal judgmental gestures; (4) societal, cultural, and religious blaming and shaming; (5) physical abuse; (6) poor-quality services; (7) living in constant fear and stigma avoidance; and (8) internal ambivalence and guilt about sexual behavior. Sexual stigma manifestations were unevenly distributed across socioecological levels. Our findings are consistent with those of existing literature documenting that, across Africa, and particularly in Ghana, national laws and religious institutions continue to drive stigma against MSM. Fundamental anti-homosexual sentiments along with beliefs associating homosexuality with foreign cultures and immorality drive the stigmatization of MSM. Stigma experienced at all socioecological levels has been shown to impact both the mental and sexual health of MSM. Deeper analysis is needed to understand more of the lived stigma experiences of MSM to develop appropriate stigma-reduction interventions. Additionally, more community-level stigma research and interventions are needed that focus on the role of family and peers in stigma toward MSM in Ghana.

Incidence and determinants of maternal sepsis in Ghana in the midst of a pandemic.

BACKGROUND: Despite being preventable, maternal sepsis continues to be a significant cause of death and morbidity, killing one in every four pregnant women globally. In Ghana, clinicians have observed that maternal sepsis is increasingly becoming a major contributor to maternal mortality. The lack of a consensus definition for maternal sepsis before 2017 created a gap in determining global and country-specific burden of maternal sepsis and its risk factors. This study determined the incidence and risk factors of clinically proven maternal sepsis in Ghana. METHODS: We conducted a prospective cohort study among 1476 randomly selected pregnant women in six health facilities in Ghana, from January to September 2020. Data were collected using primary data collection tools and reviewing the client's charts. We estimated the incidence rate of maternal sepsis per 1,000 pregnant women per person-week. Poisson regression model and the cox-proportional hazard regression model estimators were used to assess risk factors associated with the incidence of maternal sepsis at a 5% significance level. RESULTS: The overall incidence rate of maternal sepsis was 1.52 [95% CI: 1.20-1.96] per 1000 person-weeks. The majority of the participants entered the study at 10-13 weeks of gestation. The study participants' median body mass index score was 26.4 kgm-2 [22.9-30.1 kgm-2]. The risk of maternal sepsis was 4 times higher among women who developed urinary tract infection after delivery compared to those who did not (aHR: 4.38, 95% CI: 1.58-12.18, p < 0.05). Among those who developed caesarean section wound infection after delivery, the risk of maternal sepsis was 3 times higher compared to their counterparts (aHR: 3.77, 95% CI: 0.92-15.54, p < 0.05). Among pregnant women who showed any symptoms 14 days prior to exit from the study, the risk was significantly higher among pregnant women with a single symptom (aHR: 6.1, 95% CI: 2.42-15.21, p < 0.001) and those with two or more symptoms (aHR: 17.0, 95% CI: 4.19-69.00, p < 0.001). CONCLUSIONS: Our findings show a low incidence of maternal sepsis in Ghana compared to most Low and Middle-Income Countries. Nonetheless, Maternal sepsis remains an important contributor to the overall maternal mortality burden. It is essential clinicians pay more attention to ensure early and prompt diagnosis. Factors significantly predicting maternal sepsis in Ghana were additional maternal morbidity, urinary tract infections, dysuria, and multiple symptoms. We recommend that Ghana Health Service should institute a surveillance system for maternal sepsis as a monthly reportable disease.

Determinants of health facility delivery among young mothers in Ghana; insights from the 2014 Ghana Demographic and Health Survey.

BACKGROUND: Globally, young women deliver at home, often under unhygienic conditions and without skilled birth attendants. This study identified the determinants of health facility delivery among young mothers in Ghana. METHODS: We analysed secondary data from the 2014 Ghana Demographic and Health Survey, which collected data across the former ten administrative regions of Ghana. This study analysed data from the 'women file' by adjusting for the sample weight. STATA/SE version 16 was employed to analyse the data by computing descriptive statistics, Chi-square, and Binary Logistic Regression. RESULTS: Seven in ten young mothers gave birth in a health facility. Young mothers who had secondary school education were over three-fold more likely to deliver in a health facility (AOR = 3.5, 95% CI: 1.33-9.23) compared with young mothers with no formal education. Young mothers who resided in rural areas had lower odds (73%) of delivering in a health facility (AOR = 0.27; 95% CI: 0.14-0.514) compared with those in urban areas. Young mothers within the richest wealth quintile also had higher odds (8 times) of delivering in a health facility (AOR = 8.24; 95% CI: 0.95-71.77) compared with those within the poorest wealth quintile. Young mothers who obtained four to seven antenatal visits (AOR = 0.53; 95% CI: 0.27-1.03) had lower odds of delivering in a health facility compared with those who obtained eight or more antenatal visits. CONCLUSION: The majority of young mothers in Ghana gave birth in a health facility. The likelihood of delivering in a health facility was influenced by socio-demographic factors, economic factors and utilization of antenatal care services. Therefore, interventions aimed at increasing utilization of skilled delivery among young women should focus on promoting girl child education, economic status and antenatal care visits.

Risky sexual behaviours and HIV testing among young people in Ghana: evidence from the 2017/2018 Multiple Indicator Cluster Survey.

BACKGROUND: Young people have a higher chance of experimenting with sex before marriage, thus they engage in risky sexual behaviours that predispose them to HIV infections. The objective of this study was to assess the relationship between engaging in risky sexual behaviours and the uptake of HIV testing services among young people in Ghana. METHODS: We analysed secondary data from the 2017/2018 Ghana Multiple Indicator Cluster Survey, which collected data on population and health indicators across the previous ten regions of Ghana, using a Computer Personal Assisted Interviewing application. Data were analysed using descriptive statistics, Chi-square test and Binomial Logistic regression. RESULTS: Seventy-nine per cent (79%) of young women and 68% of young men did not use a condom during last sexual intercourse. In addition, 68% of young women and 87% of young men had not tested for HIV. Young women (AOR = 2.19; 95% CI 1.56-3.07) and young men (AOR = 3.38; 95% CI 1.18-9.64) aged 20-24 years had a higher likelihood of being tested for HIV compared to those aged 15-19 years. Young women with junior high school education (AOR = 2.03; 95% CI 1.08-3.81) were more likely to test for HIV compared with those who had pre-primary/no formal education. In addition, young women who were never married or in a union (AOR = 0.39; 95% CI 0.27-0.56) had 61% of reduced odds of being tested for HIV compared with those who were currently married or in a union. There was no significant association between risky sexual behaviours and HIV testing (p > 0.05). CONCLUSION: This study demonstrated that condom use among sexually active young people was low. The uptake of HIV testing services was below expectation. Age, educational status, marital status and exposure to the mass media were the salient factors influencing the uptake of HIV testing among young people. Stakeholders should implement interventions to help increase the uptake of HIV testing and condom use among young people in Ghana.

Sub-Sahara Africa is the only region in the world where the number of young people continues to increase greatly. Many of the new HIV infections among young people across the world happen in sub-Saharan Africa. Young people engage in unsafe sexual behaviours, such as having sex without a condom, beginning sexual intercourse at an early age and having sex with many partners, which increases their chance of getting infected with HIV. Testing for HIV helps in the early discovery of the virus which is crucial for effective HIV management and prevention. Increasing HIV testing is one of the health issues cherished by global health leaders. However, little is known about whether young people who engage in unsafe sexual behaviours utilize HIV testing services. The analysed data were collected as part of the 2017/2018 Multiple Indicator Cluster Survey across all the regions of Ghana. Our findings showed that many of the sexually active young people who participated in the survey had not tested for HIV, hence did not know their HIV status. Making matters worse, many of them engaged in unsafe sexual behaviours, such as unprotected sexual intercourse. Young people aged 20­24 years, those with higher education and married young women were more likely to utilize HIV testing services. To help end HIV as a public health threat by 2030, it is very necessary for stakeholders to educate young people about the dangers associated with unsafe sexual behaviours as well as encourage them to know their HIV status.

HIV care and treatment models and their association with medication possession ratio among treatment-experienced adults in three African countries.

OBJECTIVE: How clinics structure the delivery of antiretroviral therapy (ART) services may influence patient adherence. We assessed the relationship between models of HIV care delivery and adherence as measured by medication possession ratio (MPR) among treatment-experienced adults in Tanzania, Uganda and Zambia. METHODS: Eighteen clinics were grouped into three models of HIV care. Model 1-Traditional and Model 2-Mixed represented task-sharing of clinical services between physicians and clinical officers, distinguished by whether nurses played a role in clinical care; in Model 3-Task-Shifted, clinical officers and nurses shared clinical responsibilities without physicians. We assessed MPR among 3,419 patients and calculated clinic-level MPR summaries. We then calculated the mean differences of percentages and adjusted residual ratio (aRR) of the association between models of care and incomplete adherence, defined as a MPR <90%, adjusting for individual-level characteristics. RESULTS: In the adjusted analysis, patients in Model 1-Traditional were more likely than patients in Model 2-Mixed to have MPR <90% (aRR = 1.60, 95% CI 1-2.48). Patients in Model 1-Traditional were no more likely than patients in Model 3-Task-Shifted to have a MPR <90% (aRR = 1.58, 95% 0.88-2.85). There was no evidence of differences in MPR <90% between Model 2-Mixed and Model 3-Task-Shifted (aRR = 0.99, 95% CI 0.59-1.66). CONCLUSION: Non-physician-led ART programmes were associated with adherence levels as good as or better than physician-led ART programmes. Additional research is needed to optimise models of care to support patients on lifelong treatment.

Correlates of uptake of HIV testing among children and young adolescents in Akwa-Ibom state, Nigeria: a secondary data analysis of the Akwa-Ibom aids indicator survey, 2017.

BACKGROUND: In order to end the AIDS epidemic by 2030, there is a need to significantly reduce the rate of new infection among children and young adolescents. Identifying the correlates of testing behaviour is necessary to improve HIV testing campaigns by refining messages that target individuals in this age group. The objective of this study was to determine the correlates of HIV testing among children and young adolescents in Akwa-Ibom, Nigeria. METHODS: The outcome was a secondary data analysis of the 2017 Akwa-Ibom AIDS Indicator Survey. Data of 4037 children and young adolescents aged 0-14 years was assessed in this study. Analysis was done using STATA version 16. Chi-squared test and logistic regression models were used to measure association and its strength between uptake of HIV testing and some independent variables (child/caregiver's age, sex, educational status, child's location, caregiver's knowledge of HIV and caregiver ever tested for HIV) at 5% significance level. RESULTS: Result showed that only 14.2% of the children and young adolescents have been tested for HIV. Previous history of blood transfusion (AOR = 5.33, 95%C.I = 2.60-10.92, P = < 0.001), caregiver's level of education (AOR = 2.67, 95%C.I = 1.30-5.51, P = 0.008) and caregiver ever tested for HIV (AOR = 8.31, 95%C.I = 5.67-12.19, P = < 0.001) were significantly associated with uptake of HIV testing. CONCLUSION: This study concludes that a large proportion of children and young adolescents in Akwa-Ibom state have never been tested for HIV. There is a need for HIV testing interventions to be targeted towards this age groups and their parents/guardian. Addressing the knowledge gap amongst caregivers especially in rural areas is crucial towards improving the effectiveness of HIV testing interventions.

Patient-level factors influencing hypertension control in adults in Accra, Ghana.

BACKGROUND: Effective control of blood pressure is necessary to avert the risk of cardiovascular diseases from uncontrolled hypertension. Despite evidence on the benefits of hypertension control, rates of control in Ghana remain low. This study assessed the patient-level factors that influence hypertension control among adults in Accra, Ghana. METHODS: A total of 360 hypertensive patients from two hospitals in Accra, Ghana were enrolled in the study. Patient socio-demographic characteristics were tabulated and associations between patient characteristics and hypertension control were estimated using chi-square tests and logistic regression. RESULTS: Less than a quarter of the patients had a controlled blood pressure. The patient's sex [AOR = 3.53 (95% CI:1.73-7.25], educational at junior high school [AOR = 3.52(95% CI 1.72-7.22)], senior and junior high school [AOR = 2.64 (95% CI 1.40-6.66_] and AOR = 3.06 (95% CI 1.03-6.67)] and presence of a comorbidity [AOR = 2.41 (95% CI 1.32; 4.42)] predicted BP control among patients. Dyslipidaemia [AOR = 0.31, [0.11-0.89)] an increased pill burden, and length of diagnosis of 2-5 years (AOR = 0.27 (0.1-0.73)] however, were associated with reduced BP control [AOR = 0.32(95% CI: 0.18-0.57)]. The majority of patients reported forgetfulness, side effects of medication and high pill burden as reasons for missing their medications. CONCLUSION: Knowledge of hypertension among patients is low. Sex, formal education and the presence of comorbidity and more specifically dyslipidaemia influences blood pressure control. High pill burden and 2-5 years since diagnosis negatively affects the attainment of blood pressure control.

HIV comprehensive knowledge and prevalence among young adolescents in Nigeria: evidence from Akwa Ibom AIDS indicator survey, 2017.

BACKGROUND: Despite the recent increase in HIV infections among adolescents, little is known about their HIV knowledge and perceptions. This study, therefore, sought to examine the factors associated with comprehensive HIV knowledge, stigma, and HIV risk perceptions among young adolescents aged 10-14 years in Akwa Ibom State, Nigeria. Additionally, consenting parents and assenting young adolescents were tested for HIV. METHODS: We used cross-sectional data from the 2017 Akwa Ibom AIDS Indicator Survey to analyze comprehensive HIV knowledge, stigma, and HIV risk perceptions among young adolescents. Demographic characteristics of young adolescents were summarized using descriptive statistics. Chi-square test (or Fisher's exact test in cases of small subgroup sample sizes) was used to elicit associations between demographics and study outcomes. Separate multivariable logistic regression models were then conducted to determine associations with the study outcomes. Sampling weights were calculated in order to adjust for the sample design. P-values less than 0.05 were considered to be significant. RESULTS: A total of 1818 young adolescents were interviewed. The survey highlighted significant low levels of comprehensive HIV knowledge (9.4%) among young adolescents. Adolescent-parent discussions [AOR = 2.19, 95% C.I (1.10-4.38), p = 0.03], schools as sources of HIV information [AOR = 8.06, 95% C.I (1.70-38.33), p < 0.001], and sexual activeness [AOR = 2.55, 95% C.I (1.16-5.60), p = 0.02] were associated with comprehensive HIV knowledge. Majority (93%) of young adolescents perceived themselves not to be at risk of HIV. Overall, 81.5% of young adolescents reported stigmatizing tendencies towards people living with HIV. HIV prevalence among young adolescents was 0.6%. CONCLUSIONS: Results indicate low comprehensive HIV knowledge among young adolescents. Our findings suggest that there is a need for increased attention towards young adolescents particularly in the provision of comprehensive, functional sexuality education, including HIV at the family- and school-levels. Consequently, age appropriate interventions are needed to address the epidemiological risks of young adolescents that are influenced by a myriad of social issues.

Promoting respectful maternity care for adolescents in Ghana: a quasi-experimental study protocol.

BACKGROUND: Intra-partum mistreatment by healthcare providers remains a global public health and human rights challenge. Adolescents, who are typically younger, poorer and less educated have been found to be disproportionately exposed to intra-partum mistreatment. In Ghana, maternal mortality remains a leading cause of death among adolescent females, despite increasing patronage of skilled birth attendance in health facilities. In response to the the World Health Organisation Human Reproduction Programme (WHO-HRP) recommendations to address mistreatment with Respectful Maternity Care (RMC), this study aims to generate evidence on promoting respectful treatment of adolescents using an intervention that trains health providers on the concept of mistreatment, their professional roles in RMC and the rights of adolescents to RMC. METHODS: This study will employ a pre-test post-test quasi-experimental design. At pre-test and post-test, quantitative surveys will be conducted among adolescents who deliver at health facilities about their labour experience with mistreatment and RMC. A total target of 392 participants will be recruited across intervention and control facilities. Qualitative interviews will also be conducted with selected adolescents and health professionals for an in-depth understanding of the phenomenon. Following the pre-test, a facility-based training module will be implemented at intervention facilities for the facility midwives. The modules will be co-facilitated by the principal investigator and key resource persons from the district health directorate Quality of Care teams. Training will cover the rights of adolescents to quality healthcare, classifications of mistreatment, RMC as a concept and the role of professionals in providing RMC. No intervention will occur in the control facilities. Descriptive statistics, logistic regressions and difference in differences analyses will be computed. Qualitative data will be transcribed and thematically analysed. DISCUSSION: This study is designed to test the success of an intervention in promoting RMC and reducing intra-partum mistreatment towards adolescents. It is expected that the findings of this study will be beneficial in adding to the body of knowledge in improving maternal healthcare and reducing maternal mortality, especially for adolescents. TRIAL REGISTRATION: Name of the registry: Pan African Clinical Trials Registry. PACTR202008781392078 .

Strengthening research capacity through regional partners: the HRP Alliance at the World Health Organization.

BACKGROUND: Improvements in health cannot occur without cutting-edge research informing the design and implementation of health programmes and policies, highlighting the need for qualified and capable researchers and institutions in countries where disease burden is high and resources are limited. MAIN BODY: Research capacity strengthening efforts in low- and middle-income countries have included provision of training scholarships for postgraduate degrees, often in high-income countries, internships at research universities/centres, short courses, as well as involvement with research groups for hands-on experience, among others. The HRP Alliance provides opportunities for developing local research capacity in sexual and reproductive health and rights through institutions based in low- and middle-income countries linked with ongoing and past collaborative studies. It is a network of HRP research partner institutions, World Health Organization (WHO) country and regional offices, WHO special programmes and partnerships, and WHO collaborating centres. CONCLUSION: It is through the HRP Alliance that HRP seeks to improve population health by strengthening local research capacity in sexual and reproductive health across the globe, with focus in low- and middle-income countries, in alignment with WHO's quest of promoting healthier populations.

Level of adherence and associated factors among HIV-positive adolescents on antiretroviral therapy in Cameroon.

Aim: Globally, there were over 250 000 new HIV infections among adolescents in 2017, with a higher proportion of these in sub-Saharan Africa. In Cameroon, UNICEF estimated over 4 200 new HIV infections in adolescents in 2015; by 2016, there were over 40 000 adolescents who had HIV. Given that the number of adolescents living with HIV in Cameroon is on the increase, there is a need to better understand the factors influencing adherence to treatment. The objective of this study was to assess the factors associated with adherence among adolescents in Cameroon. Methods: A cross-sectional study was conducted. A total of 460 HIV+ adolescents who were receiving antiretroviral therapy were sampled randomly from nine health facilities. Questionnaires and data extraction forms were used to collect data. Descriptive (frequencies and proportions) and inferential (chi-square and multivariate logistic regression) statistical analyses methods were used to analyse the data. Statistical significance was set at p = 0.05 and 95% confidence level. Results: The level of adherence to antiretroviral therapy among the adolescents was 83%. Twelve out of 30 independent variables examined showed significant statistical association with adherence at the bivariate level. In the multivariable logistic regression analyses, however, only two variables significantly predicted adherence - experiencing side effects (AOR = 2.63; 95% CI = 1.14, 6.09; p = 0.02), and internalized stigma (AOR = 2.51; 95% CI = 1.04, 6.04; p = 0.04). Conclusion: Adherence to treatment among adolescents in Cameroon was found to be suboptimal. There is a need for more individualized, targeted medication counselling for adolescents and their guardians as well as strategies to reduce internalized stigma and improve adherence to antiretroviral treatment.

Factors influencing adherence to the new intermittent preventive treatment of malaria in pregnancy policy in Keta District of the Volta region, Ghana.

BACKGROUND: About 25% of pregnant women in malaria-endemic areas are infected with malaria and this accounts for about 15% of maternal deaths globally. Intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) is one of the main strategies for prevention of malaria in pregnancy. A new recommendation was made by the World Health Organization (WHO) that at least three doses of IPTp-SP should be administered before delivery. This study sought to determine the factors influencing adherence to the new IPTp-SP policy in Keta District, Volta region, Ghana. METHODS: A cross-sectional quantitative study among 375 nursing mothers at four selected health facilities in Keta district, Ghana was conducted using a structured questionnaire to interview participants. Sampling proportionate to the size of facility was used to determine the number of nursing mothers from each facility based on the caseload. For each facility systematic random sampling was used to select eligible nursing mothers. Data was analyzed using STATA 15. Chi-square was used to test bivariate association between categorical variables and adherence. Logistic regression analysis was used to examine sociodemographic, individual and institutional factors influencing adherence to IPTp-SP. RESULT: About 82.1% of participants adhered to the WHO policy recommendations of at least three doses of IPTp-SP. However, only 17.1% received Ghana's five dose coverage recommendation. The proportion of IPTp-SP coverage for IPTp1 was 98.9%; IPTp2 95.5%; IPTp3 80.8%; IPTp4 39.5%; IPTp5 17.1%. CONCLUSION: Adherence to IPTp-SP was satisfactory according to WHO's policy recommendation, however, majority of the participants had less than the five doses recommended in Ghana. Number of Antenatal Care (ANC) visits and knowledge of malaria were the main determinants of adherence to IPTp-SP.

Are interventions focused on gender-norms effective in preventing domestic violence against women in low and lower-middle income countries? A systematic review and meta-analysis.

BACKGROUND: One in three women experience intimate partner violence worldwide, according to many primary studies. However, systematic review and meta-analysis of intimate partner violence is very limited. Therefore, we set to summarize the findings of existing primary studies to generate evidence for informed decisions to tackle domestic violence against women in low and lower-middle income countries. METHODS: Studies were searched from main databases (Medline via PubMed, EMBASE, CINAHL, PopLine and Web of Science), Google scholar and other relevant sources using electronic and manual techniques. Published and unpublished studies written in English and conducted among women aged (15-49 years) from 1994 to 2017 were eligible. Data were extracted independently by two authors, and recorded in Microsoft Excel sheet. Heterogeneity between included studies was assessed using I2, and publication bias was explored using visual inspection of funnel plot. Statistical analysis was carried out to determine the pooled prevalence using Comprehensive Meta-Analysis software. In addition, sub-group analysis was carried out by study-setting and types of intimate partner violence. RESULTS: Fifty two studies were included in the systematic review. Of these, 33 studies were included in the meta-analysis. The pooled prevalence of lifetime intimate partner violence was 55% (95% CI: 52, 59%). Of these, main categories were lifetime physical violence [39% (95% CI: 33, 45%); psychological violence [45% (95% CI: 40, 52%)] and sexual violence [20% (95% CI: 17, 23%)]. Furthermore, the pooled prevalence of current intimate partner violence was 38% (95% CI: 34, 43%). Of these, physical violence [25% (95% CI: 21, 28%)]; psychological violence [30% (95% CI: 24, 36%)] and sexual violence [7.0% (95% CI: 6.6, 7.5%)] were the pooled prevalence for the major types of intimate partner violence. In addition, concurrent intimate partner violence was 13% (95% CI: 12, 15%). Individual, relationship, community and societal level factors were associated with intimate partner violence. Traditional community gender-norm transformation, stakeholders' engagement, women's empowerment, intervention integration and policy/legal framework were highly recommended interventions to prevent intimate partner violence. CONCLUSION: Lifetime and current intimate partner violence is common and unacceptably high. Therefore, concerned bodies will need to design and implement strategies to transform traditional gender norms, engage stakeholders, empower women and integrate service to prevent violence against women. PROTOCOL REGISTRATION: PROSPERO: 2017: CRD42017079977 .

Understanding factors influencing home delivery in the context of user-fee abolition in Northern Ghana: Evidence from 2014 DHS.

User-fee exemption for skilled delivery services has been implemented in Ghana since 2003 as a way to address financial barriers to access. However, many women still deliver at home. Based on data from the 2014 Ghana Demographic and Health Survey, we estimated the prevalence of home delivery and determined the factors contributing to homebirths among a total of 622 women in the Northern region in the context of the user-fee exemption policy in Ghana. Binary and multivariate logistic regression analyses were employed. Results suggest home delivery prevalence of 59% (365/622). Traditional birth attendants attended majority of home deliveries (93.4%). After adjusting for potential confounders, making less than four antenatal care visits (aOR = 2.42; CI = 1.91-6.45; p = 0.001), being a practitioner of traditional African religion (aOR = 16.40; CI = 3.10-25.40; p = 0.000), being a Muslim (aOR 2.10; CI = 1.46-5.30; p = 0.042), not having a health insurance (aOR = 1.85; CI = 1.773-4.72; p = 0.016), living in a male-headed household (aOR = 2.07; CI = 1.02-4.53; p < 0.01), and being unexposed to media (aOR = 3.10; CI = 1.12-5.38; p = 0.021) significantly predicted home delivery. Our results suggest that unless interventions are implemented to address other health system factors like insurance coverage, and socio-cultural and religious beliefs that hinder uptake of skilled care, the full benefits of user-fee exemption may not be realized in Ghana.

The effects of centering pregnancy on maternal and fetal outcomes in northern Nigeria; a prospective cohort analysis.

BACKGROUND: Maternal and infant mortality remains high in Nigeria primarily due to low use of skilled birth attendants. Huge disparities exist between southern and northen Nigeria on use of skilled birth attendants with south significantly higher than the north. We assessed the effect of centering pregnancy group (CPG) antenatal care on the uptake of antenatal care (ANC), facility delivery and immunization rates for infants in Kano state. METHODS: Between December 2012 and May 2014, pregnant women with similar sociodemographics and obstetric history were enrolled into intervention (CPG) and control groups and followed up prospectively. Chi-square tests were conducted to compare the differences between the intervention and the control groups with respect to background characteristics and intervention outcomes. Logistic regression was used to measure the associations between CPG and uptake of services for mother-baby pairs in care. RESULTS: A total of 517 (260 in the control group and 257 in the CPG) pregnant women enrolled and participated in the study. Thirty-six percent of women in the control group attended ANC at least once in 2nd and 3nd trimester compared to 49% of respondents in the CPG (p < 0.01). Health facility delivery was higher among CPG (13% vs. 8%; p < 0.01). When controlled for age, number of previous pregnancies, number of term deliveries, number of children alive and occupation of respondent or their spouses, respondents who participated in the CPGs compared to those who did not, were more likely to attend at least one antenatal care (ANC) session in the third trimester [adjusted risk ratio (ARR):1.52; 95% CI:1.36-1.69], more likely to immunize their babies at six weeks [ARR: 2.23; 95% CI: 1.16-4.29] and fourteen weeks [ARR: 3.46; 95% CI: 1.19-10.01] and more likely to use health services [ARR: 1.50; 95% CI: 1.06-2.13]. CONCLUSION: Centering or group pregnancy showed a positive effect on the use of antenatal services, facility delivery and postnatal services and thus is a promising intervention to increase uptake of maternal health care services in northern Nigeria. The low facility delivery remains a cause for alarm and requires further investigation to improve facility delivery in northern Nigeria.

Adherence to On-Time ART Drug Pick-Up and Its Association with CD4 Changes and Clinical Outcomes Amongst HIV Infected Adults on First-Line Antiretroviral Therapy in Nigerian Hospitals.

Medication adherence is a major determinant of antiretroviral treatment (ART) success. Promptness in medication refill pick-ups may give an indication of medication adherence. This study determined medication refill adherence among HIV positive patients on ART and its association with treatment outcomes in HIV treatment centers in Nigeria. This retrospective multi-center cohort study involved a review of ART refill records for 3534 HIV-positive patients aged 18-60 years who initiated first-line ART between January 2008 and December 2009 and were on therapy for ≥18 months after ART initiation. Drug refill records of these patients for 10 consecutive refill visits after ART initiation were analyzed. The first ten consecutive refill appointment-keeping rates after ART initiation ranged from 64.3 % to 76.1 % which decreased with successive visits. Altogether, 743 (21.1 %) patients were deemed adherent, meaning they picked up their drugs within 7 days of the drug refill appointment date on at least nine out of ten refill visits. The adherent group of patients had a mean CD4 cells increase of 206 ± 6.1 cells/dl after 12 months of ART compared to 186 ± 7.1 cells/dl reported among the nonadherent group (p = 0.0145). The proportion of patients in the adherent category who showed no OIs after 12 months on ART (81 %) was significantly higher when compared to the proportion in the non-adherent category (23.5 %), (p = 0.008). The multivariate analysis showed that the odds of being adherent was 2-3 times more in patients who had a baseline CD4 count of less than 200 cells/dl compared to those with a baseline CD4 of >350 cells/dl. (AOR 2.43, 95 % CI 1.62-3.66). In addition, for patients with baseline CD4 cell count of 201-350 cells/dl, the odds of being adherent was found to be 1.9 compared to those with baseline CD4 of greater than 350 cells/dl (AOR 1.93, 95 % CI 1.27-2.94). Pharmacy refill data can serve as an adherence measure. Adherence to on-time drug pickup on ≥90 % of refill appointments was associated with a better CD4 count response and a reduction in the presence of opportunistic infections in ART patients after 12 months of treatment.

Identifying models of HIV care and treatment service delivery in Tanzania, Uganda, and Zambia using cluster analysis and Delphi survey.

BACKGROUND: Organization of HIV care and treatment services, including clinic staffing and services, may shape clinical and financial outcomes, yet there has been little attempt to describe different models of HIV care in sub-Saharan Africa (SSA). Information about the relative benefits and drawbacks of different models could inform the scale-up of antiretroviral therapy (ART) and associated services in resource-limited settings (RLS), especially in light of expanded client populations with country adoption of WHO's test and treat recommendation. METHODS: We characterized task-shifting/task-sharing practices in 19 diverse ART clinics in Tanzania, Uganda, and Zambia and used cluster analysis to identify unique models of service provision. We ran descriptive statistics to explore how the clusters varied by environmental factors and programmatic characteristics. Finally, we employed the Delphi Method to make systematic use of expert opinions to ensure that the cluster variables were meaningful in the context of actual task-shifting of ART services in SSA. RESULTS: The cluster analysis identified three task-shifting/task-sharing models. The main differences across models were the availability of medical doctors, the scope of clinical responsibility assigned to nurses, and the use of lay health care workers. Patterns of healthcare staffing in HIV service delivery were associated with different environmental factors (e.g., health facility levels, urban vs. rural settings) and programme characteristics (e.g., community ART distribution or integrated tuberculosis treatment on-site). CONCLUSIONS: Understanding the relative advantages and disadvantages of different models of care can help national programmes adapt to increased client load, select optimal adherence strategies within decentralized models of care, and identify differentiated models of care for clients to meet the growing needs of long-term ART patients who require more complicated treatment management.

Community based intervention to prevent domestic violence against women in the reproductive age in Northwestern Ethiopia: a protocol for quasi-experimental study.

BACKGROUND: Violence against women is a well understood devastating global pandemic, and human right violation. One in three women experienced intimate partner violence worldwide. In Ethiopia, the level of domestic violence against women is one of the highest in the world. However, Ethiopia is signatory for various conventions and incorporated in legal frameworks. Nevertheless, effective implementation of the existing policy documents, and engaging different stakeholders is very limited. Therefore, we aimed to pilot feasibility of implementing available research evidence and policy documents at community level to prevent domestic violence against women in Awi zone, northwestern Ethiopia. METHODS: A community-based quasi-experimental study design will be employed using mixed method. Multistage stratified systematic sampling and purposive sampling will be used to recruit quantitative and qualitative study participants, respectively. A total of 1,269 women will be participated in the intervention, active comparator and control groups. Pre and post-test quantitative data will be collected using face-to-face interview. Qualitative data will be collected through in-depth, key informant interview and focus group discussions. INTERVENTION: advocacy meeting will be held to persuade local politicians and sustain the implementation of community based intervention to prevent domestic violence against women. Community representatives will be trained to enhance peer education to promote community awareness and engage stakeholders to transform the traditional gender norm within local context. Awareness creation and husband involvement will be made through integrating the intervention with community health extension program. Only husband involvement will not be promoted in the active comparator to test the role of husband involvement on the domestic violence prevention activities. Intervention progress will be monitored regularly. Gathered data will be entered in Epidata and exported to SPSS (23.0) software for analysis. Descriptive statistics, logistic regressions, intention to treat analysis and difference in differences will be computed. Qualitative data will be transcribed, color coded, thematically analyzed and arranged using Nvivo. DISCUSSION: This interventional study is aimed to design, pilot and translate proven research evidence, agreed conventions and country policy document to real setting implementation. We are expecting to initiate implementation of culturally acceptable intervention through engaging stakeholders. Policy makers, planners and any concerned bodies will be benefited. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03265626.