Economic and social determinants of health care utilization during the first wave of COVID-19 pandemic among adults in Ghana: a population-based cross-sectional study.

BACKGROUND: The COVID-19 pandemic had socioeconomic effects in Africa. This study assessed the social and economic determinants of healthcare utilization during the first wave of COVID-19 among adults in Ghana. METHODS: Information about individuals residing in Ghana was derived from a survey conducted across multiple countries, aiming to evaluate the impact of the COVID-19 pandemic on the mental health and overall well-being of adults aged 18 and above. The dependent variable for the study was healthcare utilization (categorized as low or high). The independent variables were economic (such as financial loss, job loss, diminished wages, investment/retirement setbacks, and non-refunded travel cancellations) and social (including food scarcity, loss of financial support sources, housing instability, challenges affording food, clothing, shelter, electricity, utilities, and increased caregiving responsibilities for partners) determinants of health. A multinomial logistic regression was conducted to identify factors associated with healthcare utilization after adjusting for confounders (age, gender, access to medical insurance, COVID-19 status, educational background, employment, and marital status of the participants). RESULTS: The analysis included 364 responses. Individuals who encountered a loss of financial support (AOR: 9.58; 95% CI: 3.44-26.73; p < 0.001), a decrease or loss of wages (AOR: 7.44, 95% CI: 3.05-18.16, p < 0.001), experienced investment or retirement setbacks (AOR: 10.69, 95% CI: 2.60-43.88, p = 0.001), and expressed concerns about potential food shortages (AOR: 6.85, 95% CI: 2.49-18.84, p < 0.001) exhibited significantly higher odds of low healthcare utilization during the initial phase of the pandemic. Contrastingly, participants facing challenges in paying for basic needs demonstrated lower odds of low healthcare utilization compared to those who found it easy to cover basic expenses (AOR: 0.19, 95% CI: 0.06-0.67, p = 0.001). CONCLUSION: Economic and social factors were associated with low healthcare utilization in Ghana during the first wave of the pandemic. Investment or retirement loss and financial support loss during the pandemic had the largest effect on healthcare utilization. Further research is needed to understand the connection between concerns about food shortages, welfare losses during pandemics and healthcare utilization during pandemics in Ghana.

Assessing health-seeking behaviour and malaria prevention practices among communities in four districts of the Volta Region of Ghana.

BACKGROUND: Malaria is a preventable disease that causes huge morbidity and mortality in malaria-endemic areas, especially among children and pregnant women. The malaria control programme focuses on the prevention of mosquito bites using insecticide-treated nets (ITNs) and mosquito aerosol sprays and coils, as well as prevention of severe disease among those infected through prompt and adequate treatment. The success of the malaria control programme in Ghana is dependent on the malaria prevention practices of people in the community. Therefore, this study evaluated the malaria prevention practices of participants in four districts of the Volta Region of Ghana. METHODS: This was a cross-sectional study conducted in Ketu South, Nkwanta South, Hohoe Municipality and Ho West districts of the Volta Region of Ghana. Questionnaire were administered to adults who consented to each household visited. Questions were asked on the socio-demographics and malaria prevention practices of the households. Data analysis was done using SPSS version 23 with frequency distribution done for all the variables. Pearson chi-square was used to determine the significant association between socio-demographics and malaria prevention practices, and Multivariate nominal logistic regression analysis was used to model the relationship between dichotomous dependent variables (ITN ownership and usage) and independent variables. RESULTS: Out of the 2493 participants; 2234 (89.6%) owned ITN and 1528 (68.4%) used ITN a night before this study, 768 (30.8%) used mosquito aerosol spray and 368 (15%) used mosquito coil. More females significantly owned ITN than males (1293, 92.4%, p ≤ 0.001). Participants from Ketu South had 1.5 times higher odds of owning an ITN compared to Ho West whose odds are not different from Nkwanta South or Hohoe (AOR, 1.56 [95% 1.09-2.22]; p = 0.01). In terms of ITN usage, participants in Nkwanta South were less likely to use ITN compared to the other districts; AOR, 0.434 [95% CI 0.31-0.62, p < 0.001]. Also, of the 668 participants that had a fever within the past 3 days, 268 (40.1%) visited a patent medicine store and 156 (23.4%) visited health facilities. CONCLUSION: There is high ownership of ITNs, but relatively low utilization among the community members. Education on malaria prevention practices should be intensified and continuous among the population of the Volta Region to ensure the success of malaria control in the region.

Pooled Multicenter Analysis of Cardiovascular Safety and Population Pharmacokinetic Properties of Piperaquine in African Patients with Uncomplicated Falciparum Malaria.

Dihydroartemisinin-piperaquine has shown excellent efficacy and tolerability in malaria treatment. However, concerns have been raised of potentially harmful cardiotoxic effects associated with piperaquine. The population pharmacokinetics and cardiac effects of piperaquine were evaluated in 1,000 patients, mostly children enrolled in a multicenter trial from 10 sites in Africa. A linear relationship described the QTc-prolonging effect of piperaquine, estimating a 5.90-ms mean QTc prolongation per 100-ng/ml increase in piperaquine concentration. The effect of piperaquine on absolute QTc interval estimated a mean maximum QTc interval of 456 ms (50% effective concentration of 209 ng/ml). Simulations from the pharmacokinetic-pharmacodynamic models predicted 1.98 to 2.46% risk of having QTc prolongation of >60 ms in all treatment settings. Although piperaquine administration resulted in QTc prolongation, no cardiovascular adverse events were found in these patients. Thus, the use of dihydroartemisinin-piperaquine should not be limited by this concern. (This study has been registered at ClinicalTrials.gov under identifier NCT02199951.).

Self-reported breast and cervical cancer screening practices among women in Ghana: predictive factors and reproductive health policy implications from the WHO study on global AGEing and adult health.

BACKGROUND: Breast and cervical cancers constitute the two leading causes of cancer deaths among women in Ghana. This study examined breast and cervical screening practices among adult and older women in Ghana. METHODS: Data from a population-based cross-sectional study with a sample of 2749 women were analyzed from the study on global AGEing and adult health conducted in Ghana between 2007 and 2008. Binary and multivariable ordinal logistic regression analyses were performed to assess the association between socio-demographic factors, breast and cervical screening practices. RESULTS: We found that 12.0 and 3.4% of adult women had ever had pelvic screening and mammography respectively. Also, 12.0% of adult women had either one of the screenings while only 1.8% had both screening practices. Age, ever schooled, ethnicity, income quantile, father's education, mother's employment and chronic disease status were associated with the uptake of both screening practices. CONCLUSION: Nationwide cancer awareness campaigns and education should target women to improve health seeking behaviours regarding cancer screening, diagnosis and treatment. Incorporating cancer screening as a benefit package under the National Health Insurance Scheme can reduce financial barriers for breast and cervical screening.

Community utilisation and satisfaction with the community-based health planning and services initiative in Ghana: a comparative study in two system learning districts of the CHPS+ project.

BACKGROUND: To strengthen the implementation of the Community-based Health Planning and Services (CHPS) programme which is Ghana's key primary health care delivery strategy, the CHPS+ Project was initiated in 2017. We examined community utilisation and satisfaction with CHPS services in two System Learning Districts (SLDs) of the project. METHODS: This community-based descriptive study was conducted in the Nkwanta South Municipality and Central Tongu District of Ghana. Data were collected from 1008 adults and analysed using frequency, percentage, chi-square, and logistic regression models. RESULTS: While the level of utilisation of CHPS services was 65.2%, satisfaction was 46.1%. Utilisation was 76.7% in Nkwanta South and 53.8% in Central Tongu. Satisfaction was also 55.2% in Nkwanta South and 37.1% in Central Tongu. Community members in Nkwanta South were more likely to utilise (AOR = 3.17, 95%CI = 3.98-9.76) and be satisfied (AOR = 2.77, 95%CI = 1.56-4.90) with CHPS services than those in Central Tongu. Females were more likely to utilise (AOR = 1.75, 95%CI = 1.27-2.39) but less likely to be satisfied [AOR = 0.47, 95%CI = 0.25-0.90] with CHPS services than males. Even though subscription to the National Health Insurance Scheme (NHIS) was just 46.3%, NHIS subscribers were more likely to utilise (AOR = 1.51, 95%CI = 1.22-2.03) and be satisfied (AOR = 1.45, 95%CI = 0.53-1.68) with CHPS services than non-subscribers. CONCLUSION: Ghana may not be able to achieve the goal of universal health coverage (UHC) by the year 2030 if current levels of utilisation and satisfaction with CHPS services persist. To accelerate progress towards the achievement of UHC with CHPS as the vehicle through which primary health care is delivered, there should be increased public education by the Ghana Health Service (GHS) on the CHPS concept to increase utilisation. Service quality should also be improved by the GHS and other stakeholders in Ghana's health industry to increase satisfaction with CHPS services. The GHS and the National Health Insurance Authority (NHIA) should also institute innovative strategies to increase subscription to the NHIS since it has implications for CHPS service utilisation and satisfaction.

Volunteer responsibilities, motivations and challenges in implementation of the community-based health planning and services (CHPS) initiative in Ghana: qualitative evidence from two systems learning districts of the CHPS+ project.

BACKGROUND: Community volunteerism is essential in the implementation of the Community-based Health Planning and Services (CHPS) in Ghana. We explored the responsibilities, motivations and challenges of community health management committees (CHMCs) in two CHPS+ Project districts in Ghana. METHODS: We used a qualitative approach to collect data through 4 focus group discussions among a purposive sample of community health volunteers in December 2018 and analysed them thematically. RESULTS: Community health management committees (CHMCs) were found to provide support in running the CHPS programme through resource mobilisation, monitoring of logistics, assisting the Community Health Officers (CHO) in the planning of CHPS activities, and the resolution of conflicts between CHOs and community members. The value, understanding and protective functions were the key motivations for serving on CHMCs. Financial, logistical and telecommunication challenges, lack of recognition and cooperation from community members, lack of motivation and lack of regular skill development training programmes for CHMC members who serve as traditional birth attendants (TBAs) were major challenges in CHMC volunteerism. CONCLUSION: Community health volunteerism needs to be prioritised by the Ghana Health Service and other health sector stakeholders to make it attractive for members to give off their best in the discharge of their responsibilities.

Extent of inappropriate prescription of artemisinin and anti-malarial injections to febrile outpatients, a cross-sectional analytic survey in the Greater Accra region, Ghana.

BACKGROUND: Febrile children seen in malaria hypo-endemic settings, such as the Greater Accra region (GAR) of Ghana are more likely to be suffering from a non-malarial febrile illness compared to those seen in hyper-endemic settings. The need for prescribers to rely on malaria test results to guide treatment practices in the GAR is even greater. This study was designed to investigate the factors associated with inappropriate artemisinin-based combination therapy (ACT) prescription. METHODS: A survey was conducted in six health facilities in the region in 2015. Treatment practices for febrile outpatient department (OPD) patients were obtained from their records. Prescribers were interviewed and availability of malaria commodities were assessed. The primary outcome was the proportion of patients prescribed ACT inappropriately. Independent variables included patient age and access to care, prescriber factors (professional category, work experience, access to guidelines, exposure to training). Data were analysed using Stata at 95% CI (α-value of 0.05). Frequencies and means were used to describe the characteristics of patients and prescribers. To identify the predictors of inappropriate ACT prescription, regression analyses were performed accounting for clustering. RESULTS: Overall, 2519 febrile OPD records were analysed; 45.6% (n = 1149) were younger than 5 years. Only 40.0% of patients were tested. The proportion of patients who were prescribed ACT inappropriately was 76.4% (n = 791 of 1036). Of these 791 patients, 141 (17.8%) were prescribed anti-malarial injections. Patients seen in facilities with rapid diagnostic tests (RDT) in stock were less likely to be prescribed ACT inappropriately, (AOR: 0.04, 95% CI 0.01-0.14, p < 0.001) compared to those seen in facilities with RDT stock-outs. Prescribers who had been trained on malaria case management within the past year were 4 times more likely to prescribe ACT inappropriately compared to those who had not been trained (AOR: 4.1; 95% CI (1.5-11.6); p < 0.01). Patients seen by prescribers who had been supervised were 8 times more likely to be  prescribed ACT inappropriately. CONCLUSION: Inappropriate ACT prescription to OPD febrile cases was high. Training and supervision of health workers appears not to be yielding the desired outcomes. Further research is needed to understand this observation.

Inclusion of men in maternal and safe motherhood services in inner-city communities in Ghana: evidence from a descriptive cross-sectional survey.

BACKGROUND: There has been a growing realisation of the need to enhance men's inclusion in maternal and safe motherhood services, especially in low-income settings. However, empirical studies on the extent to which men are involved in maternal and safe motherhood services especially in poor inner-city communities are lacking. The purpose of this study was to describe the level of men's inclusion in maternal and safe-motherhood services in inner-city communities in Ghana, and to assess the barriers of men's involvement. METHODS: A descriptive cross-sectional quantitative survey was conducted among a total of 256 randomly selected adult men in Chorkor, an inner-city fishing community in Accra, the capital city of Ghana. A multistage sampling strategy was used to select houses, households and respondents. Descriptive statistical techniques were used to analyse the data. Data analysis was done with the aid of SPSS version 20. RESULTS: Although almost all (96.6%) respondents knew the meaning of family planning, as high as 236(92.2%) have never accompanied their wives/partners to clinics to seek family planning services. Also 242(94.5%) and 251(98%) of men, respectively, knew the importance of antenatal services and supervised delivery. However, only 114(44.5%) of men ever accompanied their wives/partners to seek skilled delivery services. Men's involvement was hindered by barriers such as attitude of health workers, long waiting time and socio-cultural beliefs. CONCLUSION: The study revealed a gap between men's awareness of the importance of maternal and safe motherhood services and their actual involvement in accessing these services with their female partners. There is a need to create a supportive environment that encourages men to be involved in maternal health services to help reduce maternal/neonatal morbidity and mortality.

Treatment outcomes in a safety observational study of dihydroartemisinin/piperaquine (Eurartesim(®)) in the treatment of uncomplicated malaria at public health facilities in four African countries.

BACKGROUND: Dihydroartemisinin-piperaquine (DHA-PQ) is one of five WHO recommended artemisinin combination therapy (ACT) for the treatment of uncomplicated malaria. However, little was known on its post-registration safety and effectiveness in sub-Saharan Africa. DHA-PQ provides a long post-treatment prophylactic effect against re-infection; however, new infections have been reported within a few weeks of treatment, especially in children. This paper reports the clinical outcomes following administration of DHQ-PQ in real-life conditions in public health facilities in Burkina Faso, Ghana, Mozambique, and Tanzania for the treatment of confirmed uncomplicated malaria. METHODS: An observational, non-comparative, longitudinal study was conducted on 10,591 patients with confirmed uncomplicated malaria visiting public health facilities within seven health and demographic surveillance system sites in four African countries (Ghana, Tanzania, Burkina Faso, Mozambique) between September 2013 and April 2014. Patients were treated with DHA-PQ based on body weight and followed up for 28 days to assess the clinical outcome. A nested cohort of 1002 was intensely followed up. Clinical outcome was assessed using the proportion of patients who reported signs and symptoms of malaria after completing 3 days of treatment. RESULTS: A total of 11,097 patients were screened with 11,017 enrolled, 94 were lost to follow-up, 332 withdrew and 10,591 (96.1%) patients aged 6 months-85 years met protocol requirements for analysis. Females were 52.8 and 48.5% were <5 years of age. Malaria was diagnosed by microscopy and rapid diagnostic test in 69.8% and 29.9%, respectively. At day 28, the unadjusted risk of recurrent symptomatic parasitaemia was 0.5% (51/10,591). Most of the recurrent symptomatic malaria patients (76%) were children <5 years. The mean haemoglobin level decreased from 10.6 g/dl on day 1 to 10.2 g/dl on day 7. There was no significant renal impairment in the nested cohort during the first 7 days of follow-up with minimal non-clinically significant changes noted in the liver enzymes. CONCLUSION: DHA-PQ was effective and well tolerated in the treatment of uncomplicated malaria and provides an excellent alternative first-line ACT in sub-Saharan Africa.

The effect of dosing strategies on the therapeutic efficacy of artesunate-amodiaquine for uncomplicated malaria: a meta-analysis of individual patient data.

BACKGROUND: Artesunate-amodiaquine (AS-AQ) is one of the most widely used artemisinin-based combination therapies (ACTs) to treat uncomplicated Plasmodium falciparum malaria in Africa. We investigated the impact of different dosing strategies on the efficacy of this combination for the treatment of falciparum malaria. METHODS: Individual patient data from AS-AQ clinical trials were pooled using the WorldWide Antimalarial Resistance Network (WWARN) standardised methodology. Risk factors for treatment failure were identified using a Cox regression model with shared frailty across study sites. RESULTS: Forty-three studies representing 9,106 treatments from 1999-2012 were included in the analysis; 4,138 (45.4%) treatments were with a fixed dose combination with an AQ target dose of 30 mg/kg (FDC), 1,293 (14.2%) with a non-fixed dose combination with an AQ target dose of 25 mg/kg (loose NFDC-25), 2,418 (26.6%) with a non-fixed dose combination with an AQ target dose of 30 mg/kg (loose NFDC-30), and the remaining 1,257 (13.8%) with a co-blistered non-fixed dose combination with an AQ target dose of 30 mg/kg (co-blistered NFDC). The median dose of AQ administered was 32.1 mg/kg [IQR: 25.9-38.2], the highest dose being administered to patients treated with co-blistered NFDC (median = 35.3 mg/kg [IQR: 30.6-43.7]) and the lowest to those treated with loose NFDC-25 (median = 25.0 mg/kg [IQR: 22.7-25.0]). Patients treated with FDC received a median dose of 32.4 mg/kg [IQR: 27-39.0]. After adjusting for reinfections, the corrected antimalarial efficacy on day 28 after treatment was similar for co-blistered NFDC (97.9% [95% confidence interval (CI): 97.0-98.8%]) and FDC (98.1% [95% CI: 97.6%-98.5%]; P = 0.799), but significantly lower for the loose NFDC-25 (93.4% [95% CI: 91.9%-94.9%]), and loose NFDC-30 (95.0% [95% CI: 94.1%-95.9%]) (P < 0.001 for all comparisons). After controlling for age, AQ dose, baseline parasitemia and region; treatment with loose NFDC-25 was associated with a 3.5-fold greater risk of recrudescence by day 28 (adjusted hazard ratio, AHR = 3.51 [95% CI: 2.02-6.12], P < 0.001) compared to FDC, and treatment with loose NFDC-30 was associated with a higher risk of recrudescence at only three sites. CONCLUSIONS: There was substantial variation in the total dose of amodiaquine administered in different AS-AQ combination regimens. Fixed dose AS-AQ combinations ensure optimal dosing and provide higher antimalarial treatment efficacy than the loose individual tablets in all age categories.

Feasibility and cost of using mobile phones for capturing drug safety information in peri-urban settlement in Ghana: a prospective cohort study of patients with uncomplicated malaria.

BACKGROUND: The growing need to capture data on health and health events using faster and efficient means to enable prompt evidence-based decision-making is making the use of mobile phones for health an alternative means to capture anti-malarial drug safety data. This paper examined the feasibility and cost of using mobile phones vis-à-vis home visit to monitor adverse events (AEs) related to artemisinin-based combination therapy (ACT) for treatment of uncomplicated malaria in peri-urban Ghana. METHODS: A prospective, observational, cohort study conducted on 4270 patients prescribed ACT in 21 health facilities. The patients were actively followed by telephone or home visit to document AEs associated with anti-malarial drugs. Call duration and travel distances of each visit were recorded. Pre-paid call cards and fuel for motorbike travels were used to determine cost of conducting both follow-ups. Ms-Excel 2010 and STATA 11.2 were used for analysis. RESULTS: Of the 4270 patients recruited, 4124 (96.6 %) were successfully followed up and analyzed. Of these, 1126/4124 (27.3 %) were children under 5 years. Most 3790/4124 (91.9 %) follow-ups were done within 7 days of ACT intake. Overall, follow up by phone (2671/4124-64.8 %) was almost two times the number done by home visits (1453/4124-35.2 %). Duration of telephone calls ranged from 38 s to 53 min, costing between GH¢0.26 (0.20USD) and GH¢41.70 (27.USD). On the average, the calls lasted 3 min 51 s (SD = 3 min, 21 s) costing GH¢2.70 (0.77USD). Distance travelled for home visit ranged from 0.65 to 62 km costing GH¢0.29 (0.20USD) and GH¢279.00 (79.70USD). Thirty-two per cent (1128/4124) of patients reported AEs. In total, 1831 AE were reported, 1016/1831(55.5 %) by telephone and 815/1831 (44.5 %) by home visits. Events such as nausea, dizziness, diarrhoea, and vomiting were commonly reported. CONCLUSION: Majority of patients was successfully followed up by telephone and reported the most AEs. The cost of telephone interviewing was almost two times less than the cost of home visit. Telephone follow up should be considered for monitoring drug adverse events in low resource settings.

Prospective observational study to evaluate the clinical safety of the fixed-dose artemisinin-based combination Eurartesim® (dihydroartemisinin/piperaquine), in public health facilities in Burkina Faso, Mozambique, Ghana, and Tanzania.

BACKGROUND: The World Health Organization recommends artemisinin-based combination (ACT) for the treatment of uncomplicated malaria. Post-licensure safety data on newly registered ACT is critical for evaluating their risk/benefit profile in malaria endemic countries. The clinical safety of the newly registered combination, Eurartesim®, following its introduction into the public health system in four African countries was assessed. METHODS: This was a prospective, observational, open-label, non-comparative, longitudinal, multi-centre study using cohort event monitoring. Patients with confirmed malaria had their first dose observed and instructed on how to take the second and the third doses at home. Patients were contacted on day 5 ± 2 to assess adherence and adverse events (AEs). Spontaneous reporting of AEs was continued till day 28. A nested cohort who completed full treatment course had repeated electrocardiogram (ECG) measurements to assess effect on QTc interval. RESULTS: A total of 10,925 uncomplicated malaria patients were treated with Eurartesim®. Most patients,95% (10,359/10,925), did not report any adverse event following at least one dose of Eurartesim®. A total of 797 adverse events were reported. The most frequently reported, by system organ classification, were infections and infestations (3. 24%) and gastrointestinal disorders (1. 37%). In the nested cohort, no patient had QTcF > 500 ms prior to day 3 pre-dose 3. Three patients had QTcF > 500 ms (509 ms, 501 ms, 538 ms) three to four hours after intake of the last dose. All the QTcF values in the three patients had returned to <500 ms at the next scheduled ECG on day 7 (470 ms, 442 ms, 411 ms). On day 3 pre- and post-dose 3, 70 and 89 patients, respectively, had a QTcF increase of ≥ 60 ms compared to their baseline, but returned to nearly baseline values on day 7. CONCLUSION: Eurartesim® single course treatment for uncomplicated falciparum malaria is well-tolerated. QT interval prolongation above 500 ms may occur at a rate of three per 1,002 patients after the third dose with no association of any clinical symptoms. QT interval prolongation above 60 ms was detected in less than 10% of the patients without any clinical abnormalities.

An exploration of moral hazard behaviors under the national health insurance scheme in Northern Ghana: a qualitative study.

BACKGROUND: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 through an Act of Parliament (Act 650) as a strategy to improve financial access to quality basic health care services. Although attendance at health facilities has increased since the introduction of the NHIS, there have been media reports of widespread abuse of the NHIS by scheme operators, service providers and insured persons. The aim of the study was to document behaviors and practices of service providers and clients of the NHIS in the Kassena-Nankana District (KND) of Ghana that constitute moral hazards (abuse of the scheme) and identify strategies to minimize such behaviors. METHODS: Qualitative methods through 14 Focused Group Discussions (FGDs) and 5 individual in-depth interviews were conducted between December 2009 and January 2010. Thematic analysis was performed with the aid of QSR NVivo 8 software. RESULTS: Analysis of FGDs and in-depth interviews showed that community members, health providers and NHIS officers are aware of various behaviors and practices that constitute abuse of the scheme. Behaviors such as frequent and 'frivolous' visits to health facilities, impersonation, feigning sickness to collect drugs for non-insured persons, over charging for services provided to clients, charging clients for services not provided and over prescription were identified. Suggestions on how to minimize abuse of the NHIS offered by respondents included: reduction of premiums and registration fees, premium payments by installment, improvement in the picture quality of the membership cards, critical examination and verification of membership cards at health facilities, some ceiling on the number of times one can seek health care within a specified time period, and general education to change behaviors that abuse the scheme. CONCLUSION: Attention should be focused on addressing the identified moral hazard behaviors and pursue cost containment strategies to ensure the smooth operation of the scheme and enhance its sustainability.

Ownership and technical efficiency of hospitals: evidence from Ghana using data envelopment analysis.

BACKGROUND: In order to measure and analyse the technical efficiency of district hospitals in Ghana, the specific objectives of this study were to (a) estimate the relative technical and scale efficiency of government, mission, private and quasi-government district hospitals in Ghana in 2005; (b) estimate the magnitudes of output increases and/or input reductions that would have been required to make relatively inefficient hospitals more efficient; and (c) use Tobit regression analysis to estimate the impact of ownership on hospital efficiency. METHODS: In the first stage, we used data envelopment analysis (DEA) to estimate the efficiency of 128 hospitals comprising of 73 government hospitals, 42 mission hospitals, 7 quasi-government hospitals and 6 private hospitals. In the second stage, the estimated DEA efficiency scores are regressed against hospital ownership variable using a Tobit model. This was a retrospective study. RESULTS: In our DEA analysis, using the variable returns to scale model, out of 128 district hospitals, 31 (24.0%) were 100% efficient, 25 (19.5%) were very close to being efficient with efficiency scores ranging from 70% to 99.9% and 71 (56.2%) had efficiency scores below 50%. The lowest-performing hospitals had efficiency scores ranging from 21% to 30%.Quasi-government hospitals had the highest mean efficiency score (83.9%) followed by public hospitals (70.4%), mission hospitals (68.6%) and private hospitals (55.8%). However, public hospitals also got the lowest mean technical efficiency scores (27.4%), implying they have some of the most inefficient hospitals.Regarding regional performance, Northern region hospitals had the highest mean efficiency score (83.0%) and Volta Region hospitals had the lowest mean score (43.0%).From our Tobit regression, we found out that while quasi-government ownership is positively associated with hospital technical efficiency, private ownership negatively affects hospital efficiency. CONCLUSIONS: It would be prudent for policy-makers to examine the least efficient hospitals to correct widespread inefficiency. This would include reconsidering the number of hospitals and their distribution, improving efficiency and reducing duplication by closing or scaling down hospitals with efficiency scores below a certain threshold. For private hospitals with inefficiency related to large size, there is a need to break down such hospitals into manageable sizes.

The use of non-prescribed anti-malarial drugs for the treatment of malaria in the Bolgatanga municipality, northern Ghana.

BACKGROUND: The use of non-prescribed anti-malarial drugs can lead to treatment failure and development of drug-resistant parasites. This study investigated the use of non-prescribed anti-malarial drugs for the treatment of malaria in the Bolgatanga Municipality of northern Ghana. METHODS: This was a cross-sectional survey of a random sample of 392 adults and children with episodes of malaria in the last four weeks prior to the study. RESULTS: Majority of survey respondents 96.9% (380) knew the symptoms of malaria, 75% (294) knew the causes of malaria and 93.1% (365) were aware of mode of transmission of malaria. The use of non-prescribed anti-malarial drugs was 16.8% (95% CI: 13.3-21.0) among the respondents. About 56% (95% CI: 43.3-68.3) of the respondents who took non-prescribed anti-malaria drugs took non-artemisinin-based combination therapy (chloroquine, artemether, amodiaquine and sulphadoxine-pyrimethamine). Respondents above five years of age were more likely to use non-prescribed anti-malarial drugs than those below five years of age [P < 0.001]; respondents who knew the right source of malaria treatment were less likely to use non-prescribed anti-malarial drugs than those who did not [P = 0.002]. Respondents using non-prescribed anti-malarials were influenced by people around them who used non-prescribed anti-malarials. Thus, these respondents were more likely to use non-prescribed anti-malarials than those who were not influenced [P = 0.004]. CONCLUSIONS: Respondents' knowledge of malaria treatment and the influence of people using non-prescribed anti-malarials are factors affecting use of non-prescribed anti-malarials. The study concludes that there is high use of non-prescribed anti-malarial drugs in the municipality and most of the non-prescribed anti-malarias were non-artemisinin-based combination therapy. The study recommends education of the general public and chemical sellers to reduce the use of non-prescribe anti-malaria drugs.

Spatio-temporal malaria transmission patterns in Navrongo demographic surveillance site, northern Ghana.

BACKGROUND: The relationship between entomological measures of malaria transmission intensity and mortality remains uncertain. This is partly because transmission is heterogeneous even within small geographical areas. Studying this relationship requires high resolution, spatially structured, longitudinal entomological data. Geostatistical models that have been used to analyse the spatio-temporal heterogeneity have not considered the uncertainty in both sporozoite rate (SR) and mosquito density data. This study analysed data from Kassena-Nankana districts in northern Ghana to obtain small area estimates of malaria transmission rates allowing for this uncertainty. METHODS: Independent Bayesian geostatistical models for sporozoite rate and mosquito density were fitted to produce explicit entomological inoculation rate (EIR) estimates for small areas and short time periods, controlling for environmental factors. RESULTS: Mosquitoes were trapped from 2,803 unique locations for three years using mainly CDC light traps. Anopheles gambiae constituted 52%, the rest were Anopheles funestus. Mean biting rates for An. funestus and An. gambiae were 32 and 33 respectively. Most bites occurred in September, the wettest month. The sporozoite rates were higher in the dry periods of the last two years compared with the wet period. The annual EIR varied from 1,132 to 157 infective bites. Monthly EIR varied between zero and 388 infective bites. Spatial correlation for SR was lower than that of mosquito densities. CONCLUSION: This study confirms the presence of spatio-temporal heterogeneity in malaria transmission within a small geographical area. Spatial variance was stronger than temporal especially in the SR. The estimated EIR will be used in mortality analysis for the area.

Non-specific effects of diphtheria-tetanus-pertussis and measles vaccinations? An analysis of surveillance data from Navrongo, Ghana.

OBJECTIVES: Studies from low-income countries have suggested that routine vaccinations may have non-specific effects on child mortality; measles vaccine (MV) is associated with lower mortality and diphtheria-tetanus-pertussis (DTP) with relatively higher mortality. We used data from Navrongo, Ghana, to examine the impact of vaccinations on child mortality. METHODS: Vaccination status was assessed at the initiation of a trial of vitamin A supplementation and after 12 and 24 months of follow-up. Within the placebo group, we compared the mortality over the first 4 months and the full 2 years of follow-up for different vaccination status groups with different likelihoods of additional vaccinations during follow-up. The frequency of additional vaccinations was assessed among children whose vaccination card was seen at 12 and 24 months of follow-up. RESULTS: Among children with a vaccination card, more than 75% received missing DTP or MV during the first 12 months of follow-up, whereas only 25% received these vaccines among children with no vaccination card at enrollment. Children without a card at enrollment had a significant threefold higher mortality over the 2-year follow-up period than those fully vaccinated. The small group of children with DTP3-4 but no MV at enrollment had lower mortality than children without a card and had the same mortality as fully vaccinated children. In contrast, children with 1-2 DTP doses but no MV had a higher mortality during the first 4 months than children without a card [MRR = 1.65 (0.95, 2.87)]; compared with the fully vaccinated children, they had significantly higher mortality after 4 months [MRR = 2.38 (1.07, 5.30)] and after 2 years [MRR = 2.41 (1.41, 4.15)]. Children with 0-2 DTP doses at enrollment had higher mortality after 4 months (MRR = 1.67 (0.82, 3.43) and after 2 years [MRR = 1.85 (1.16, 2.95)] than children who had all three doses of DTP at enrollment. CONCLUSIONS: As hypothesised, DTP vaccination was associated with higher child mortality than measles vaccination. To optimise vaccination policies, routine vaccinations need to be evaluated in randomised trials measuring the impact on survival.

Socio-cultural factors associated with knowledge, attitudes and menstrual hygiene practices among Junior High School adolescent girls in the Kpando district of Ghana: A mixed method study.

BACKGROUND: Good menstrual hygiene practice is critical to the health of adolescent girls and women. In Ghanaian public schools, the School Health Education Program which includes menstrual health education has been instituted to equip adolescents with knowledge on menstruation and its related good hygiene practices. However, in most communities, menstruation is scarcely discussed openly due to mostly negative social and religious beliefs about menstruation. In this study, we examined socio-cultural factors associated with knowledge, attitudes and menstrual hygiene practices among Junior High School adolescent girls in the Kpando Municipality of Ghana. MATERIALS AND METHODS: A mixed method approach was employed with 480 respondents. A survey was conducted among 390 adolescent girls using interviewer-administered questionnaires to collect data on knowledge of menstruation and menstrual hygiene practices. Focus Group Discussions (FGDs) using a discussion guide were conducted among 90 respondents in groups of 9 members. The FGD was used to collect data on socio-cultural beliefs and practices regarding menstruation. Descriptive and inferential statistics and content analysis were used to analyze the quantitative and qualitative data respectively. RESULTS: Most (80%) of the study participants had good knowledge of menstruation. Also, most (82%) of the participants practiced good menstrual hygiene. Attending a public (AOR = 0.24, 95% CI = 0.12-0.48, p<0.001) and rural (AOR = 0.40, 95% CI = 0.21-0.75, p<0.01) school was significantly associated with reduced odds of practicing good menstrual hygiene. Good knowledge of menstruation was associated with increased odds of good hygiene practices (AOR = 4.31, 95% CI = 2.39-7.90, p<0.001). Qualitative results showed that teachers provided adolescents with more detailed biological information on menstruation than key informants (family members) did at menarche. However, both teachers and family members spoke positively of menstruation to adolescent girls. Social and religious beliefs indicate that menstruation is evil and unclean. Such beliefs influenced community members' attitudes towards adolescent girls and led to practices such as isolating menstruating girls and limiting their ability to interact and participate in certain community and religious activities. CONCLUSION: Despite the prominence of negative social and religious beliefs about menstruation, good menstrual hygiene practice was high among study participants. Knowledge of menstruation; place of residents; and type of school were the major factors associated with good menstrual hygiene practice. It is therefore, necessary to intensify the School Health Education Program in both rural and urban public and intensively involve private schools as well to ensure equal access to accurate information on menstruation and good menstrual hygiene practices among adolescent girls.

Assessment of the performance and challenges in the implementation of the test, treat and track (T3) strategy for malaria control among children under-five years in Ghana.

BACKGROUND: The World Health Organization recommended the Test, Treat and Track (T3) strategy for malaria control that, every suspected malaria case should be tested prior to treatment with Artemisinin-based combination therapy (ACT) and tracked. We assessed the performance and challenges in the implementation of T3 strategy among children under-five years in Volta and Oti Regions of Ghana. METHOD: A descriptive cross-sectional study was carried in 69 health facilities. Exit interviews were conducted for caregivers of children with fever using a semi-structured questionnaire. Clinicians were interviewed at the out-patient department in each facility. Descriptive statistics was conducted, Chi-square test and logistic regression were used to determine the associations between completion of T3 and independent variables. RESULTS: Most children, 818/900 (90.9%) were tested for malaria and 600/818 (73.4%) were positive for malaria parasitaemia using rapid diagnostic test. Of those testing positive for malaria, 530/600 (88.3%) received treatment with ACTs. Half, (109/218) of the children testing negative for malaria also received ACTs. Also, 67/82 (81.7%) of children not tested for malaria received ACTs. Only 408/900 (45.3%) children completed T3 with Community Health-based Planning Services (CHPS) compound having the highest completion rate 202/314 (64.3%). CHPS Compounds were 6.55 times more likely to complete T3 compared to the hospitals [(95% CI: 3.77, 11.35), p<0.001]. Health facilities with laboratory services were 2.08 times more likely to complete T3 [(95% CI: 1.55, 2.79), p<0.001] The main challenge identified was clinicians' perception that RDTs do not give accurate results. CONCLUSION: Testing fever cases for malaria before treatment and treating positive cases with ACTs was high. Treating negative cases and those not tested with ACTs was also high. Health facilities having laboratory services and facility being CHPS compounds were key predictors of completing T3. Clinician's not trusting RDT results can affect the T3 strategy in malaria control. Periodic training/monitoring is required to sustain adherence to the strategy.

Application of the hub and spokes model in improving access to cervical cancer screening in Ghana.

Objective: To examine the contribution of lower-level health facilities in increasing access to cervical cancer screening in the North Tongu District. Design: A descriptive cross-sectional study design was used. The Cervical Cancer Prevention and Training Centre (CCPTC) of the Catholic Hospital, Battor, served as the hub, and six health facilities (3 health centres and 3 CHPS compounds) served as the spokes. From April 2018 to September 2019, the well-resourced CCPTC trained 6 nurses at selected Community-based Health Planning and Services (CHPS) / Health Centres (HCs) (spokes) to provide cervical cancer screening services. The nurses, after training, started screening with VIA and HPV DNA testing. Participants: A total of 3,451women were screened by the trained nurses. This comprised 1,935 (56.1%) from the hub and 1,516 (43.9%) from the spokes. Main outcome measure: The detection of screen positives. Results: The screen positives were 19.4% (375/1935) at the hub and 4.9% (74/1516) at the spokes. Conclusion: We have demonstrated that a hub and spokes model for cervical cancer screening is possible in limited resource settings. Designating and resourcing a 'hub' that supports a network of 'spokes' could increase women's access to cervical cancer screening. This approach could create awareness about cervical cancer screening services and how they can be accessed. Funding: None declared.