A School Meals Program Implemented at Scale in Ghana Increases Height-for-Age during Midchildhood in Girls and in Children from Poor Households: A Cluster Randomized Trial.

BACKGROUND: Attention to nutrition during all phases of child and adolescent development is necessary to ensure healthy physical growth and to protect investments made earlier in life. Leveraging school meals programs as platforms to scale-up nutrition interventions is relevant as programs function in nearly every country in the world. OBJECTIVE: The aim of this study was to evaluate the impact of a large-scale school meals program in Ghana on school-age children's anthropometry indicators. METHODS: A longitudinal cluster randomized control trial was implemented across the 10 regions of Ghana, covering 2869 school-age children (aged 5-15 y). Communities were randomly assigned to 1) control group without intervention or 2) treatment group providing the reformed national school feeding program, providing 1 hot meal/d in public primary schools. Primary outcomes included height-for-age (HAZ) and BMI-for-age (BAZ) z scores. The analysis followed an intention-to-treat approach as per the published protocol for the study population and subgroup analysis by age (i.e., midchildhood for children 5-8 y and early adolescence for children 9-15 y), gender, poverty, and region of residence. We used single-difference ANCOVA with mixed-effect regression models to assess program impacts. RESULTS: School meals had no effect on HAZ and BAZ in children aged 5-15 y. However, in per-protocol subgroup analysis, the school feeding intervention improved HAZ in 5- to 8-y-old children (effect size: 0.12 SDs), in girls (effect size: 0.12 SDs)-particularly girls aged 5-8 y living in the northern regions, and in children aged 5-8 y in households living below the poverty line (effect size: 0.22 SDs). There was also evidence that the intervention influenced food allocation and sharing at the household level. CONCLUSION: School meals can provide a platform to scale-up nutrition interventions in the early primary school years, with important benefits accruing for more disadvantaged children. This trial was registered at www.isrctn.com as ISRCTN66918874.

Ghana's National Health insurance scheme and maternal and child health: a mixed methods study.

BACKGROUND: Ghana is attracting global attention for efforts to provide health insurance to all citizens through the National Health Insurance Scheme (NHIS). With the program's strong emphasis on maternal and child health, an expectation of the program is that members will have increased use of relevant services. METHODS: This paper uses qualitative and quantitative data from a baseline assessment for the Maternal and Newborn errals Evaluation from the Northern and Central Regions to describe women's experiences with the NHIS and to study associations between insurance and skilled facility delivery, antenatal care and early care-seeking for sick children. The assessment included a quantitative household survey (n = 1267 women), a quantitative community leader survey (n = 62), qualitative birth narratives with mothers (n = 20) and fathers (n = 18), key informant interviews with health care workers (n = 5) and focus groups (n = 3) with community leaders and stakeholders. The key independent variables for the quantitative analyses were health insurance coverage during the past three years (categorized as all three years, 1-2 years or no coverage) and health insurance during the exact time of pregnancy. RESULTS: Quantitative findings indicate that insurance coverage during the past three years and insurance during pregnancy were associated with greater use of facility delivery but not ANC. Respondents with insurance were also significantly more likely to indicate that an illness need not be severe for them to take a sick child for care. The NHIS does appear to enable pregnant women to access services and allow caregivers to seek care early for sick children, but both the quantitative and qualitative assessments also indicated that the poor and least educated were less likely to have insurance than their wealthier and more educated counterparts. Findings from the qualitative interviews uncovered specific challenges women faced regarding registration for the NHIS and other barriers such lack of understanding of who and what services were covered for free. CONCLUSION: Efforts should be undertaken so all individuals understand the NHIS policy including who is eligible for free services and what services are covered. Increasing access to health insurance will enable Ghana to further improve maternal and child health outcomes.

Factors influencing householders' access to improved water in low-income urban areas of Accra, Ghana.

We analysed householders' access to improved water for drinking and other domestic uses in five selected low-income urban areas of Accra, Ghana using a survey of 1,500 households. Our definitions of improved water were different from those suggested by the World Health Organization (WHO). The results revealed that only 4.4% of the respondents had access to improved drinking water compared to 40.7% using the WHO definition. However, 88.7% of respondents had access to improved water for domestic uses compared to 98.3% using the WHO definition. Using logistic regression analysis, we established that the significant determinant of householders' access to improved drinking water was income. However, for access to improved water for other domestic uses, the significant factors were education, income and location of the household. Compared to migrants, indigenous people and people from mixed areas were less likely to have access to improved water for other domestic purposes. For the analysis using the WHO definitions, most of the independent variables were not statistically significant in determining householders' access, and those variables that were significant generated parameter estimates inconsistent with evidence from the literature and anecdotal evidence from officials of public health and water supply companies in Ghana.

Poor mental health in Ghana: who is at risk?

BACKGROUND: Poor mental health is a leading cause of disability worldwide with considerable negative impacts, particularly in low-income countries. Nevertheless, empirical evidence on its national prevalence in low-income countries, particularly in Africa, is limited. Additionally, researchers and policy makers are now calling for empirical investigations of the association between empowerment and poor mental health among women. We therefore sought to estimate the national prevalence of poor mental health in Ghana, explore its correlates on a national level, and examine associations between empowerment and poor mental health among women. METHODS: We conducted a cross-sectional analysis using data from a nationally representative survey conducted in Ghana in 2009-2010. Interviews were conducted face-to-face with participants (N = 9,524 for overall sample; n = 3,007 for women in relationships). We used the Kessler Psychological Distress Scale (K10) to measure psychological distress and assessed women's attitudes about their roles in decision-making, attitudes towards intimate partner violence, partner control, and partner abuse. We used weighted multivariable multinomial regression models to determine the factors independently associated with experiencing psychological distress for our overall sample and for women in relationships. RESULTS: Overall, 18.7% of the sample reported either moderate (11.7%) or severe (7.0%) psychological distress. The prevalence of psychological distress was higher among women than men. Overall, the prevalence of psychological distress differed by gender, marital status, education, wealth, region, health and religion, but not by age or urban/rural location. Women who reported having experienced physical abuse, increased partner control, and who were more accepting of women's disempowerment had greater likelihoods of psychological distress (P-values < 0.05). CONCLUSIONS: Psychological distress is substantial among both men and women in Ghana, with nearly 20% having moderate or severe psychological distress, an estimate higher than those found among South African (16%) or Australian (11%) adults. Women who are disempowered in the context of intimate relationships may be particularly vulnerable to psychological distress. Results identify populations to be targeted by interventions aiming to improve mental health.

Psychological distress in Ghana: associations with employment and lost productivity.

OBJECTIVES: Mental health disorders account for 13% of the global burden of disease, a burden that low-income countries are generally ill-equipped to handle. Research evaluating the association between mental health and employment in low-income countries, particularly in sub-Saharan Africa, is limited. We address this gap by examining the association between employment and psychological distress. METHODS: We analyzed data from the Ghana Socioeconomic Panel Survey using logistic regression (N = 5,391 adults). In multivariable analysis, we estimated the association between employment status and psychological distress, adjusted for covariates. We calculated lost productivity from unemployment and from excess absence from work that respondents reported was because of their feelings of psychological distress. FINDINGS: Approximately 21% of adults surveyed had moderate or severe psychological distress. Increased psychological distress was associated with increased odds of being unemployed. Men and women with moderate versus mild or no psychological distress had more than twice the odds of being unemployed. The association of severe versus mild or no distress with unemployment differed significantly by sex (P-value for interaction 0.004). Among men, the adjusted OR was 12.4 (95% CI: 7.2, 21.3), whereas the association was much smaller for women (adjusted OR = 3.8, 95% CI: 2.5, 6.0). Extrapolating these figures to the country, the lost productivity associated with moderate or severe distress translates to approximately 7% of the gross domestic product of Ghana. CONCLUSIONS: Psychological distress is strongly associated with unemployment in Ghana. The findings underscore the importance of addressing mental health issues, particularly in low-income countries.