Defining operational research priorities to improve malaria control and elimination in sub-Saharan Africa: results from a country-driven research prioritization setting process.

BACKGROUND: In order to reignite gains and accelerate progress toward improved malaria control and elimination, policy, strategy, and operational decisions should be derived from high-quality evidence. The U.S. President's Malaria Initiative (PMI) Insights project together with the Université Cheikh Anta Diop of Dakar, Senegal, conducted a broad stakeholder consultation process to identify pressing evidence gaps in malaria control and elimination across sub-Saharan Africa (SSA), and developed a priority list of country-driven malaria operational research (OR) and programme evaluation (PE) topics to address these gaps. METHODS: Five key stakeholder groups were engaged in the process: national malaria programmes (NMPs), research institutions in SSA, World Health Organization (WHO) representatives in SSA, international funding agencies, and global technical partners who support malaria programme implementation and research. Stakeholders were engaged through individual or small group interviews and an online survey, and asked about key operational challenges faced by NMPs, pressing evidence gaps in current strategy and implementation guidance, and priority OR and PE questions to address the challenges and gaps. RESULTS: Altogether, 47 interviews were conducted with 82 individuals, and through the online survey, input was provided by 46 global technical partners. A total of 33 emergent OR and PE topics were identified through the consultation process and were subsequently evaluated and prioritized by an external evaluation committee of experts from NMPs, research institutions, and the WHO. The resulting prioritized OR and PE topics predominantly focused on generating evidence needed to close gaps in intervention coverage, address persistent challenges faced by NMPs in the implementation of core strategic interventions, and inform the effective deployment of new tools. CONCLUSION: The prioritized research list is intended to serve as a key resource for informing OR and PE investments, thereby ensuring future investments focus on generating the evidence needed to strengthen national strategies and programme implementation and facilitating a more coordinated and impactful approach to malaria operational research.

Adolescent perception of sexual and reproductive health rights and access to reproductive health information and services in Adaklu district of the Volta Region, Ghana.

BACKGROUND: One of the key targets of Ghana's Adolescent Health Service Policy and Strategy is to ensure that 90% of adolescents and young people have knowledge of sexual and reproductive health services and rights. This phenomenon has led to the establishment of adolescent-friendly health facilities to increase access to health information and services among adolescents. Despite these efforts, access to health information and service utilisation remains low among adolescents. Our study seeks to examine adolescents' perception of sexual and reproductive health rights (SRHR) and access to reproductive health information and services in the Adaklu district of the Volta region of Ghana. METHODS: A baseline cross-sectional household survey of 221 adolescents aged 10-19 years in 30 randomly selected communities was used. A structured questionnaire was developed and administered to the respondents. A binary logistic regression analysis was used to examine the association between adolescents' perception of adolescent sexual and reproductive health rights (ASRHR) and access to reproductive health information and services. RESULTS: Adolescents' perception of SRHR was poor, and this poor perception may have been reflected in a few proportions (10%) of adolescents accessing SRH information and services. Majority (91.9%) of adolescents do not use sexual and reproductive health (SRH) services in the Adaklu district. Adolescents who attained primary education (aOR = 5.99, CI: 1.16-30.95), those who never had sexual communication with their father (aOR = 8.89, CI: 1.99-39.60) and adolescents who never experienced any form of sexual coercion (aOR = 11.73, CI: 1.61-85.68) had a higher likelihood of not utilising SRH services in Adaklu district. Regarding access to SRH information, adolescents who ever discussed sexual matters with their fathers, those who ever used contraceptives and adolescents who ever experienced sexual coercion had lower odds of accessing information on contraception, sexually transmitted infections, and teenage pregnancy. CONCLUSIONS: Access to and use of sexual and reproductive information and health services among adolescents in Adaklu district remain very low, which has implications for adolescents' knowledge and perception of their SRHR. Considering the factors predicting this phenomenon, it is recommended that interventions can be tailored to address the unique challenges faced by adolescent in accessing comprehensive SRH support.

Provision and experience of care among women with hypertension in pregnancy: a multi-center qualitative study in Ghana.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) remain a leading global health problem with complex clinical presentations and potentially grim birth outcomes for both mother and fetus. Improvement in the quality of maternal care provision and positive women's experiences are indispensable measures to reduce maternal and perinatal adverse outcomes. OBJECTIVE: To explore the perspectives and lived experiences of healthcare provision among women with HDP and the associated challenges. METHODS: A multi-center qualitative study using in-depth interviews (IDIs) and focus group discussions (FGDs) was conducted in five major referral hospitals in the Greater Accra Region of Ghana between June 2018 and March 2019. Women between 26 and 34 weeks' gestation with confirmed HDP who received maternity care services were eligible to participate. Thematic content analysis was performed using the inductive analytic framework approach. RESULTS: Fifty IDIs and three FGDs (with 22 participants) were conducted. Most women were between 20 and 30 years, Akans (ethnicity), married/cohabiting, self-employed and secondary school graduates. Women reported mixed (positive and negative) experiences of maternal care. Positive experiences reported include receiving optimal quality of care, satisfaction with care and good counselling and reassurance from the health professionals. Negative experiences of care comprised ineffective provider-client communication, inappropriate attitudes by the health professionals and disrespectful treatment including verbal and physical abuse. Major health system factors influencing women's experiences of care included lack of logistics, substandard professionalism, inefficient national health insurance system and unexplained delays at health facilities. Patient-related factors that influenced provision of care enumerated were financial limitations, chronic psychosocial stress and inadequate awareness about HDP. CONCLUSION: Women with HDP reported both positive and negative experiences of care stemming from the healthcare system, health providers and individual factors. Given the importance of positive women's experiences and respectful maternal care, dedicated multidisciplinary women-centered care is recommended to optimize the care for pregnant women with HDP.

High blood pressure (hypertension) in pregnancy can have severe complications for both mother and fetus including loss of life. The outcome of pregnancy for women who develop hypertension during pregnancy can be improved by ensuring optimal quality of care. In this study, we explored the opinions and experiences of women whose pregnancies were affected by hypertension concerning the care they received during their recent admission at different hospitals in Ghana and the challenges they faced. In four major referral hospitals in the Greater Accra Region of Ghana, we interviewed the women and had focus group discussions. Women who were pregnant for 26 weeks up to 34 weeks and had hypertension in pregnancy were invited for inclusion in the study.We conducted in-depth interviews with fifty women and three focus group discussions with 22 women. Most women who participated in the study were between 20 and 30 years old, Akans (ethnicity), married/cohabiting, self-employed and secondary school graduates. The women reported both positive and negative experiences of care during their admission at the hospitals. Examples of positive experiences were receiving good quality of care, satisfaction with care, and adequate counselling from the health workers. Examples of negative experiences were poor communication between the providers and affected women, inappropriate attitudes by the healthcare providers, and disrespectful treatment such as verbal and physical abuse. The major factors in the health system that influenced women's experiences of care were lack of logistics, substandard professionalism, inefficient national health insurance system and long delays at health facilities prior to receiving treatment. The individual women's factors that affected the quality of care included financial constraints, psychosocial stress and inadequate knowledge about hypertension during pregnancy.In conclusion, we determined that women with hypertension in pregnancy experience both positive and negative aspects of care and these may be due to challenges associated with the healthcare system, health providers and women themselves. There is the need to ensure optimal quality and respectful maternity care considering the nature of hypertension in pregnancy. These women require dedicated hospital staff with significant  experience to improve the quality of care provided to women with hypertension in pregnancy.

Motivators and demotivators to accessing malaria in pregnancy interventions in sub-Saharan Africa: a meta-ethnographic review.

BACKGROUND: Despite the introduction of efficacious interventions for malaria control, sub-Saharan Africa continues to bear the highest burden of malaria and its associated effects on vulnerable populations, such as pregnant women and children. This meta-ethnographic review contributes to literature on malaria in pregnancy interventions in sub-Saharan Africa by offering insights into the multiple factors that motivate or demotivate women from accessing MiP interventions. METHODS: A meta-ethnographic approach was used for the synthesis. Original qualitative research articles published from 2010 to November 2021 in English in sub-Saharan Africa were searched for. Articles focusing on WHO's recommended interventions such as intermittent preventive treatment with sulfadoxine-pyrimethamine, long-lasting insecticidal nets and testing and treatment of Malaria in Pregnancy (MiP) were included. Selected articles were uploaded into Nvivo 11 for thematic coding and synthesis. RESULTS: Twenty-seven original qualitative research articles were included in the analysis. Main factors motivating uptake of MiP interventions were: (1) well organized ANC, positive attitudes of health workers and availability of MiP services; (2) Women's knowledge of the effects of malaria in pregnancy, previous experience of accessing responsive ANC; (3) financial resources and encouragement from partners, relatives and friends and (4) favourable weather condition and nearness to a health facility. Factors that demotivated women from using MiP services were: (1) stock-outs, ANC charges and health providers failure to provide women with ample education on the need for MiP care; (2) perception of not being at risk and the culture of self-medication; (3) fear of being bewitched if pregnancy was noticed early, women's lack of decision-making power and dependence on traditional remedies and (4) warm weather, long distances to health facilities and the style of construction of houses making it difficult to hang LLINs. CONCLUSIONS: Health system gaps need to be strengthened in order to ensure that MiP interventions become accessible to women. Additionally, health managers need to involve communities in planning, designing and implementing malaria interventions for pregnant women. It is important that the health system engage extensively with communities to facilitate pregnant women and communities understanding of MiP interventions and the need to support pregnant women to access them.

Mixed effect analysis of factors influencing the use of insecticides treated bed nets among pregnant women in Ghana: evidence from the 2019 Malaria Indicator Survey.

BACKGROUND: Malaria during pregnancy is a major cause of maternal morbidity globally and leads to poor birth outcomes. The World Health Organization has recommended the use of insecticide treated bed nets (ITN) as one of the effective malaria preventive strategies among pregnant women in malaria endemic areas. This study, therefore, seeks to examine the individual and household factors associated with the use of ITNs among pregnant women in Ghana. METHODS: Data for this study was obtained from the 2019 Ghana Malaria Indicator Survey (GMIS) conducted between September 25 and November 24, 2019. The weighted sample comprised 353 pregnant women aged 15-49 years. Data was analyzed with SPSS version 22 using both descriptive and multilevel logistics regression modelling. Statistically significant level was set at p < 0.05. RESULTS: The study found that 49.2% of pregnant women in Ghana use ITN to prevent malaria. Pregnant women aged 35-49 years (AOR = 3.403, CI: 1.191-9.725), those with no formal education (AOR = 5.585, CI = 1.315-23.716), and those who had secondary education (AOR = 3.509, CI = 1.076-11.440) had higher odds of using ITN. Similarly, higher odds of ITN usage was found among who belonged to the Akan ethnic group (AOR = 7.234, CI = 1.497-34.955), dwell in male-headed households (AOR = 2.232, CI = 1.105-4.508) and those whose household heads are aged 60-69 years (AOR = 4.303, CI = 1.160-15.966). However, pregnant women who resided in urban areas (AOR = 0.355, CI = 0.216-0.582), those whose household heads aged 40-49 years (AOR = 0.175, CI = 0.066-0.467) and those who belonged to richer (AOR =0.184, CI = 0.050-0.679) and richest (AOR = 0.107, CI = 0.021-0.552) households had lower odds of using ITN for malaria prevention. CONCLUSIONS: Individual socio-demographic and household factors such as pregnant women's age, educational level, place of residence, ethnicity, sex and age of household head, and household wealth quintile are associated with the use of ITN for malaria prevention among pregnant women. These factors ought to be considered in strengthening malaria prevention campaigns and develop new interventions to help increase ITN utilization among vulnerable population living in malaria- endemic areas.

Determinants of communication on sexual issues between adolescents and their parents in the Adaklu district of the Volta region, Ghana: a multinomial logistic regression analysis.

BACKGROUND: Poor communication on sexual issues between adolescents and their parents results in high rates of negative sexual practices such as teenage pregnancy. Contributing factors to this poor communication on sexual issues between adolescents and their parents in a high teenage pregnancy setting have not been adequately explored. We sought to fill this gap by examining the factors that predict communication on sexual issues between adolescents and their parents in the Adaklu district of the Volta region of Ghana. METHODS: A baseline cross-sectional household survey of 221 adolescents aged 10-19 years in 30 randomly selected communities was used. A well-structured questionnaire was developed. A multinomial logistic regression analysis was used to examine factors that significantly influenced communication between adolescents and their parents regarding sex. RESULTS: Only 11.3% of adolescents had discussions on sexual issues with both parents while 27.6% of communicated sexual issues with only one parent in Adaklu district. Adolescent males (AOR = 0.21, CI = 0.06-0.75), those aged 10-14 years (AOR = 0.41, CI = 0.04-0.57), non-members of adolescent health clubs (AOR = 0.46, CI = 0.21-1.00), and those living with only a father (AOR = 0.19, CI = 0.06-0.61) had lower odds of communicating with their parents on sexual issues. CONCLUSIONS: Adolescent-parental communication on sexual issues in Adaklu district is very low. This situation requires more empowerment of adolescents to enable them to discuss sexual issues with their parents through increased engagement with adolescent health club activities and capacity building capacity of parents with the right information on sexual and reproductive health by health staff within the district. Additionally, parents need to be equipped with communication skills to enable them to communicate effectively with their children.

Parent-adolescent and older sibling adolescent communication on issues about sex is considered an important aspect of adolescent development and well-being, as it ensures informed decision making and good behavior and a protective factor for adolescent sexual health. However, poor communication on sexual issues between adolescents and their parents results in high rates of negative sexual practices such as teenage pregnancy. Contributing factors to this poor communication on sexual issues between adolescents and their parents in a high teenage pregnancy setting have not been adequately explored. This paper, therefore, examines the factors that predict communication on sexual issues between adolescents and their parents in the Adaklu district of the Volta region of Ghana. It highlights individual, household, societal and sexual-related factors that predict communication on sexual issues between adolescents and their parents in an area with a high rate of teenage pregnancy among adolescent girls.The data on adolescent sexual and reproductive health in Adaklu district show poor communication on sexual issues between adolescents (aged 10­19 years) and their parents. Improving communication on sexual issues between adolescents and their parents in rural settings requires capacity building of parents (especially mothers) with the right information and communication skills for discussing sexual and reproductive health issues with their children.

Evaluation of a package of continuum of care interventions for improved maternal, newborn, and child health outcomes and service coverage in Ghana: A cluster-randomized trial.

BACKGROUND: In low- and middle-income countries (LMICs), the continuum of care (CoC) for maternal, newborn, and child health (MNCH) is not always complete. This study aimed to evaluate the effectiveness of an integrated package of CoC interventions on the CoC completion, morbidity, and mortality outcomes of woman-child pairs in Ghana. METHODS AND FINDINGS: This cluster-randomized controlled trial (ISRCTN: 90618993) was conducted at 3 Health and Demographic Surveillance System (HDSS) sites in Ghana. The primary outcome was CoC completion by a woman-child pair, defined as receiving antenatal care (ANC) 4 times or more, delivery assistance from a skilled birth attendant (SBA), and postnatal care (PNC) 3 times or more. Other outcomes were the morbidity and mortality of women and children. Women received a package of interventions and routine services at health facilities (October 2014 to December 2015). The package comprised providing a CoC card for women, CoC orientation for health workers, and offering women with 24-hour stay at a health facility or a home visit within 48 hours after delivery. In the control arm, women received routine services only. Eligibility criteria were as follows: women who gave birth or had a stillbirth from September 1, 2012 to September 30, 2014 (before the trial period), from October 1, 2014 to December 31, 2015 (during the trial period), or from January 1, 2016 to December 31, 2016 (after the trial period). Health service and morbidity outcomes were assessed before and during the trial periods through face-to-face interviews. Mortality was assessed using demographic surveillance data for the 3 periods above. Mixed-effects logistic regression models were used to evaluate the effectiveness as difference in differences (DiD). For health service and morbidity outcomes, 2,970 woman-child pairs were assessed: 1,480 from the baseline survey and 1,490 from the follow-up survey. Additionally, 33,819 cases were assessed for perinatal mortality, 33,322 for neonatal mortality, and 39,205 for maternal mortality. The intervention arm had higher proportions of completed CoC (410/870 [47.1%]) than the control arm (246/620 [39.7%]; adjusted odds ratio [AOR] for DiD = 1.77; 95% confidence interval [CI]: 1.08 to 2.92; p = 0.024). Maternal complications that required hospitalization during pregnancy were lower in the intervention (95/870 [10.9%]) than in the control arm (83/620 [13.4%]) (AOR for DiD = 0.49; 95% CI: 0.29 to 0.83; p = 0.008). Maternal mortality was 8/6,163 live births (intervention arm) and 4/4,068 live births during the trial period (AOR for DiD = 1.60; 95% CI: 0.40 to 6.34; p = 0.507) and 1/4,626 (intervention arm) and 9/3,937 (control arm) after the trial period (AOR for DiD = 0.11; 95% CI: 0.11 to 1.00; p = 0.050). Perinatal and neonatal mortality was not significantly reduced. As this study was conducted in a real-world setting, possible limitations included differences in the type and scale of health facilities and the size of subdistricts, contamination for intervention effectiveness due to the geographic proximity of the arms, and insufficient number of cases for the mortality assessment. CONCLUSIONS: This study found that an integrated package of CoC interventions increased CoC completion and decreased maternal complications requiring hospitalization during pregnancy and maternal mortality after the trial period. It did not find evidence of reduced perinatal and neonatal mortality. TRIAL REGISTRATION: The study protocol was registered in the International Standard Randomised Controlled Trial Number Registry (90618993).

COVID-19 vaccine uptake among health care workers in Ghana: a case for targeted vaccine deployment campaigns in the global south.

BACKGROUND: Health care workers (HCWs) are among the high-risk groups in contracting and dying from COVID-19. World Health Organization estimates that over 10,000 HCWs in Africa have been infected with COVID-19 making it a significant occupational health hazard to HCWs. In Ghana, over 100 HCWs have already been infected and dozen others died from the virus. Acceptability and uptake of the COVID-19 vaccine is therefore critical to promote health and safety of HCWs as the country battles out of a third wave of the pandemic. OBJECTIVE: The study sought to ascertain the correlates of HCWs likelihood of participating in a COVID-19 vaccine trial and accepting the vaccine when given the opportunity. METHODS: The study was a web-based cross-sectional survey among HCWs (n = 1605) in all sixteen (16) administrative regions in Ghana. Data were analyzed with STATA statistical analysis software (version 14). Chi-square (X2) and Fisher's exact tests were used to test for differences in categorical variables; bivariate probit regression analysis with Average Marginal Effect (AME) was employed to ascertain the determinants of HCWs' likelihood of participating in a COVID-19 vaccine trial and taking the vaccine. RESULTS: It was found that 48% of HCWs will participate in a COVID-19 vaccine trial when given the opportunity; 70% will accept the COVID-19 vaccine; younger HCWs (AME = 0.28, SE = 0.16, p < 0.1), non-Christians (AME = 21, SE = 0.09, p < 0.05) and those who worked in faith-based health facilities (AME = 18, SE = 0.07, p < 0.05) were more likely to participate in a COVID-19 vaccine trial. Female HCWs (AME = - 11, SE = 0.04, p < 0.05) and those with lower educational qualification were less likely to accept a COVID-19 vaccine (AME = - 0.16, SE = 0.08, p < 0.1). Reasons cited for unwillingness to participate in a COVID-19 vaccine trial or uptake the vaccine were mainly fear, safety concerns, mistrust, uncertainty, spiritual and religious beliefs. CONCLUSIONS: Acceptance of the COVID-19 vaccine appear to be high among HCWs; conversely, willingness to volunteer for the vaccine trial was low. Continuous targeted and integrated public health education for HCWs will enhance vaccine acceptability to promote safety and population health in the global south as Ghana intensifies efforts to produce COVID-19 vaccines locally.

Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa.

BACKGROUND: There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given. METHODS: Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007-2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones. RESULTS: Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of < 5-year-olds not prescribed ACT ranged up to 41.8% across sites. The odds of not being prescribed an ACT were 2-32 times higher for patients in settings with lower-transmission intensity (using test positivity as a proxy) compared to areas of higher transmission. mRDT-positive children in low-transmission settings were especially likely not to be prescribed ACT, with proportions untreated up to 70%. Of the 7426 mRDT-positive patients not prescribed an ACT, 4121 (55.5%) were prescribed other, non-recommended non-ACT antimalarial medications, and the remainder (44.5%) were prescribed no antimalarial. CONCLUSIONS: In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children < 5 years and those in low-transmission settings, were most likely to not be prescribed antimalarials, and young children in low-transmission settings were least likely to be treated for malaria. This major public health risk must be addressed in training and practice. TRIAL REGISTRATION: Reported in individual primary studies.

Effect of pre-consultation testing on clinicians' adherence to malaria test results and waiting time among children under 5 years in the Northern Zone of Volta Region of Ghana.

BACKGROUND: The Ministry of Health, Ghana, in accordance with global policy, recommends that all suspected malaria cases be confirmed parasitologically before treatment. Not all clinicians, however, base their treatment on test results. Patients also spend a lot of time at health facilities waiting to consult a clinician before being asked to go for testing and to see a clinician with test results. The purpose of the study was to determine if testing all children aged 6 to 59 months with fever reporting at an outpatients department (OPD) for malaria before consultation with a clinician (pre-consultation testing) will influence clinicians to adhere to test results and also reduce the time spent by such patients. METHODS: A quasi-experimental study design was used involving two randomly selected government-owned hospitals in the Northern Volta, Ghana. In each hospital, 439 children were recruited between November 2018 and January 2019. The intervention hospital implemented pre-consultation testing. In the comparator arm, standard practices, which involved patients seeing the clinician before he/she decides whether to send the patient for testing or not, were maintained. RESULTS: Out of 878 children screened the overall prevalence of malaria was 31.9% by malaria rapid diagnostic test (RDT) and 26.7% by microscopy. Clinicians in the intervention arm adhered more to the malaria test results than those in the comparator arm (93.2 vs. 84.3%; p < 0.001). The proportion of children who tested negative but were still diagnosed with malaria was significantly lower in the intervention arm compared to the comparator arm (8.4 vs. 21.2%: p < 0.001). Clinicians and mothers/caregivers in both arms preferred pre-consulting testing. Six out of every 10 mothers/caregivers in the comparator arm viewed the waiting time as 'too long'' compared to 4 out of every 10 mothers in the intervention arm. On average, patient waiting time was significantly lower in the intervention arm (2.61 h) than in the comparator arm (3.42 h). CONCLUSION: Pre-consultation testing significantly improves clinicians' adherence to malaria test results, shortens patients' waiting time and leads to overall patient satisfaction. There is a need to establish RDT corners at OPDs of health facilities to implement pre-consultation testing.

Coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) influences delivery outcomes among women with obstetric referrals at the district level in Ghana.

BACKGROUND: The aim of the study was to determine the coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) and its relationship with delivery outcomes among obstetric referral cases at the district level of healthcare. METHODS: An implementation research within three districts of the Greater Accra region was conducted from May 2017 to February 2018, to assess the role of an enhanced inter-facility communication system on processes and outcomes of obstetric referrals. A cross-sectional analysis of the data on IPTp coverage as well as delivery outcomes for the period of study was conducted, for all the referrals ending up in deliveries. Primary outcomes were maternal and neonatal complications at delivery. IPTp coverage was determined as percentages and classified as adequate or inadequate. Associated factors were determined using Chi square. Odds ratios (OR, 95% CI) were estimated for predictors of adequate IPTp dose coverage for associations with delivery outcomes, with statistical significance set at p = 0.05. RESULTS: From a total of 460 obstetric referrals from 16 lower level facilities who delivered at the three district hospitals, only 223 (48.5%) received adequate (at least 3) doses of IPTp. The district, type of facility where ANC is attended, insurance status, marital status and number of antenatal clinic visits significantly affected IPTp doses received. Adjusted ORs show that adequate IPTp coverage was significantly associated with new-born complication [0.80 (0.65-0.98); p = 0.03], low birth weight [0.51 (0.38-0.68); p < 0.01], preterm delivery [0.71 (0.55-0.90); p = 0.01] and malaria as indication for referral [0.70 (0.56-0.87); p < 0.01]. Positive association with maternal complication at delivery was seen but was not significant. CONCLUSION: IPTp coverage remains low in the study setting and is affected by type of health facility that ANC is received at, access to health insurance and number of times a woman attends ANC during pregnancy. This study also confirmed earlier findings that, as an intervention IPTp prevents bad outcomes of pregnancy, even among women with obstetric referrals. It is important to facilitate IPTp service delivery to pregnant women across the country, improve coverage of required doses and maximize the benefits to both mothers and newborns.

Trends and correlates of maternal, newborn and child health services utilization in primary healthcare facilities: an explorative ecological study using DHIMSII data from one district in the Volta region of Ghana.

BACKGROUND: Sustainable Development Goal 3 aims at reducing global neonatal mortality to at least 12 per 1000 livebirths, under-five mortality to at least 25 per 1000 livebirths and maternal mortality ratio to less than 70 per 100,000 livebirths by 2030. Considering the achievement so far, many countries in sub-Saharan Africa, including Ghana are not likely to achieve these targets. Low utilization of maternal, newborn and child health (MNCH) services partly account for this predicament. This study explored the trend and correlates of MNCH services utilization in one administrative district in the Volta Region of Ghana. METHODS: This is an explorative ecological study employing trend analysis of 2015-2017 data from Ghana Health Service District Health Information Management System II. Univariate Poisson regression models were used to determine the factors associated with MNCH services utilization at 95% confidence level. RESULTS: Cumulative record of 17,052 antenatal care (ANC) attendance and 2162 facility-based spontaneous vaginal deliveries (SVDs) was discovered. Compelling evidence of potential unskilled deliveries was observed in 23% of the 26 facilities reported in the DHIMSII data. High cumulative number of midwives in health facilities associated positively with high records of ANC visits (IRR = 1.30, [95% CI:1.29, 1.32]; p = 0.0001), facility-based SVDs (IRR = 1.30 [95% CI:1.25, 1.35]; p = 0.0001) and BCG immunizations (IRR = 1.32 [95% CI:1.29, 1.34]; p = 0.0001). Likewise, high records of ANC visits correlated positively with high facility-based SVDs and child immunizations records (p < 0.0001). CONCLUSION: Targeted health system and community level interventions alongside progressive frontline health staff motivation and retention strategies could further enhance enrollment and retention of mothers in pre-natal and postnatal care services throughout the continuum of care to guarantee better MNCH health outcomes. Investments in universal coverage for quality ANC services has the potential to enhance utilization of supervised deliveries and post-natal care services such as immunizations.

Can an mhealth clinical decision-making support system improve adherence to neonatal healthcare protocols in a low-resource setting?

BACKGROUND: This study assessed health workers' adherence to neonatal health protocols before and during the implementation of a mobile health (mHealth) clinical decision-making support system (mCDMSS) that sought to bridge access to neonatal health protocol gap in a low-resource setting. METHODS: We performed a cross-sectional document review within two purposively selected clusters (one poorly-resourced and one well-resourced), from each arm of a cluster-randomized trial at two different time points: before and during the trial. The total trial consisted of 16 clusters randomized into 8 intervention and 8 control clusters to assess the impact of an mCDMSS on neonatal mortality in Ghana. We evaluated health workers' adherence (expressed as percentages) to birth asphyxia, neonatal jaundice and cord sepsis protocols by reviewing medical records of neonatal in-patients using a checklist. Differences in adherence to neonatal health protocols within and between the study arms were assessed using Wilcoxon rank-sum and permutation tests for each morbidity type. In addition, we tracked concurrent neonatal health improvement activities in the clusters during the 18-month intervention period. RESULTS: In the intervention arm, mean adherence was 35.2% (SD = 5.8%) and 43.6% (SD = 27.5%) for asphyxia; 25.0% (SD = 14.8%) and 39.3% (SD = 27.7%) for jaundice; 52.0% (SD = 11.0%) and 75.0% (SD = 21.2%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. In the control arm, mean adherence was 52.9% (SD = 16.4%) and 74.5% (SD = 14.7%) for asphyxia; 45.1% (SD = 12.8%) and 64.6% (SD = 8.2%) for jaundice; 53.8% (SD = 16.0%) and 60.8% (SD = 11.7%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. We observed nonsignificant improvement in protocol adherence in the intervention clusters but significant improvement in protocol adherence in the control clusters. There were 2 concurrent neonatal health improvement activities in the intervention clusters and over 12 in the control clusters during the intervention period. CONCLUSION: Whether mHealth interventions can improve adherence to neonatal health protocols in low-resource settings cannot be ascertained by this study. Neonatal health improvement activities are however likely to improve protocol adherence. Future mHealth evaluations of protocol adherence must account for other concurrent interventions in study contexts.

Impact of a bottom-up community engagement intervention on maternal and child health services utilization in Ghana: a cluster randomised trial.

BACKGROUND: Ghana is among African countries not likely to achieve the Sustainable Development Goal (SDG) three (3) target of reducing maternal mortality to 70 per 100,000 live births by the year 2030 if maternal and child health services utilization are not improved. Community engagement in health is therefore advocated to help address this challenge. This study evaluated the impact of a community engagement intervention on maternal and child health services utilization in Ghana. METHODS: This study was a cluster randomised trial among primary healthcare facilities (n = 64) in the Greater Accra and Western regions in Ghana. Multivariate multiple regression analysis and paired-ttest were used to determine impact of the community engagement intervention on maternal and child health indicators at baseline and follow-up. RESULTS: Intervention health facilities recorded significant improvements over control facilities in terms of average spontaneous vaginal deliveries per month per health facility (baseline mean = 15, follow-up mean = 30, p = 0.0013); child immunizations (baseline mean = 270, follow-up mean = 455, p = 0.0642) and female condoms distribution (baseline mean = 0, follow-up mean = 2, p = 0.0628). Other improved indicators in intervention facilities were average number of Human Immunodeficiency Virus (HIV) tests for non-pregnant women (baseline mean = 55, follow-up 104, p = 0.0213); HIV tests for pregnant women (baseline mean = 40, follow-up mean = 119, p = 0.0067) and malaria tests (baseline mean = 43, follow-up mean = 380, p = 0.0174). Control facilities however performed better than intervention facilities in terms of general laboratory tests, voluntary counselling and testing, treatment of sexually transmitted infections, male child circumcisions and other minor surgical procedures. CONCLUSION: Community engagement in health has the potential of improving utilization of maternal and child health services. There is the need for multi-stakeholder dialogues on complementing existing quality improvement interventions with community engagement strategies.

Pre-referral Rectal Artesunate Treatment by Community-Based Treatment Providers in Ghana, Guinea-Bissau, Tanzania, and Uganda (Study 18): A Cluster-Randomized Trial.

BACKGROUND: If malaria patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate prior to hospital referral can prevent death and disability. The goal is to reduce death from malaria by having rectal artesunate treatment available and used. How best to do this remains unknown. METHODS: Villages remote from a health facility were randomized to different community-based treatment providers trained to provide rectal artesunate in Ghana, Guinea-Bissau, Tanzania, and Uganda. Prereferral rectal artesunate treatment was provided in 272 villages: 109 through community-based health workers (CHWs), 112 via trained mothers (MUMs), 25 via trained traditional healers (THs), and 26 through trained community-chosen personnel (COMs); episodes eligible for rectal artesunate were established through regular household surveys of febrile illnesses recording symptoms eligible for prereferral treatment. Differences in treatment coverage with rectal artesunate in children aged <5 years in MUM vs CHW (standard-of-care) villages were assessed using the odds ratio (OR); the predictive probability of treatment was derived from a logistic regression analysis, adjusting for heterogeneity between clusters (villages) using random effects. RESULTS: Over 19 months, 54 013 children had 102 504 febrile episodes, of which 32% (31 817 episodes) had symptoms eligible for prereferral therapy; 14% (4460) children received treatment. Episodes with altered consciousness, coma, or convulsions constituted 36.6% of all episodes in treated children. The overall OR of treatment between MUM vs CHW villages, adjusting for country, was 1.84 (95% confidence interval [CI], 1.20-2.83; P = .005). Adjusting for heterogeneity, this translated into a 1.67 higher average probability of a child being treated in MUM vs CHW villages. Referral compliance was 81% and significantly higher with CHWs vs MUMs: 87% vs 82% (risk ratio [RR], 1.1 [95% CI, 1.0-1.1]; P < .0001). There were more deaths in the TH cluster than elsewhere (RR, 2.7 [95% CI, 1.4-5.6]; P = .0040). CONCLUSIONS: Prereferral episodes were almost one-third of all febrile episodes. More than one-third of patients treated had convulsions, altered consciousness, or coma. Mothers were effective in treating patients, and achieved higher coverage than other providers. Treatment access was low. CLINICAL TRIALS REGISTRATION: ISRCTN58046240.

Factors influencing choice of care-seeking for acute fever comparing private chemical shops with health centres and hospitals in Ghana: a study using case-control methodology.

BACKGROUND: Several public health interventions to improve management of patients with fever are largely focused on the public sector yet a high proportion of patients seek care outside the formal healthcare sector. Few studies have provided information on the determinants of utilization of the private sector as against formal public sector. Understanding the differences between those who attend public and private health institutions, and their pathway to care, has significant practical implications. The chemical shop is an important source of care for acute fever in Ghana. METHODS: Case-control methodology was used to identify factors associated with seeking care for fever in the Dangme West District, Ghana. People presenting to health centres, or hospital outpatients, with a history or current fever were compared to counterparts from the same community with fever visiting a chemical shop. RESULTS: Of 600 patients, 150 each, were recruited from the district hospital and two health centres, respectively, and 300 controls from 51 chemical shops. Overall, 103 (17.2 %) patients tested slide positive for malaria. Specifically, 13.7 % (41/300) of chemical shop patients, 30.7 % (46/150) health centre and 10.7 % (16/150) hospital patients were slide positive. While it was the first option for care for 92.7 % (278/300) chemical shop patients, 42.7 % (64/150) of health centre patients first sought care from a chemical shop. More health centre patients (61.3 %; 92/150) presented with fever after more than 3 days than chemical shop patients (27.7 %; 83/300) [AOR = 0.19; p < 0.001 CI 0.11-0.30]. Although the hospital was the first option for 83.3 % (125/150) of hospital patients, most (63.3 %; 95/150) patients arrived there over 3 days after their symptoms begun. Proximity was significantly associated with utilization of each source of care. Education, but not other socioeconomic or demographic factors were significantly associated with chemical shop use. CONCLUSIONS: The private drug retail sector is the first option for the majority of patients, including poorer patients, with fever in this setting. Most patients with fever arrive at chemical shops with less delay and fewer signs of severity than at public health facilities. Improving chemical shop skills is a good opportunity to diagnose, treat or refer people with fever early.

Provider adherence to first antenatal care guidelines and risk of pregnancy complications in public sector facilities: a Ghanaian cohort study.

BACKGROUND: Guideline utilization aims at improvement in quality of care and better health outcomes. The objective of the current study was to determine the effect of provider complete adherence to the first antenatal care guidelines on the risk of maternal and neonatal complications in a low resource setting. METHODS: Women delivering in 11 health facilities in the Greater Accra region of Ghana were recruited into a cohort study. Their first antenatal visit records were reviewed to assess providers' adherence to the guidelines, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected. Participants were followed up for 6 weeks post-partum to complete data collection on outcomes. The incidence of maternal and neonatal complications was estimated. The effects of complete adherence on risk of maternal and neonatal complications were estimated and expressed as relative risks (RRs) with their 95% confidence intervals (CI) adjusted for a potential clustering effect of health facilities. RESULTS: Overall, 926 women were followed up to 6 weeks post-partum. Mean age (SD) of participants was 28.2 (5.4) years. Complete adherence to guidelines pertained to the care of 48.5% of women. Incidence of preterm deliveries, low birth weight, stillbirths and neonatal mortality were 5.3, 6.1, 0.4 and 1.4% respectively. Complete adherence to the guidelines decreased risk of any neonatal complication [0.72 (0.65-0.93); p = 0.01] and delivery complication [0.66 (0.44-0.99), p = 0.04]. CONCLUSION: Complete provider adherence to antenatal care guidelines at first antenatal visit influences delivery and neonatal outcomes. While there is the need to explore and understand explanatory mechanisms for these observations, programs that promote complete adherence to guidelines will improve the pregnancy outcomes.

Predicting stillbirth in a low resource setting.

BACKGROUND: Stillbirth is a major contributor to perinatal mortality and it is particularly common in low- and middle-income countries, where annually about three million stillbirths occur in the third trimester. This study aims to develop a prediction model for early detection of pregnancies at high risk of stillbirth. METHODS: This retrospective cohort study examined 6,573 pregnant women who delivered at Federal Medical Centre Bida, a tertiary level of healthcare in Nigeria from January 2010 to December 2013. Descriptive statistics were performed and missing data imputed. Multivariable logistic regression was applied to examine the associations between selected candidate predictors and stillbirth. Discrimination and calibration were used to assess the model's performance. The prediction model was validated internally and over-optimism was corrected. RESULTS: We developed a prediction model for stillbirth that comprised maternal comorbidity, place of residence, maternal occupation, parity, bleeding in pregnancy, and fetal presentation. As a secondary analysis, we extended the model by including fetal growth rate as a predictor, to examine how beneficial ultrasound parameters would be for the predictive performance of the model. After internal validation, both calibration and discriminative performance of both the basic and extended model were excellent (i.e. C-statistic basic model = 0.80 (95 % CI 0.78-0.83) and extended model = 0.82 (95 % CI 0.80-0.83)). CONCLUSION: We developed a simple but informative prediction model for early detection of pregnancies with a high risk of stillbirth for early intervention in a low resource setting. Future research should focus on external validation of the performance of this promising model.

Motivation and incentive preferences of community health officers in Ghana: an economic behavioral experiment approach.

BACKGROUND: Health worker shortage in rural areas is one of the biggest problems of the health sector in Ghana and many developing countries. This may be due to fewer incentives and support systems available to attract and retain health workers at the rural level. This study explored the willingness of community health officers (CHOs) to accept and hold rural and community job postings in Ghana. METHODS: A discrete choice experiment was used to estimate the motivation and incentive preferences of CHOs in Ghana. All CHOs working in three Health and Demographic Surveillance System sites in Ghana, 200 in total, were interviewed between December 2012 and January 2013. Respondents were asked to choose from choice sets of job preferences. Four mixed logit models were used for the estimation. The first model considered (a) only the main effect. The other models included interaction terms for (b) gender, (c) number of children under 5 in the household, and (d) years worked at the same community. Moreover, a choice probability simulation was performed. RESULTS: Mixed logit analyses of the data project a shorter time frame before study leave as the most important motivation for most CHOs (ß 2.03; 95 % CI 1.69 to 2.36). This is also confirmed by the largest simulated choice probability (29.1 %). The interaction effect of the number of children was significant for education allowance for children (ß 0.58; 95 % CI 0.24 to 0.93), salary increase (ß 0.35; 95 % CI 0.03 to 0.67), and housing provision (ß 0.16; 95 % CI -0.02 to 0.60). Male CHOs had a high affinity for early opportunity to go on study leave (ß 0.78; 95 % CI -0.06 to 1.62). CHOs who had worked at the same place for a long time greatly valued salary increase (ß 0.28; 95 % CI 0.09 to 0.47). CONCLUSIONS: To reduce health worker shortage in rural settings, policymakers could provide "needs-specific" motivational packages. They should include career development opportunities such as shorter period of work before study leave and financial policy in the form of salary increase to recruit and retain them.

Public health facility resource availability and provider adherence to first antenatal guidelines in a low resource setting in Accra, Ghana.

BACKGROUND: Lack of resources has been identified as a reason for non-adherence to clinical guidelines. Our aim was to describe public health facility resource availability in relation to provider adherence to first antenatal visit guidelines. METHODS: A cross-sectional analysis of the baseline data of a prospective cohort study on adherence to first antenatal care visit guidelines was carried out in 11 facilities in the Greater Accra Region of Ghana. Provider adherence was studied in relation to health facility resource availability such as antenatal workload for clinical staffs, routine antenatal drugs, laboratory testing, protocols, ambulance and equipment. RESULTS: Eleven facilities comprising 6 hospitals (54.5 %), 4 polyclinics (36.4 %) and 1 health center were randomly sampled. Complete provider adherence to first antenatal guidelines for all the 946 participants was 48.1 % (95 % CI: 41.8-54.2 %), varying significantly amongst the types of facilities, with highest rate in the polyclinics. Average antenatal workload per month per clinical staff member was higher in polyclinics compared to the hospitals. All facility laboratories were able to conduct routine antenatal tests. Most routine antenatal drugs were available in all facilities except magnesium sulphate and sulphadoxine-pyrimethamine which were lacking in some. Antenatal service protocols and equipment were also available in all facilities. CONCLUSION: Although antenatal workload varies across different facility types in the Greater Accra region, other health facility resources that support implementation of first antenatal care guidelines are equally available in all the facilities. These factors therefore do not adequately account for the low and varying proportions of complete adherence to guidelines across facility types. Providers should be continually engaged for a better understanding of the barriers to their adherence to these guidelines.