Practice points for lymphoedema care in low- and middle- income countries developed by nominal group technique.

BACKGROUND: Lymphoedema is a common, distressing, and debilitating condition affecting more than 200 million people globally. There is a small body of evidence to guide lymphoedema care which underpins several lymphoedema clinical practice guidelines developed for high-income countries (HIC). Some of these recommendations are unlikely to be feasible in low-resource settings. AIM: To develop practice points for healthcare workers that optimise lymphoedema care in low- and middle-income countries (LMIC). METHODS: A nominal group technique (NGT) was undertaken to gain consensus on which content from HIC guidelines was important and feasible to include in practice points for LMIC, and other important advice or recommendations. Participants included experts, clinicians, and volunteers involved in lymphoedema care in LMIC. The NGT followed five key stages: silent 'ideas' generation, round-robin rationale, clarification, refinement and verification. The first, fourth and fifth stages were completed via email, and the second and third during a video meeting in order to generate a series of consensus based prevention, assessment, diagnosis, and management of lymphoedema in LMIC practice points. RESULTS: Of sixteen participants invited, ten members completed stage 1 of the NGT (ideas generation), of whom six contributed to stages 2 (round-robin) and 3 (clarification). All those who completed stage 1 also completed stages 4 (refinement) and 5 (verification). Practice points unanimously agreed on included Complex Decongestive Therapy (CDT) and good skin care, with management to be determined by lymphoedema stage. For podoconiosis-endemic areas, the use of socks and shoes was identified as very important in the prevention of non-filarial lymphoedema and other lymphoedema-causing conditions. Participants indicated that diagnosing lymphoedema using the lymphoscintigraphy and Indocyanine green (ICG) fluorescent lymphography was not possible due to unavailability and cost in LMIC. Surgical procedures for lymphoedema management were unanimously eliminated due to the unavailability of technology, limited workforce, and expensive cost in LMIC. CONCLUSION: The consensus-based practice points generated by this project provide healthcare workers with guidance on caring for people with lymphoedema in LMIC. Further development of workforce capacity is needed.

Pre-service healthcare professionals attitudes and self-efficacy towards individuals with intellectual disability in Ghana.

BACKGROUND: Intellectual disability (ID) involves impairment of general mental abilities, restricting the participation of individuals in conceptual, social and practical activities. Consequently, rehabilitation services are critical in efforts towards promoting the social and educational inclusion of persons with ID. However, the preparedness of health professionals in performing such a role depends on their perceptions of individuals with ID. Ajzen's theory of planned behaviour was used as theoretical framework to understand the relationship between the perceived attitude and self-efficacy of healthcare students towards persons with ID. METHOD: A cross-sectional survey was conducted among healthcare students (N = 328) in a Ghanaian university. The Community Living Attitude Scale for ID(CLAS-ID) and General Self-efficacy (GSE) Scale were employed to assess their attitudes and self-efficacy towards people with ID respectively. The data were analysed using SPSS and AMOS and were subjected to a t-test, ANOVA, correlation and regression. RESULT: The healthcare students were ambivalent about both self-efficacy and attitudes towards persons with ID, and there was correlation between attitudes and self-efficacy. Attitudes and self-efficacy also varied across the demographic characteristics of the respondents including age, having a relative with ID, level of study, religion, and programme of study. CONCLUSION: The study underscores the necessity for healthcare curriculum reform and provides corresponding recommendations. The study emphasizes the importance of enhancing healthcare students' understanding of ID, changing their attitudes, and bolstering their self-efficacy. This is crucial to foster positive attitudes, confidence in providing support to individuals with ID, and raising awareness within the broader community. To achieve this, health educators are encouraged to incorporate exposure to individuals with ID into healthcare students' training, along with more structured field experiences designed to increase their contact and interaction with individuals with ID. Such initiatives would enable students to better understand the uniqueness and requirements of individuals with ID.

Financial toxicity of cancer care in low- and middle-income countries: a systematic review and meta-analysis.

INTRODUCTION: The costs associated with cancer diagnosis, treatment and care present enormous financial toxicity. However, evidence of financial toxicity associated with cancer in low- and middle-income countries (LMICs) is scarce. AIM: To determine the prevalence, determinants and how financial toxicity has been measured among cancer patients in LMICs. METHODS: Four electronic databases were searched to identify studies of any design that reported financial toxicity among cancer patients in LMICs. Random-effects meta-analysis was used to derive the pooled prevalence of financial toxicity. Sub-group analyses were performed according to costs and determinants of financial toxicity. RESULTS: A total of 31 studies were included in this systematic review and meta-analysis. The pooled prevalence of objective financial toxicity was 56.96% (95% CI, 30.51, 106.32). In sub-group meta-analyses, the objective financial toxicity was higher among cancer patients with household size of more than four (1.17% [95% CI, 1.03, 1.32]; p = 0.02; I2 = 0%), multiple cycles of chemotherapy (1.94% [95% CI, 1.00, 3.75]; p = 0.05; I2 = 43%) and private health facilities (2.87% [95% CI, 1.89, 4.35]; p < 0.00001; I2 = 26%). Included studies hardly focused primarily on subjective measures of financial toxicity, such as material, behavioural and psychosocial. One study reported that 35.4% (n = 152 of 429) of cancer patients experienced high subjective financial toxicity. CONCLUSIONS: This study indicates that cancer diagnosis, treatment and care impose high financial toxicity on cancer patients in LMICs. Further rigorous research on cancer-related financial toxicity is needed.

Improving care for cancer-related and other forms of lymphoedema in low- and middle-income countries: a qualitative study.

BACKGROUND: Lymphoedema is a common, distressing and debilitating condition that can be related to cancer and its treatment or other conditions. Little is known about current practices in the diagnosis, assessment and management of lymphoedema in low- and middle-income countries (LMIC). AIM: To describe current practices in diagnosing, assessing and managing cancer-related and other forms of lymphoedema in LMIC, and related barriers and facilitators. METHODS: An exploratory-descriptive qualitative study. Participants were lymphoedema experts or health care professionals identified via published lymphoedema papers and professional organizations respectively. Sampling was purposive to ensure a diversity of perspectives and experience. Data collection was via semi-structured telephone/video interviews, and questions canvassed participants' experiences and perceptions of lymphoedema care in LMIC. Interviews were audio-recorded and transcribed verbatim. Analysis proceeded via inductive coding before mapping codes to the World Health Organization's (WHO) Innovative Care for Chronic Conditions Framework. RESULTS: Nineteen participants were interviewed, most of whom were physiotherapists (n = 11). Ten participants worked permanently in a LMIC, while the remainder were based in a high-income country (HIC) and had been involved in initiatives to improve lymphoedema care across multiple LMIC. Participants indicated that management of cancer versus non-cancer related lymphoedema was similar, but that pathways to care were more straight-forward for those receiving cancer care, leading to earlier diagnosis. Key facilitators to optimizing lymphoedema care in LMIC included: 1) joining forces to overcome lymphoedema-related stigma; 2) building workforce capabilities; and 3) partnering with patients and families to support self-management. Ideas for building workforce included developing health professional knowledge, supporting a commitment to multidisciplinary team care, and adapting HIC guidelines for lymphoedema care to LMIC. Partnering with patients and families to support self-management involved following the person-centred approach, establishing clear communication, promoting adherence to management, adapting management to available resources, and involving patient family and friends in lymphoedema care. CONCLUSION: Raising community and health professional awareness regarding lymphoedema and its management is a key first step to improving care outcomes. Resources for clinicians and patients/families developed for lymphoedema care in HIC need to be adapted for low resource settings.

Perceived self-efficacy of students and its influence on attitudes and knowledge about HIV/AIDS in Ghana.

Globally, human immunodeficiency syndrome (HIV) and its accompanying acquired immune deficiency syndrome (AIDS) have long been a public health threat due to the high death toll and the various effects on individuals and societies. Unfortunately, in developing countries such as Ghana, persons living with HIV/AIDS are victims of discrimination and rejection and are often excluded from social activities. Consequently, there is a need for mitigation strategies aimed at reducing the spread of the disease. Indeed, in human society, beliefs are fundamental to understanding people's intentions towards a given phenomenon. The purpose of this study was to assess students' perceived self-efficacy, attitude towards and knowledge about HIV/AIDS. In this study, Bandura's self-efficacy theory was used as a framework to assess the relationship between students' perceived self-efficacy, attitude towards and knowledge about HIV/AIDS. A total of 342 students of at least 15 years old were recruited from junior and senior high schools and a public university to complete two scales: the general self-efficacy and attitude and knowledge about HIV/AIDS scales. While there was a positive correlation among self-efficacy, attitude and knowledge, attitude and knowledge combined to predict self-efficacy. The limitations of the study, recommendations for future research and policy implications are discussed herein.

Living with HIV in Ghana: Disclosure of status and experiences of persons receiving antiretroviral therapy.

Barriers to treatment faced by people living with HIV (PLWH) have been well explored in the literature. Despite the importance of antiretroviral therapy (ART) in the treatment of HIV and prevention of AIDS, in the Ghanaian context only about 32% of infected persons have access to treatment. This underscores a need to understand the experiences of PLWH receiving ART to provide baseline information for policymakers' efforts to increase access to treatment. This study captures the voices of PLWH who were receiving ART in Ghana. A total of 35 participants receiving treatment in a hospital setting (11 males, 24 females; mean age 38 years, age range 21-60 years) took part in semi-structured face-to-face interviews to discuss their opinions about the cause of their HIV infection and its impact on their lives. The study found that the participants were susceptible to discrimination in their communities and at health care facilities. Some participants experienced marriage breakdowns, unemployment, social isolation, and were unable to perform everyday chores and responsibilities. Concerted efforts to address the barriers to treatment faced by PLWH are needed.

Prevalence and incidence of cancer related lymphedema in low and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Little is known about the prevalence and incidence in low and middle-income countries (LMICs) of secondary lymphedema due to cancer. The purpose of the study is to estimate the prevalence and incidence in LMICs of secondary lymphedema related to cancer and/or its treatment(s) and identify risk factors. METHOD: A systematic review and meta-analysis was conducted. Medline, EMBASE and CINAHL were searched in June 2019 for peer-reviewed articles that assessed prevalence and/or incidence of cancer-related lymphedema in LMICs. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Estimates of pooled prevalence and incidence estimates were calculated with 95% confidence intervals (CI), with sub-group analyses grouping studies according to: country of origin, study design, risk of bias, setting, treatment, and lymphedema site and measurement. Heterogeneity was measured using X2 and I2, with interpretation guided by the Cochrane Handbook for Systematic Reviews. RESULTS: Of 8766 articles, 36 were included. Most reported on arm lymphedema secondary to breast cancer treatment (n = 31), with the remainder reporting on leg lymphedema following gynecological cancer treatment (n = 5). Arm lymphedema was mostly measured by arm circumference (n = 16/31 studies), and leg lymphedema through self-report (n = 3/5 studies). Eight studies used more than one lymphedema measurement. Only two studies that measured prevalence of leg lymphedema could be included in a meta-analysis (pooled prevalence =10.0, 95% CI 7.0-13.0, I2 = 0%). The pooled prevalence of arm lymphedema was 27%, with considerable heterogeneity (95% CI 20.0-34.0, I2 = 94.69%, n = 13 studies). The pooled incidence for arm lymphedema was 21%, also with considerable heterogeneity (95% CI 15.0-26.0, I2 = 95.29%, n = 11 studies). There was evidence that higher body mass index (> 25) was associated with increased risk of arm lymphedema (OR: 1.98, 95% CI 1.45-2.70, I2 = 84.0%, P < 0.0001, n = 4 studies). CONCLUSION: Better understanding the factors that contribute to variability in cancer-related arm lymphedema in LMICs is an important first step to developing targeted interventions to improve quality of life. Standardising measurement of lymphedema globally and better reporting would enable comparison within the context of information about cancer treatments and lymphedema care.

Socio-economic and demographic determinants of female genital mutilation in sub-Saharan Africa: analysis of data from demographic and health surveys.

BACKGROUND: Owing to the severe repercussions associated with female genital mutilation (FGM) and its illicit status in many countries, the WHO, human rights organisations and governments of most sub-Saharan African countries have garnered concerted efforts to end the practice. This study examined the socioeconomic and demographic factors associated with FGM among women and their daughters in sub-Saharan Africa (SSA). METHODS: We used pooled data from current Demographic and Health Surveys (DHS) conducted between January 1, 2010 and December 31, 2018 in 12 countries in SSA. In this study, two different samples were considered. The first sample was made up of women aged 15-49 who responded to questions on whether they had undergone FGM. The second sample was made up of women aged 15-49 who had at least one daughter and responded to questions on whether their daughter(s) had undergone FGM. Both bivariate and multivariable analyses were performed using STATA version 13.0. RESULTS: The results showed that FGM among women and their daughters are significantly associated with household wealth index, with women in the richest wealth quintile (AOR, 0.51 CI 0.48-0.55) and their daughters (AOR, 0.64 CI 0.59-0.70) less likely to undergo FGM compared to those in the poorest wealth quintile. Across education, the odds of women and their daughters undergoing FGM decreased with increasing level of education as women with higher level of education had the lowest propensity of undergoing FGM (AOR, 0.62 CI 0.57-0.68) as well as their daughters (AOR, 0.32 CI 0.24-0.38). FGM among women and their daughters increased with age, with women aged 45-49 (AOR = 1.85, CI 1.73-1.99) and their daughters (AOR = 12.61, CI 10.86-14.64) more likely to undergo FGM. Whiles women in rural areas were less likely to undergo FGM (AOR = 0.81, CI 0.78-0.84), their daughters were more likely to undergo FGM (AOR = 1.09, CI 1.03-1.15). Married women (AOR = 1.67, CI 1.59-1.75) and their daughters (AOR = 8.24, CI 6.88-9.87) had the highest odds of undergoing FGM. CONCLUSION: Based on the findings, there is the need to implement multifaceted interventions such as advocacy and educational strategies like focus group discussions, peer teaching, mentor-mentee programmes at both national and community levels in countries in SSA where FGM is practiced. Other legislative instruments, women capacity-building (e.g., entrepreneurial training), media advocacy and community dialogue could help address the challenges associated with FGM. Future studies could consider the determinants of intention to discontinue or continue the practice using more accurate measures in countries identified with low to high FGM prevalence.

Rehabilitation and management outcomes of musculoskeletal injuries in a major referral hospital in Ghana.

BACKGROUND: The devastating impact of musculoskeletal injury (MSI) on human lives, the economy, and health services cannot be overemphasised. This has ignited discussion at international fora, as countries have been exhorted to prioritise management of MSI in order to maintain a healthy society. In the Ghanaian context, the knowledge base management of MSI is very low, which has provided the impetus to explore the management of MSI and the rehabilitation systems at a tertiary hospital in Ghana. METHODS: The study was a retrospective cross-sectional study, using the consecutive sampling method to recruit patients who were discharged after admission at the accident and emergency unit, as well as patients undergoing orthopaedic review, at the St. Joseph's Orthopaedic Hospital in Koforidua over a six-month period. RESULTS: A total of 269 musculoskeletal injury patients were recruited for the study. Half of the participants (51%) had had surgery in addition to pain medication. The overall mean recovery days were 26.81 ± 33.94 days, and the average disability days spent in the hospital were estimated at 16.54 ± 27.97 days. Individuals reported financial constraints as a major challenge to their full participation in rehabilitation. CONCLUSION: The findings of this study have implications for policymaking in Ghana. Particularly, the need to improve health facilities to enable MSI patients to seek treatment is highlighted. Also, the need to train health professionals who will be able to administer appropriate medication for MSI patients is discussed extensively.

The accessibility of health services to young deaf adolescents in Ghana.

Quality health care is a fundamental human right, which is enshrined in several international and domestic legislative instruments. In the Ghanaian context, there are reports that adults with disabilities encounter barriers in their attempts to access health care. However, scholarly attention is yet to explore the perspectives of young people and adolescents with disabilities. Therefore, this quantitative study was conducted from the perspective of critical disability studies, where young deaf adolescents (YDAs) were regarded as right bearers, and where they shared their perspectives on health accessibility decisions, barriers, and needs. Sixty-seven participants, made up of 44 male and 23 female students, took part in this quantitative study. Although many YDAs who took part in this study indicated that it was not difficult to access health facilities, they claim to have encountered communication barriers. Sign language interpreters in health facilities and introduction of sign language courses in health training institutions to improve communication between health professionals and deaf patients have been suggested as ways of addressing the barriers faced by YDAs in Ghana.

Causes, trends and severity of musculoskeletal injuries in Ghana.

BACKGROUND: Musculoskeletal [MSK] injuries are common causes of long-term pain and physical disability which affect many people worldwide. The economic and social impacts on the individual, society and national health systems are enormous making a matter of public health concern. Therefore, this study examined the causes and extent of MSK injuries in a referral hospital in Ghana. METHODS: A prospective study design with consecutive sampling method was used to recruit patients admitted at Trauma Unit as well as those receiving orthopaedic reviews at St. Joseph's Orthopaedic Hospital over a ten-month period. A structured questionnaire, Visual Analogue Scale (VAS) and Abbreviated Injury Scale (AIS) were used to collect data which were analysed descriptively using SPSS version 20. RESULTS: A total of 269 MSK injury patients were identified - of these, 137 (50.9%) males with an average age of 38 years (SD = 19.88). Nearly half (49.1%) of the injuries sustained were fractures, and common causes were vehicular crash 113 (42.0%) and fall 68 (25.3%). Body parts affected most were the knee (19.62) and the mean levels of pain for all injuries were 6.04 ± 2.44 and 3.25 (±1.50) respectively. CONCLUSION: Ghana needs a healthy population to steer its development trajectory. Policy makers in Ghana should pay attention to both preventive as well as management of MSK injuries, or else, most of the country's working class could live with lasting effects of injuries which may have significant impacts on the economy.

Guidelines Relevant to Diagnosis, Assessment, and Management of Lymphedema: A Systematic Review.

Significance: Lymphedema is a common, distressing and debilitating condition with various etiologies. Effective diagnosis, assessment, and management rely on evidence-based clinical practice guidelines ("guidelines"). This study aims to describe and compare international guidelines on lymphedema diagnosis, assessment, and management. Recent Advances: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and registered on the International Prospective Register of Systematic Reviews (PROSPERO). Systematic searches of electronic literature databases and the web were completed in December 2020 for lymphedema guidelines published in English since 2000. Quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE)-II reporting checklist. Synthesis took a narrative approach to compare guideline recommendations and associated levels of evidence. Critical Issues: This systematic review of 1,564 articles and 159 web pages yielded 14 guidelines. All guidelines were from high-income countries. Ten focused exclusively on lymphedema, and four on cancer. Most (n = 13) guidelines recommended an integrated medical, psychological assessment, and physical examination, with a limb volume measurement of >10% in the affected limb compared, confirming a lymphedema diagnosis. Recommended management involved Complex Decongestive Therapy (CDT) followed by self-management using skincare, self-lymphatic drainage massage, exercise, and compression. Future Directions: The underlying etiology of lymphedema appeared to make little difference to guideline recommendations regarding care. High-quality guidelines are available to guide lymphedema care. However, their suitability for low-resource settings is unclear.

Cross-national study of communal attitudes toward individuals with intellectual disabilities in sub-Saharan Africa: Cameroon vs. Ghana.

BACKGROUND: An intellectual disability (ID) is characterized by a deficit in the functional, cognitive, and adaptive skills required for independent living. Due to the low cognitive capabilities of individuals with IDs, they have become victims of marginalization, exclusion, and denial of their fundamental rights to basic necessities in societies around the world. While efforts are being made to improve service provision to and acceptance of individuals with disabilities, the extent of communal acceptance and recognition of these individuals as equal members of society remains underexplored in sub-Saharan African countries such as Cameroon and Ghana. OBJECTIVE: As attitudes toward individuals with IDs are pivotal in shaping national policies, this cross-national study examined communal attitudes toward persons with IDs in Cameroon and Ghana. METHOD: The Community Living Attitude Scale for Intellectual Disabilities (CLAS-ID) was used to collect data from a total of 741 university students in the two countries. The validity of the scale was assessed using confirmatory factor analysis and principal component analysis. The association between the background variables and attitudes was examined using t-tests, analysis of variance, linear regression, and two-way factor analysis. RESULTS: The results showed the validity of the CLAS-ID as a valid tool for measuring communal attitudes toward individuals with IDs in sub-Saharan Africa. The participants appeared ambivalent about attitude towards individuals with ID and other findings showed no association between attitudes and variables such as gender, relation, and contact with individuals with IDs. CONCLUSION: We discuss the need for innovative approaches aimed at changing attitudes toward individuals with IDs in sub-Saharan Africa as well as other study implications.

Understanding the linkages between male circumcision and multiple sexual partnership among married Ghanaian men: Analysis of data from the 2014 Ghana demographic and health survey.

INTRODUCTION: This current study sought to investigate the association between male circumcision status and engaging in multiple sexual partnership among men in Ghana. METHODS: Data from this study come from the men's file of the 2014 Ghana demographic and health survey. Both descriptive and inferential statistics were conducted among 1, 948 men and the level of statistical significance was pegged at p < 0.05. RESULTS: Results revealed that men who have been circumcised were more likely to engage in multiple sexual partnership (AOR = 3.36; CI:1.14-9.89), compared to those who have not been circumcised. With the covariates, men with primary level of education were more likely to have multiple sexual partners (AOR = 2.01; CI:1.10-3.69), compared to those with no education. With wealth status, men with richest (AOR = 2.27; CI:1.04-4.97), richer (AOR = 2.05; CI: 1.03-4.08), and middle wealth status (AOR = 1.83; CI:1.01-3.34) had the highest likelihood of having multiple sexual partners, compared to those with poorest wealth status. Conversely, men who professed the Islamic faith were less likely to engage in multiple sexual partnership (AOR = 0.58; CI: 0.36-0.94), compared to Christians. Similarly, men who resided in the Brong Ahafo (AOR = 0.51; CI: 0.26-0.99), Upper East (AOR = 0.41; CI:0.19-0.89), and Ashanti regions (AOR = 0.39; CI: 0.20-0.78) were less likely to engage in multiple sexual partnership. CONCLUSION: Based on the current findings, educational campaigns by stakeholder groups (e.g., Ministry of Health in collaboration with the National Commission on Civic Education, civil society, educational institutions) should sensitize the sexually active population at the community level to consistently use condoms, especially when they have multiple sexual partners, even when a man is circumcised. Campaign messages must clearly emphasize that male circumcision should not substitute precautionary measures such as delay in the onset of sexual relationships, averting penetrative sex, reducing the number of sexual partners as well as correct and consistent use of male or female condoms regardless one's social standing.

Screening for hearing loss among school going children.

Hearing loss results from a deviation in the perception of sounds in one's environment. A child may have hearing loss at a hearing threshold of ≥16 dB. Hearing loss is among the frequent disorders and affects lots of people globally. Hearing loss negatively affects many areas needed for classroom learning, language development, academic performance, and social development. These consequences can be reduced by early detection with appropriate audiological and speech therapy interventions. In developing countries like Ghana, there is no such laid down formal hearing screening programs for early detection of any signs of impairments. The present study was aimed at identifying the prevalence and causes of hearing loss among basic school children aged between 5 and 17 years at Freetown Basic School, Ho. The study sought to determine the causes and prevalence of hearing loss. Out of the 210 participants, 44 (21%) failed the audiometric screening test. Out of the 44 students who failed the audiometric screening test, 25 (11.9%) had hearing loss across all the test frequencies. Prevalence of hearing loss among basic school children was found to be 11.9%. This shows that hearing loss is not uncommon among school going children in the Ho Municipality. It was determined from the study that the prevailing causes of the hearing impairments may be attributable to abused use of ototoxic drugs and ear-aches and infections with majority of participants recording mild hearing loss. It can be concluded that hearing loss among school going children is preventable if appropriate measures are put in place.