Effect of a community-based primary healthcare programme on adverse pregnancy outcomes in Northern Ghana.

BACKGROUND: Pregnancy complications and adverse birth outcomes are among the major contributors to poor maternal and child health. Mothers in remote communities are at higher risk of adverse birth outcomes due to constraints in access to healthcare services. In Ghana, a community-based primary healthcare programme called the Ghana Essential Health Interventions Programme (GEHIP) was implemented in a rural region to help strengthen primary healthcare delivery and improve maternal and child healthcare services delivery. This study assessed the effect of this programme on adverse pregnancy outcomes. METHODS: Baseline and end-line survey data from reproductive-aged women from the GEHIP project were used in this analysis. Difference-in-differences and logistic regressions were used to examine the impact and equity effect of GEHIP on adverse pregnancy outcomes using household wealth index and maternal educational attainment as equity measures. The analysis involves the comparison of project baseline and end-line outcomes in intervention and non-intervention districts. RESULTS: The intervention had a significant effect in the reduction of adverse pregnancy outcomes (OR = 0.96, 95% CI:0.93-0.99). Although disadvantaged groups experience larger reductions in adverse pregnancy outcomes, controlling for covariates, there was no statistically significant equity effect of GEHIP on adverse pregnancy outcomes using either the household wealth index (OR = 0.99, 95% CI:0.85-1.16) or maternal educational attainment (OR = 0.68, 95% CI: 0.44-1.07) as equity measures. CONCLUSION: GEHIP's community-based healthcare programme reduced adverse pregnancy outcomes but no effect on relative equity was established. Factoring in approaches for targeting disadvantaged populations in the implementation of community-based health programs is crucial to ensuring equity in health outcomes.

Equity in maternal healthcare utilisation in Ghana: Do community-based primary health care programmes matter?

OBJECTIVE: Improving equity in the use of maternal health services in rural and remote communities is critical to meeting the Sustainable Development Goals targets on maternal and child health. This study examines the effect of a community-based primary healthcare strengthening programme on improving the utilisation of antenatal care (ANC4+), skilled delivery and health facility delivery. METHODS: Baseline and endline survey data of women of reproductive age for intervention and comparison districts were used to examine the equity impact of the Ghana Essential Health Interventions Programme (GEHIP) on antenatal care visits, skilled delivery and health facility delivery. The Wagstaff extension of the concentration index and regression models are used to assess equity effects of the programme on the utilisation of these services by wealth index and educational attainment. RESULTS: Coverage rates increased for both intervention and comparison districts, but were generally higher in intervention districts than comparison districts at endline (90% vs. 88% for ANC4+, 88% vs. 84% for skilled delivery and 93% vs. 88% for health facility delivery). Only ANC4+ showed a statistically significant positive treatment effect of the intervention (Dif-in-Dif = 0.071, p-value = 0.010). Equity analysis showed a mixed picture with intervention districts achieving significant equity improvement for skilled delivery for both wealth index and maternal education but only education equity for health facility delivery, while comparison districts achieved both wealth and education equity improvements for two indicators (health facility delivery and skilled delivery). No significant equity/inequity effects were found for ANC4+. CONCLUSION: Efforts to improve community-based healthcare access have been associated with improved coverage of maternal health services; however, the effect on improving equity in service coverage is mixed. Results indicate a need to extend community-based primary health care development beyond general improvements in access to ensure equity in the coverage of maternal and child health services that such programmes provide.

Impact of community health interventions on maternal and child health indicators in the upper east region of Ghana.

BACKGROUND: This paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training. METHODS: A mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus-post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process. RESULTS: After intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI). CONCLUSIONS: A pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance.

The Impact of Childhood Mortality on Fertility in Rural Tanzania: Evidence From the Ifakara and Rufiji Health and Demographic Surveillance Systems.

This manuscript examines the relationship between child mortality and subsequent fertility using longitudinal data on births and childhood deaths occurring among 15,291 Tanzanian mothers between 2000 and 2015. Generalized hazard regression analyses assess the effect of child loss on the hazard of conception, adjusting for child-level, mother-level, and contextual covariates. Results show that time to conception is most reduced if an index child dies during the subsequent birth interval, representing the combined effect of biological and volitional replacement. Deaths occurring during prior birth intervals were associated with accelerated time to conception during future intervals, consistent with hypothesized insurance effects of anticipating future child loss, but this effect is smaller than replacement effects. The analysis reveals that residence in areas of relatively high child mortality is associated with hastened parity progression, again consistent with the insurance hypothesis. Investigation of high-order interactions suggests that insurance effects tend to be greater in low-mortality communities, replacement effects tend to be stronger in high-mortality community contexts, and wealthier families tend to exhibit a weaker insurance response but a stronger replacement response to childhood mortality relative to poorer families.

It's a woman's thing: gender roles sustaining the practice of female genital mutilation among the Kassena-Nankana of northern Ghana.

INTRODUCTION: The practice of female genital mutilation (FGM/C) in traditional African societies is grounded in traditions of patriarchy that subjugate women. It is widely assumed that approaches to eradicating the practice must therefore focus on women's empowerment and changing gender roles. METHODS: This paper presents findings from a qualitative study of the FGM/C beliefs and opinions of men and women in Kassena-Nankana District of northern Ghana. Data are analyzed from 22 focus group panels of young women, young men, reproductive age women, and male social leaders. RESULTS: The social systemic influences on FGM/C decision-making are complex. Men represent exogenous sources of social influence on FGM/C decisions through their gender roles in the patriarchal system. As such, their FGM/C decision influence is more prominent for uncircumcised brides at the time of marriage than for FGM/C decisions concerning unmarried adolescents. Women in extended family compounds are relatively prominent as immediate sources of influence on FGM/C decision-making for both brides and adolescents. Circumcised women are the main source of social support for the practice, which they exercise through peer pressure in concert with co-wives. Junior wives entering a polygynous marriage or a large extended family are particularly vulnerable to this pressure. Men are less influential and more open to suggestions of eliminating the practice of FGM/C than women. CONCLUSION: Findings attest to the need for social research on ways to involve men in the promotion of FGM/C abandonment, building on their apparent openness to social change. Investigation is also needed on ways to marshal women's social networks for offsetting their extended family familial roles in sustaining FGM/C practices.

Adapting a nurse-led primary care initiative to cardiovascular disease control in Ghana: a qualitative study.

BACKGROUND: Cardiovascular Disease (CVD) is a growing cause of morbidity and mortality in Ghana, where rural primary health care is provided mainly by the Community-based Health Planning and Services (CHPS) initiative. CHPS locates nurses in community-level clinics for basic curative and preventive health services and provides home and outreach services. But CHPS currently lacks capacity to screen for or treat CVD and its risk factors. METHODS: In two rural districts, we conducted in-depth interviews with 21 nurses and 10 nurse supervisors to identify factors constraining or facilitating CVD screening and treatment. Audio recordings were transcribed, coded for content, and analyzed for key themes. RESULTS: Respondents emphasized three themes: community demand for CVD care; community access to CVD care; and provider capacity to render CVD care. Nurses and supervisors noted that community members were often unaware of CVD, despite high reported prevalence of risk factors. Community members were unable to travel for care or afford treatment once diagnosed. Nurses lacked relevant training and medications for treating conditions such as hypertension. Respondents recognized the importance of CVD care, expressed interest in acquiring further training, and emphasized the need to improve ancillary support for primary care operations. CONCLUSIONS: CHPS staff expressed multiple constraints to CVD care, but also cited actions to address them: CVD-focused training, provision of essential equipment and pharmaceuticals, community education campaigns, and referral and outreach transportation equipment. Results attest to the need for trial of these interventions to assess their impact on CVD risk factors such as hypertension, depression, and alcohol abuse.

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.

A qualitative appraisal of stakeholders' perspectives of a community-based primary health care program in rural Ghana.

BACKGROUND: The Ghana Community-based Health Planning and Services (CHPS) initiative is a national strategy for improving access to primary health care services for underserved communities. Following a successful trial in the North Eastern part of the country, CHPS was adopted as Ghana's flagship programme for achieving the Universal Health Coverage. Recent empirical evidence suggests, however, that scale-up of CHPS has not necessarily replicated the successes of the pilot study. This study examines the community's perspective of the performance of CHPS and how the scale up could potentially align with the original experimental study. METHOD: Applying a qualitative research methodology, this study analysed transcripts from 20 focus group discussions (FGDs) in four functional CHPS zones in separate districts of the Northern and Volta Regions of Ghana to understand the community's assessment of CHPS. The study employed the thematic analysis to explore the content of the CHPS service provision, delivery and how community members feel about the service. In addition, ordinary least regression model was applied in interpreting 126 scores consigned to CHPS by the study respondents. RESULTS: Two broad areas of consensus were observed: general favourable and general unfavourable thematic areas. Favourable themes were informed by approval, appreciation, hard work and recognition of excellent services. The unfavourable thematic area was informed by rudeness, extortion, inappropriate and unprofessional behaviour, lack of basic equipment and disappointments. The findings show that mothers of children under the age of five, adolescent girls without children, and community leaders generally expressed favourable perceptions of CHPS while fathers of children under the age of five and adolescent boys without children had unfavourable expressions about the CHPS program. A narrow focus on maternal and child health explains the demographic divide on the perception of CHPS. The study revealed wide disparities in actual CHPS deliverables and community expectations. CONCLUSIONS: A communication gap between health care providers and community members explains the high and unrealistic expectations of CHPS. Efforts to improve program acceptability and impact should address the need for more general outreach to social networks and men rather than a sole focus on facility-based maternal and child health care.

The impact of paid community health worker deployment on child survival: the connect randomized cluster trial in rural Tanzania.

BACKGROUND: This paper reports on a rigorously designed non-masked randomized cluster trial of the childhood survival impact of deploying paid community health workers to provide doorstep preventive, promotional, and curative antenatal, newborn, child, and reproductive health care in three rural Tanzanian districts. METHODS: From August, 2011 to June 2015 ongoing demographic surveillance on 380,000 individuals permitted monitoring of neonatal, infant and under-5 mortality rates for 50 randomly selected intervention and 51 comparison villages. Over the initial 2 years of the project, logistics and supply support systems were managed by the Ifakara Health Institute. In 2013, the experiment transitioned its operational design to logistical support managed by the Ministry of Health and Social Welfare with the goal of enhancing government operational ownership and utilization of results for policy. RESULTS: The baseline under 5 mortality rate was 81.3 deaths per 1000 live births with a 95% confidence interval (CI) of 77.2-85.6 in the intervention group and 82.7/1000 (95% CI 78.5-87.1) in the comparison group yielding an adjusted hazard ratio (HR) of 0.99 (95% CI 0.88-1.11, p = 0.867). After 4 years of implementation, the under 5 mortality rate was 73.2/1000 (95% CI 69.3-77.3) in the intervention group and 77.4/1000 (95% CI 73.8-81.1) in the comparison group (adjusted HR 0.95 [95% CI 0.86-1.07], p = 0.443). The intervention had no impact on neonatal mortality in either the first 2 years (HR 1.10 [95% CI 0.89-1.36], p = .392) or last 2 years of implementation (HR 0.98 [95% CI 0.74-1.30], p = .902). Although community health worker deployment significantly reduced mortality among children aged 1-59 months during the first 2 years of implementation (HR 0.85 [95% CI 0.76-0.96], p = 0.008), mortality among post neonates was the same in both groups in years three and four (HR 1.03 [95% CI 0.85-1.24], p = 0.772). Results adjusted for stock-out effects show that diminishing impact was associated with logistics system lapses that constrained worker access to essential drugs and increased post-neonatal mortality risk in the final two project years (HR 1.42 [95% CI 1·07-1·88], p = 0·015). CONCLUSIONS: Community health worker home-visit deployment had a null effect among neonates, and 2 years of initial impact among children over 1 month of age, but a null effect when tests were based on over 1 month of age data merged for all four project years. The atrophy of under age five effects arose because workers were not continuously equipped with essential medicines in years three and four. Analyses that controlled for stock-out effects suggest that adequately supplied workers had survival effects on children aged 1 to 59 months. TRIAL REGISTRATION: Registration for trial number ISRCTN96819844 was retrospectively completed on June 21, 2012.

The impact of adding community-based distribution of oral contraceptives and condoms to a cluster randomized primary health care intervention in rural Tanzania.

BACKGROUND: Efforts to expand access to family planning in rural Africa often focus on the deployment of community health agents (CHAs). METHODS: This paper reports on results of the impact of a randomized cluster trial of CHA deployment on contraceptive uptake among 3078 baseline and 2551 endline women of reproductive age residing in 50 intervention and 51 comparison villages in Tanzania. Qualitative data were collected to broaden understanding of method preference, reasons for choice, and factors that explain non-use. RESULTS: Regression difference-in-differences results show that doorstep provision of oral contraceptive pills and condoms was associated with a null effect on modern contraceptive uptake [p = 0.822; CI 0.857; 1.229]. Discussions suggest that expanding geographic access without efforts to improve spousal and social support, respect preference for injectable contraceptives, and address perceived risk of side-effects offset the benefits of adopting contraceptives provided by community-based services. CONCLUSIONS: The results of this study demonstrate that increasing access to services does not necessarily catalyze contraceptive use as method choice and spousal dynamics are key components of demand for contraception. Findings attest to the importance of strategies that respond to the climate of demand. TRIAL REGISTRATION: Controlled-Trial.com ISRCTN96819844. Retrospectively registered on 29.03.2012.

Contraceptive use intentions and unmet need for family planning among reproductive-aged women in the Upper East Region of Ghana.

BACKGROUND: Motivations for use of contraceptives vary across populations. While some women use contraceptives for birth spacing, others adopt contraception for stopping childbearing. As part of efforts to guide the policy framework to promote contraceptive utilization among women in Ghana, this paper examines the intentions for contraceptive use among reproductive-aged women in one of the most impoverished regions of Ghana. METHODS: This paper utilizes data collected in 2011 from seven districts in the Upper East Region of northern Ghana to examine whether women who reported the use of contraceptives did so for the purposes of stopping or spacing childbirth. A total of 5511 women were interviewed on various health and reproductive health related issues, including fertility and family planning behavior. Women were asked if they would like to have any more children (for those who already had children or those who were pregnant at the time of the survey). RESULTS: The prevalence of contraceptive use was low at 13%, while unmet need is highly pervasive and demand for family planning is predominantly for spacing future childbearing rather than for the purpose of stopping. Overall, about 31.7%of women not using contraceptives reported a need for spacing while 17.6% expressed a need for limiting. Thus, the latent demand for family planning is dominated by preferences for space rather than limiting childbearing. CONCLUSION: Results show that there is latent demand for family planning and therefore if family planning programs are appropriately implemented they can yield the desired impact.

Association between spousal violence and the incidence of acute respiratory infection among children under five: random-effect modelling using data from Nigeria and Bangladesh.

Acute respiratory infection (ARI) is a major cause of mortality among children under the age of five in developing countries. This paper examines Demographic and Health Survey (DHS) data on maternal recall of episodes of ARI in the contrasting settings of Bangladesh and Nigeria, where about 11.1% and 3.3% of under-5 children, respectively, are reported to have symptoms of ARI. The surveys found that about 25.6% of married Bangladeshi women and 15.4% of married Nigerian women reported experiencing spousal violence in the past year. To test the proposition that women's experience of intimate partner violence (IPV) is associated with adversity in their children, the study examined the relationship between spousal violence in the past year and childhood ARI in the past 2 weeks among children under the age of five in Bangladesh and Nigeria. Data were taken from a nationally representative sample of mothers aged 15-49 years obtained from the 2007 Bangladesh DHS and 2008 Nigeria DHS. Random-effects multiple logistic regression models were estimated to assess the association of maternal exposure to IPV with the incidence of ARI in the past 2 weeks among under-5 children after controlling for the potentially confounding effects of maternal social and demographic characteristics. Results from Nigeria suggest that the odds of ARI incidence among children of mothers who were IPV victims were almost two times higher than among their counterparts whose mothers had not experienced IPV (OR = 1.78; 95% CI: 1.45-2.19; p <0.001). Similarly, the odds for the children of Bangladeshi IPV victims were elevated one and half times (OR = 1.61; 95% CI: 1.21-2.14; p <0.001). The findings suggest that under-5 children suffer indirect health consequences of gender-based violence.

What do you do with success? The science of scaling up a health systems strengthening intervention in Ghana.

BACKGROUND: The completion of an implementation research project typically signals the end of research. In contrast, the Ghana Health Service has embraced a continuous process of evidence-based programming, wherein each research episode is followed by action and a new program of research that monitors and guides the utilization of lessons learned. This paper reviews the objectives and design of the most recent phase in this process, known as a National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+). METHODS: A mixed method evaluation strategy has been launched involving: i) baseline and endline randomized sample surveys with 247 clusters dispersed in 14 districts of the Northern and Volta Regions to assess the difference in difference effect of stepped wedge differential cluster exposure to CHPS+ activities on childhood survival, ii) a monitoring system to assess the association of changes in service system readiness with CHPS+ interventions, and iii) a program of qualitative systems appraisal to gauge stakeholder perceptions of systems problems, reactions to interventions, and perceptions of change. Integrated survey and monitoring data will permit multi-level longitudinal models of impact; longitudinal QSA data will provide data on the implementation process. DISCUSSION: A process of exchanges, team interaction, and catalytic financing has accelerated the expansion of community-based primary health care in Ghana's Upper East Region (UER). Using two Northern and two Volta Region districts, the UER systems learning concept will be transferred to counterpart districts where a program of team-based peer training will be instituted. A mixed method research system will be used to assess the impact of this transfer of innovation in collaboration with national and regional program management. This arrangement will generate embedded science that optimizes prospects that results will contribute to national CHPS reform policies and action.

Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries.

BACKGROUND: Achieving the United Nations Sustainable Development Goals in sub-Saharan Africa will require substantial improvements in the coverage and performance of primary health care delivery systems. Projects supported by the Doris Duke Charitable Foundation's (DDCF) African Health Initiative (AHI) created public-private-academic and community partnerships in five African countries to implement and evaluate district-level health system strengthening interventions. In this study, we captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions. METHODS: We used qualitative data from key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through AHI in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. RESULTS: Four major overarching lessons were highlighted. First, variety and inclusiveness of concerned key players (public, academic and private) are necessary to address complex health system issues at all levels. Second, a learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Third, inclusion of strong implementation science tools and strategies allowed informed and measured learning processes and efficient dissemination of best practices. Fourth, five to seven years was the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the PHIT partnership projects. CONCLUSION: The AHI experience has raised remaining, if not overlooked, challenges and potential solutions to address complex health systems strengthening intervention designs and implementation issues, while aiming to measurably accomplish sustainable positive change in dynamic, learning, and varied contexts.

Trends in socioeconomic disparities in a rapid under-five mortality transition: a longitudinal study in the United Republic of Tanzania.

OBJECTIVE: To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011. METHODS: We used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. We estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models. FINDINGS: The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births (95% confidence interval, CI: 119.3-147.4) in 2000 to 66.2 (95% CI: 59.0-74.3) in 2011 and in Rufiji from 118.4 deaths per 1000 live births (95% CI: 107.1-130.7) in 2000 to 76.2 (95% CI: 66.7-86.9) in 2011. Combining both sites, in 2000-2001, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 1.08-1.92) higher than for children of mothers who had received education beyond primary school and in 2010-2011, the HR was 1.18 (95% CI: 0.90-1.55). In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 (95% CI: 0.99-1.47) in 2000-2001 to 1.48 (95% CI: 1.15-1.89) in 2010-2011, while in Ifakara, disparities narrowed from 1.30 (95% CI: 1.09-1.55) to 1.15 (95% CI: 0.95-1.39) in the same period. CONCLUSION: While childhood survival has improved, mortality disparities still persist, suggesting a need for policies and programmes that both reduce child mortality and address socioeconomic disparities.

Respondents' Exposure to Community-based Services and Reported Fertility-Regulation Behavior: A Decade of Data from the Navrongo Community Health and Family Planning Project.

This article examines a decade of demographic surveillance data from rural northern Ghana linked with prospective panel survey data recording respondents' reported fertility-regulation behavior. We assess the impact of access to community-based contraceptive services, reported fertility-regulation behavior, and their interaction on the risk of a conception that results in a birth. The effects of service exposure differ by marital status. Reported use of any method to delay or avoid pregnancy appears to be more effective in reducing the risk of conception among the unmarried in areas offering community-based contraceptive services, relative to those in areas where services are facility based. Among both married and unmarried survey respondents who state that they are not using contraception, the risk of conception is lower among women in areas with community-based services than among women in communities without these services. The lower risk of conception among women who are receiving community-based services and who report that they are regulating their fertility may be due to increased efficacy and duration of fertility regulation. Among women who report that they are not regulating their fertility, under-reporting of contraceptive use in experimental areas is likely to play a role in explaining these findings.

Child Wanted and When? Fertility Intentions, Wantedness, and Child Survival in Rural Northern Ghana.

Panel survey data collected in rural northern Ghana asked women about the "wantedness" status of their children. Parous women were asked whether they wanted more children, while those who had never had a child were asked whether they wanted to have children in the future; those who said that they did not want to have any more children in the future were asked whether they wanted to become pregnant when they last became pregnant and, if so, whether they wanted to become pregnant at the time, or would have preferred to be pregnant earlier or later. This article analyzes longitudinal responses to these questions over a 10-year period. Birth and survival histories of subsequently born children linked to preference data permit investigation of the question: are "wanted" children more likely to survive than "unwanted" children? Hazard models are estimated to determine whether children born to women who indicated that they did not want to have a child at the time they did, or did not want any more children in the future, have a higher risk of mortality relative to children who were reported wanted at the time of pregnancy. Results show no significant differences in adjusted mortality risks between children who were reported to be wanted and those reported to be unwanted.

A qualitative analysis of the effect of a community-based primary health care programme on reproductive preferences and contraceptive use among the Kassena-Nankana of northern Ghana.

BACKGROUND: In 2000, Ghana launched the Community-based Health Planning and Services (CHPS) initiative to improve access to health and family planning services. This initiative was based in part on research, known as the Navrongo Project, conducted in the Kassena-Nankana district (KND) between 1994 to 2003 which demonstrated significant impact on fertility and child mortality. This paper examines current contraceptive perceptions in communities that were exposed to the Project's service models over the 1994 to 2003 period, and the post-experimental policies of the CHPS era. METHODS: Qualitative study was conducted in the KND of Ghana from June to September, 2012, by convening 8 male and 8 female FGD panels as well as 8 in-depth interviews of community leaders. Data collection was stratified by original experimental cell of the Navrongo Project to permit appraisal of social effects of contrasting experimental conditions. Inductive content analysis was performed with QSR Nvivo 10 to identify predominant themes. RESULTS: While findings show that exposure to community-based services was associated with enhanced approval of birth spacing and limitation, this view is grounded in perceptions that childhood survival has improved. Nonetheless, concerns were expressed about contraceptive side effects, prominently permanent sterility. Strategies for male outreach and community engagement originally introduced during the Navrongo Project have not been sustained with CHPS scale-up. The apparent atrophy of attention to the needs of men may explain the resistance of some males to the notion of female reproductive autonomy and the practice of some women to adopt contraception in secret. Despite this apparent programmatic dearth of male engagement, there is evidence to suggest that social impact of the original male engagement strategy persists in communities where male mobilization was combined with doorstep provision of family planning care during the Navrongo Project. CONCLUSION: Community-based services fostered attitudinal change towards family planning in a traditional sub-Saharan African setting. Sustained exposure to primary health care that have improved the survival of children has made the use of contraception more acceptable. Efforts should be embedded in primary health care programmes that address concerns about child survival while also consigning sustained priority to the information needs of men.

A time-use study of community health worker service activities in three rural districts of Tanzania (Rufiji, Ulanga and Kilombero).

BACKGROUND: Despite expanding international commitment to community health worker (CHW) deployment, little is known about how such workers actually use their time. This paper investigates this issue for paid CHWs named "Community Health Agents," which in Swahili is "Wawezeshaji wa Afya ya Jamii" ("WAJA"), trained for 9 months in primary health care service delivery and deployed to villages as subjects of a randomized trial of their impact on childhood survival in three rural districts of Tanzania. METHODS: To capture information about time allocation, 30 WAJA were observed during conventional working hours by research assistants for 5 days each over a period of 4 weeks. Results were presented in term of percentage time allocation for direct client treatment, documentation activities, health education, health promotion non-work-related activities and personal activities. RESULTS: During routine 8-h workdays, 59.5 % of WAJA time was spent on the provision of health services and other work-related activities. Overall, WAJA spent 27.8 % of their work on traveling from home to home, 33.1 % on health education, 9.9 % of health promotion and only 12.3 % on direct patient care. Other activities related to documentation (7.8 %) and supervision (2.5 %). CONCLUSIONS: Results reflect the pressing obligations of WAJA to engage in activities other than direct work responsibilities during routine work hours. Time spent on work activities is primarily used for health education, promotion, moving between households, and direct patient care. However, greater effort should be directed to strengthening supervisory systems and follow-up of challenges WAJAs facing in order to increase proportion of working hours.