Termination of pregnancy data completeness and feasibility in population-based surveys: EN-INDEPTH study.

BACKGROUND: Termination of pregnancy (TOP) is a common cause of maternal morbidity and mortality in low- and middle-income countries. Population-based surveys are the major data source for TOP data in LMICs but are known to have shortcomings that require improving. The EN-INDEPTH multi-country survey employed a full pregnancy history approach with roster and new questions on TOP and Menstrual Restoration. This mixed methods paper assesses the completeness of responses to questions eliciting TOP information from respondents and reports on practices, barriers, and facilitators to TOP reporting. METHODS: The EN-INDEPTH study was a population-based cross-sectional study. The Full Pregnancy History arm of the study surveyed 34,371 women of reproductive age between 2017 and 2018 in five Health and Demographic Surveillance System (HDSS) sites of the INDEPTH network: Bandim, Guinea-Bissau; Dabat, Ethiopia; IgangaMayuge, Uganda; Kintampo, Ghana; and Matlab, Bangladesh. Completeness and time spent in answering TOP questions were evaluated using simple tabulations and summary statistics. Exact binomial 95% confidence intervals were computed for TOP rates and ratios. Twenty-eight (28) focus group discussions were undertaken and analysed thematically. RESULTS: Completeness of responses regarding TOP was between 90.3 and 100.0% for all question types. The new questions elicited between 2.0% (1.0-3.4), 15.5% (13.9-17.3), and 11.5% (8.8-14.7) lifetime TOP cases over the roster questions from Dabat, Ethiopia; Matlab, Bangladesh; and Kintampo, Ghana, respectively. The median response time on the roster TOP questions was below 1.3 minutes in all sites. Qualitative results revealed that TOP was frequently stigmatised and perceived as immoral, inhumane, and shameful. Hence, it was kept secret rendering it difficult and uncomfortable to report. Miscarriages were perceived to be natural, being easier to report than TOP. Interviewer techniques, which were perceived to facilitate TOP disclosure, included cultural competence, knowledge of contextually appropriate terms for TOP, adaptation to interviewee's individual circumstances, being non-judgmental, speaking a common language, and providing detailed informed consent. CONCLUSIONS: Survey roster questions may under-represent true TOP rates, since the new questions elicited responses from women who had not disclosed TOP in the roster questions. Further research is recommended particularly into standardised training and approaches to improving interview context and techniques to facilitate TOP reporting in surveys.

Open defecation and attainment of Sustainable Development Goal Six: evidence from Kintampo Surveillance System, Ghana.

Objective: This study examined whether the open-defecation (OD) free target is achievable by 2030. Design: Longitudinal study. Setting: Seven sub-Districts of Kintampo North Municipal, and five sub-Districts of Kintampo South District. Data source: Kintampo health and demographic surveillance system. Participants: Data was collected from household heads or their representatives over a 12-year period from 2005 to 2016. Main outcome: Open-defecation and attainment of OD free by 2030. Results: In an exploratory analysis, the correlation between the total number of households, year, and total number of OD households was obtained. The average percentage yearly increase or decrease in OD was computed and used to project the percentage of OD for the years 2020, 2025 and 2030. In addition, geo-spatial technology was used to visualize variability in OD across the twelve sub-Districts. The results showed that the OD free target is not achievable in 2030 or even if the current trend continues. In 2016, 44.2 per cent of the 31,571 households defecated openly. In six out of the 12 sub-Districts, more than half of the households openly defecated. Four out of these six sub-Districts were in the Kintampo North Municipality. Conclusion: The 2030 OD free target is not achievable in the Kintampo districts of Ghana if the current trend continues. Funding: Kintampo Health Research Centre funded this work.

The Influence of Apparent Temperature on Mortality in the Kintampo Health and Demographic Surveillance Area in the Middle Belt of Ghana: A Retrospective Time-Series Analysis.

Globally, studies have shown that diurnal changes in weather conditions and extreme weather events have a profound effect on mortality. Here, we assessed the effect of apparent temperature on all-cause mortality and the modifying effect of sex on the apparent temperature-mortality relationship using mortality and weather data archived over an eleven-year period. An overdispersed Poisson regression and distributed lag nonlinear models were used for this analysis. With these models, we analysed the relative risk of mortality at different temperature values over a 10-day lag period. By and large, we observed a nonlinear association between mean daily apparent temperature and all-cause mortality. An assessment of different temperature values over a 10-day lag period showed an increased risk of death at the lowest apparent temperature (18°C) from lag 2 to 4 with the highest relative risk of mortality (RR = 1.61, 95% CI: 1.2, 2.15, p value = 0.001) occurring three days after exposure. The relative risk of death also varied between males (RR = 0.31, 95% CI: 0.10, 0.94) and females (RR = 4.88, 95% CI: 1.40, 16.99) by apparent temperature and lag. On the whole, males are sensitive to both temperature extremes whilst females are more vulnerable to low temperature-related mortality. Accordingly, our findings could inform efforts at reducing temperature-related mortality in this context and other settings with similar environmental and demographic characteristics.

Potential gains in reproductive-aged life expectancy if maternal mortality were eradicated from the Kintampo districts of Central Ghana.

BACKGROUND: Almost 99% of pregnancy or childbirth-related complications globally is estimated to occur in developing regions. Yet, little is known about the demographic impact of maternal causes of death (COD) in low-and middle-income countries. Assuming that critical interventions were implemented such that maternal mortality is eradicated as a major cause of death, how would it translate to improved longevity for reproductive-aged women in the Kintampo districts of Ghana? METHODS: The study used longitudinal health and demographic surveillance data from the Kintampo districts to assess the effect of hypothetically eradicating maternal COD on reproductive-aged life expectancy by applying multiple decrement and associated single decrement life table techniques. RESULTS: According to the results, on the average, women would have lived an additional 4.4 years in their reproductive age if maternal mortality were eradicated as a cause of death, rising from an average of 28.7 years lived during the 2005-2014 period to 33.1 years assuming that maternal mortality was eradicated. The age patterns of maternal-related mortality and all-cause mortality depict that the maternal-related mortality is different from the all-cause mortality for women of reproductive age. CONCLUSION: This observation suggests that other COD are competing with maternal mortality among the WRA in the study area and during the study period.

Intermittent preventive treatment of pregnant women in Kintampo area of Ghana with sulphadoxine-pyrimethamine (SP): trends spanning 2011 and 2015.

OBJECTIVE: In Ghana, intermittent preventive treatment during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) is recommended for the prevention of malaria-related adverse outcomes. This study demonstrates the coverage of IPTp-SP use among pregnant women over a period (2011-2015) and the impact of various sociodemographic groups on the uptake of IPTp-SP. DESIGN: Retrospective analysis using data from all pregnant women in the Kintampo Health and Demographic Surveillance System area on the uptake of IPTp-SP. SETTING: Kintampo North Municipality and Kintampo South District of Ghana. PARTICIPANTS: All pregnant women in the Kintampo Health and Demographic Surveillance System area. PRIMARY AND SECONDARY OUTCOME MEASURES: The number of doses of IPTp-SP taken by pregnant women were examined. Logistic regression was used to assess the determinant of uptake of IPTp-SP while adjusting for within-subject correlation from women with multiple pregnancies. RESULTS: Data from 2011 to 2015 with a total of 17 484 pregnant women were used. The coverage of the recommended three or more doses of IPTp-SP among all pregnant women was 40.6%, 44.0%, 45.9%, 20.9% and 32.4% in 2011, 2012, 2013, 2014 and 2015, respectively. In the adjusted analysis, age, household size, education, religion, number of antenatal care visits, ethnicity, marital status, wealth index and place of residence were significantly associated with the uptake of three or more doses of IPTp-SP. Having middle school education or higher, aged 20 years and above, visiting antenatal care five times or more (OR 2.83, 95% CI 2.64 to 3.03), being married (OR 1.10, 95% CI 1.02 to 1.19) and those in higher wealth quintiles were significantly more likely to take three or more doses of IPTp-SP. CONCLUSION: The uptake of the recommended three or more doses of IPTp-SP is low in the study area. We recommend a community-based approach to identify women during early pregnancy and to administer IPTp-SP.

CHILDHOOD RESPIRATORY MORBIDITY AND COOKING PRACTICES AMONG HOUSEHOLDS IN A PREDOMINANTLY RURAL AREA OF GHANA.

BACKGROUND: Household air pollution is a leading risk factor for respiratory morbidity and mortality in developing countries where biomass fuel is mainly used for cooking. MATERIALS AND METHOD: A household cross-sectional survey was conducted in a predominantly rural area of Ghana in 2007 to determine the prevalence of respiratory symptoms and their associated risk factors. Household cooking practices were also assessed as part of the survey. RESULTS: Household heads of twelve thousand, three hundred and thirty-three households were interviewed. Fifty-seven percent (7006/12333) of these households had at least one child less than five years of age. The prevalence of symptoms of acute lower respiratory infections (ALRI) was 13.7% (n= 957, 95% CI 12.8 - 15.5%). A majority (77.8%, 95% CI, 77.7 - 78.5%) of households used wood as their primary fuel. Majority of respondents who used wood as their primary fuel obtained them by gathering wood from their neighborhood (95.6%, 9177/9595) and used a 3-stone local stove for cooking (94.9%, 9101/9595). In a randomly selected subset of respondents, females were the persons who mostly gathered firewood from the fields (90.8%, 296/326) and did the cooking (94.8%, 384/406) for the household. CONCLUSION: Symptoms of ALRI reported by caregivers is high in the Kintampo area of Ghana where biomass fuel use is also high. There is the need to initiate interventions that use improved cook stoves and to test the health benefits of such interventions.

Childhood respiratory morbidity and cooking practices among households in a predominantly rural area of Ghana

Background: Household air pollution is a leading risk factor for respiratory morbidity and mortality in developing countries where biomass fuel is mainly used for cooking. Materials and Method: A household cross-sectional survey was conducted in a predominantly rural area of Ghana in 2007 to determine the prevalence of respiratory symptoms and their associated risk factors. Household cooking practices were also assessed as part of the survey. Results: Household heads of twelve thousand; three hundred and thirty-three households were interviewed. Fifty-seven percent 7006/12333) of these households had at least one child less than five years of age. The prevalence of symptoms of acute lower respiratory infections (ALRI) was 13.7% (n= 957; 95% CI 12.8 - 15.5%). A majority (77.8%; 95% CI; 77.7 - 78.5%) of households used wood as their primary fuel. Majority of respondents who used wood as their primary fuel obtained them by gathering wood from their neighborhood (95.6%; 9177/9595) and used a 3-stone local stove for cooking (94.9%; 9101/9595). In a randomly selected subset of respondents; females were the persons who mostly gathered firewood from the fields (90.8%; 296/326) and did the cooking (94.8%; 384/406) for the household. Conclusion: Symptoms of ALRI reported by caregivers is high in the Kintampo area of Ghana where biomass fuel use is also high. There is the need to initiate interventions that use improved cook stoves and to test the health benefits of such interventions

Baseline malaria vector transmission dynamics in communities in Ahafo mining area in Ghana.

BACKGROUND: Malaria vector dynamics are relevant prior to commencement of mining activities. A baseline entomology survey was conducted in Asutifi and Tano (referred to as Ahafo) in the Brong-Ahafo geo-political region of Ghana during preparatory stages for mining by Newmont Ghana Gold Limited. METHODS: Between November 2006 and August 2007, eight Centre for Disease Control light traps were set daily (Monday-Friday) to collect mosquitoes. Traps were hanged in rooms that were selected from a pool of 1,100 randomly selected houses. Types of materials used in construction of houses were recorded and mosquito prevention measures were assessed from occupants. RESULTS: A total of 5,393 mosquitoes were caught that comprised Anopheles gambiae (64.8%), Anopheles funestus (4.2%), as well as Culicines, comprising of Culex (30.4%) and Aedes species (0.6%). The entomological inoculation rate in Asutifi (279 infective bites/person/month) and Tano (487 infective bites/person/month) demonstrate relatively high malaria transmission in Ahafo. The presence or absence of Anopheles vectors in rooms was influenced by the type of roofing material (OR 2.33, 95%CI: 1.29-4.22, p = 0.01) as well as the presence of eaves gaps (OR 1.80, 95%CI: 1.37-2.37, p < 0.01). It was also associated with bed net availability in the room (OR 1.39, 95%CI: 1.08-1.80, p = 0.01). Over 80% of the houses were roofed with corrugated zinc sheets. Over 60% of the houses in Ahafo had no eaves gaps to give access to mosquito entry and exit into rooms and mosquito bed net coverage was over 50%. Other measures used in preventing mosquito bites included; coil (22.1%), insecticide spray (9.4%), repellent cream (4.0%) and smoky fires (1.1%), contributed minimally to individual mosquito preventive measures in impact areas. Similarly, levels of protection; coil (16.9%), insecticide spray (2.8%) and repellent cream (0.3%) for the non-impact areas, depict low individual prevention measures. CONCLUSIONS: The survey identified areas where intensified vector control activities would be beneficial. It also demonstrates that transmission in Asutifi and Tano is high even before the commencement of mining operations. This study serves as baseline information to assess impact of mining activities in relation to future vector control interventions.

The non-specific effects of vaccines and other childhood interventions: the contribution of INDEPTH Health and Demographic Surveillance Systems.

Most childhood interventions (vaccines, micronutrients) in low-income countries are justified by their assumed effect on child survival. However, usually the interventions have only been studied with respect to their disease/deficiency-specific effects and not for their overall effects on morbidity and mortality. In many situations, the population-based effects have been very different from the anticipated effects; for example, the measles-preventive high-titre measles vaccine was associated with 2-fold increased female mortality; BCG reduces neonatal mortality although children do not die of tuberculosis in the neonatal period; vitamin A may be associated with increased or reduced child mortality in different situations; effects of interventions may differ for boys and girls. The reasons for these and other contrasts between expectations and observations are likely to be that the immune system learns more than specific prevention from an intervention; such training may enhance or reduce susceptibility to unrelated infections. INDEPTH member centres have been in an ideal position to document such additional non-specific effects of interventions because they follow the total population long term. It is proposed that more INDEPTH member centres extend their routine data collection platform to better measure the use and effects of childhood interventions. In a longer perspective, INDEPTH may come to play a stronger role in defining health research issues of relevance to low-income countries.

Personal exposures to fine particulate matter and black carbon in households cooking with biomass fuels in rural Ghana.

OBJECTIVE: To examine cooking practices and 24-h personal and kitchen area exposures to fine particulate matter (PM2.5) and black carbon in cooks using biomass in Ghana. METHODS: Researchers administered a detailed survey to 421 households. In a sub-sample of 36 households, researchers collected 24-h integrated PM2.5 samples (personal and kitchen area); in addition, the primary cook was monitored for real-time PM2.5. All filters were also analyzed for black carbon using a multi-wavelength reflectance method. Predictors of PM2.5 exposure were analyzed, including cooking behaviors, fuel, stove and kitchen type, weather, demographic factors and other smoke sources. RESULTS: The majority of households cooked outdoors (55%; 231/417), used biomass (wood or charcoal) as their primary fuel (99%; 412/413), and cooked on traditional fires (77%, 323/421). In the sub-sample of 29 households with complete, valid exposure monitoring data, the 24-h integrated concentrations of PM2.5 were substantially higher in the kitchen sample (mean 446.8 µg/m3) than in the personal air sample (mean 128.5 µg/m3). Black carbon concentrations followed the same pattern such that concentrations were higher in the kitchen sample (14.5 µg/m3) than in the personal air sample (8.8 µg/m3). Spikes in real-time personal concentrations of PM2.5 accounted for the majority of exposure; the most polluted 5%, or 72 min, of the 24-h monitoring period accounted for 75% of all exposure. Two variables that had some predictive power for personal PM2.5 exposures were primary fuel type and ethnicity, while reported kerosene lantern use was associated with increased personal and kitchen area concentrations of black carbon. CONCLUSION: Personal concentrations of PM2.5 exhibited considerable inter-subject variability across kitchen types (enclosed, semi-enclosed, outdoor), and can be elevated even in outdoor cooking settings. Furthermore, personal concentrations of PM2.5 were not associated with kitchen type and were not predicted by kitchen area samples; rather they were driven by spikes in PM2.5 concentrations during cooking. Personal exposures were more enriched with black carbon when compared to kitchen area samples, underscoring the need to explore other sources of incomplete combustion such as roadway emissions, charcoal production and kerosene use.

Community engagement in biomedical research in an African setting: the Kintampo Health Research Centre experience.

BACKGROUND: Community engagement (CE) is becoming relevant in health research activities; however, models for CE in health research are limited in developing countries. The Kintampo Health Research Centre (KHRC) conducts research to influence health policy locally and also internationally. Since its establishment in 1994 with the mandate of conducting relevant public health studies in the middle part of Ghana, KHRC has embarked on a series of clinical and operational studies involving community members. In these studies, community members have been engaged through community durbars before, during and also after all study implementations. Lessons learnt from these activities suggested the need to embark on further CE processes that could serve as a model for emerging research institutions based in African communities. METHODS: Interactive community durbars, workshops, in-depth discussions, focus group discussions and radio interactions were used as the main methods in the CE process. RESULTS: Community members outlined areas of research that they perceived as being of interest to them. Though community members expressed continual interest in our traditional areas of research in communicable, maternal, neonatal and child health, they were interested in new areas such as non- communicable diseases such as diabetes and hypertension. Misconceptions about KHRC and its research activities were identified and clarified. This research provided KHRC the opportunity to improve communication guidelines with the community and these are being used in engaging the community at various stages of our research, thus improving on the design and implementation of research. CONCLUSION: KHRC has developed a culturally appropriate CE model based on mutual understanding with community members. The experience obtained in the CE process has contributed to building CE capacity in KHRC. Other health research institutions in developing countries could consider the experiences gained.

Effect of vitamin A supplementation on cause-specific mortality in women of reproductive age in Ghana: a secondary analysis from the ObaapaVitA trial.

OBJECTIVE: To determine the effect of weekly low-dose vitamin A supplementation on cause-specific mortality in women of reproductive age in Ghana. METHODS: A cluster-randomized, triple-blind, placebo-controlled trial was conducted in seven districts of the Brong Ahafo region of Ghana. Women aged 15-45 years who were capable of giving informed consent and intended to live in the trial area for at least 3 months were enrolled and randomly assigned, according to their cluster of residence, to receive oral vitamin A (7500 µg) or placebo once a week. Randomization was blocked, with two clusters in each fieldwork area allocated to vitamin A and two to placebo. Every 4 weeks, fieldworkers distributed capsules and collected data during home visits. Verbal autopsies were conducted by field supervisors and reviewed by physicians, who assigned a cause of death. Cause-specific mortality rates in both arms were compared by means of random-effects Poisson regression models to allow for the cluster randomization. Analysis was by intention-to-treat, based on cluster of residence, with women eligible for inclusion once they had consistently received the supplement or placebo capsules for 6 months. FINDINGS: The analysis was based on 581 870 woman-years and 2624 deaths. Cause-specific mortality rates were found to be similar in the two study arms. CONCLUSION: Low-dose vitamin A supplements administered weekly are of no benefit in programmes to reduce mortality in women of childbearing age.

Résumé OBJECTIF: Déterminer l'effet de la supplémentation hebdomadaire en vitamine A à faible dose sur la mortalité spécifique des femmes en âge de procréer au Ghana. MÉTHODES: Une étude randomisée, en triple aveugle, contrôlée contre placebo, a été menée dans sept districts de la région de Brong Ahafo au Ghana. Les femmes âgées de 15 à 45 ans, capables de donner un consentement éclairé et amenées à vivre dans la région de l'étude pendant au moins 3 mois, ont été incluses et il a été déterminé qu'elles recevraient une fois par semaine, au hasard selon leur groupe de résidence, de la vitamine A par voie orale (7 500 µg) ou un placebo. La randomisation a été fixée par deux groupes dans chaque zone recevant la vitamine A et deux groupes recevant le placebo. Toutes les 4 semaines, les agents de terrain distribuaient les capsules et recueillaient les données lors de visites à domicile. Des autopsies orales ont été effectuées par les superviseurs sur le terrain et analysées par des médecins, qui déterminaient la cause du décès. Les taux de mortalité spécifique dans les deux groupes ont été comparés à l'aide d'une régression de Poisson pour valider la randomisation des groupes. L'analyse, basée sur l'intention de traiter, était basée sur le groupe de résidence, pour des femmes éligibles à l'étude ayant reçu les capsules de supplément ou de placebo de manière constante pendant 6 mois. RÉSULTATS: L'analyse s'est basée sur 581 870 années-femmes et 2624 décès. Les taux de mortalité spécifique ont été jugés similaires dans les deux groupes de l'étude. CONCLUSION: Les suppléments en vitamine A à faible dose administrés hebdomadairement ne sont d'aucune utilité dans les programmes visant à réduire la mortalité chez les femmes en âge de procréer.

Resumen OBJETIVO: Determinar el efecto de la administración semanal de dosis bajas de vitamina A en la mortalidad por causas específicas de mujeres en edad reproductiva en Ghana. MÉTODOS: Se realizó un ensayo aleatorio de grupos, triple ciego y controlado por placebo en siete distritos de la región de Brong Ahafo, en Ghana. Se inscribieron mujeres de entre 15 y 45 años de edad capaces de dar su consentimiento informado y que tuvieran previsto vivir en el área de ensayo durante al menos tres meses. De acuerdo con el grupo de residencia al que habían sido asignadas de forma aleatoria, recibieron semanalmente vitamina A por vía oral (7500 µg) o placebo. La distribución aleatoria se limitó en cada área de trabajo a dos grupos a los que se les administró vitamina A y dos grupos que recibieron placebo. Cada cuatro semanas, los investigadores de campo distribuyeron cápsulas y recogieron datos durante las visitas a los hogares. Las autopsias verbales realizadas por los supervisores de campo fueron revisadas por médicos, quienes determinaron la causa de la muerte. Se compararon las tasas de mortalidad por causas específicas de ambos brazos mediante los modelos de regresión de Poisson con efectos aleatorios para facilitar la distribución aleatoria de los grupos. El análisis fue por intención de tratar, según el grupo de residencia y con mujeres que cumplieron las condiciones de inclusión una vez habían recibido de forma constante las cápsulas de suplemento o placebo durante seis meses. RESULTADOS: El análisis se basó en 581 870 años-mujer y 2624 muertes. Se descubrió que las tasas de mortalidad por causas específicas fueron similares en ambos brazos del estudio. CONCLUSIÓN: Los suplementos de dosis bajas de vitamina A administrados semanalmente no presentan ninguna ventaja en los programas para reducir la mortalidad de las mujeres en edad reproductiva.

Effect of vitamin A supplementation in women of reproductive age on cause-specific early and late infant mortality in rural Ghana: ObaapaVitA double-blind, cluster-randomised, placebo-controlled trial.

Objectives To assess the effect of vitamin A supplementation in women of reproductive age in Ghana on cause- and age-specific infant mortality. In addition, because of recently published studies from Guinea Bissau, effects on infant mortality by sex and season were assessed. Design Double-blind, cluster-randomised, placebo-controlled trial. Setting 7 contiguous districts in the Brong Ahafo region of Ghana. Participants All women of reproductive age (15-45 years) resident in the study area randomised by cluster of residence. All live born infants from 1 June 2003 to 30 September 2008 followed up through 4-weekly home visits. Intervention Weekly low-dose (25 000 IU) vitamin A. Main outcome measures Early infant mortality (1-5 months); late infant mortality (6-11 months); infection-specific infant mortality (0-11 months). Results 1086 clusters, 62 662 live births, 52 574 infant-years and 3268 deaths yielded HRs (95% CIs) comparing weekly vitamin A with placebo: 1.04 (0.88 to 1.05) early infant mortality; 0.99 (0.84 to 1.18) late infant mortality; 1.03 (0.92 to 1.16) infection-specific infant mortality. There was no evidence of modification of the effect of vitamin A supplementation on infant mortality by sex (Wald statistic =0.07, p=0.80) or season (Wald statistic =0.03, p=0.86). Conclusions This is the largest analysis of cause of infant deaths from Africa to date. Weekly vitamin A supplementation in women of reproductive age has no beneficial or deleterious effect on the causes of infant death to age 6 or 12 months in rural Ghana. Trial registration number http://ClinicalTrials.gov: NCT00211341.

Demographic patterns and trends in Central Ghana: baseline indicators from the Kintampo Health and Demographic Surveillance System.

BACKGROUND: The dearth of health and demographic data in sub-Saharan Africa from vital registration systems and its impact on effective planning for health and socio-economic development is widely documented. Health and Demographic Surveillance Systems have the capacity to address the dearth of quality data for policy making in resource-poor settings. OBJECTIVE: This article demonstrates the utility of the Kintampo Health and Demographic Surveillance System (KHDSS) by showing the patterns and trends of population change from 2005 to 2009 in the Kintampo North Municipality and Kintampo South districts of Ghana through data obtained from the KHDSS biannual update rounds. DESIGN: Basic demographic rates for fertility, mortality, and migration were computed by year. School enrolment was computed as a percentage in school by age and sex for 6-18 year-olds. Socio-economic status was derived by use of Principal Components Analysis on household assets. RESULTS: Over the period, an earlier fertility decline was reversed in 2009; mortality declined slightly for all age-groups, and a significant share of working-age population was lost through out-migration. Large minorities of children of school-going age are not in school. Socio-economic factors are shown to be important determinants of fertility and mortality. CONCLUSION: Strengthening the capacity of HDSSs could offer added value to evidence-driven policymaking at local level.

Malaria epidemiology in the Ahafo area of Ghana.

BACKGROUND: Plasmodium falciparum malaria remains endemic in sub-Saharan Africa including Ghana. The epidemiology of malaria in special areas, such as mining areas needs to be monitored and controlled. Newmont Ghana Gold Limited is conducting mining activities in the Brong Ahafo Region of Ghana that may have an impact on the diseases such as malaria in the mining area. METHODS: Prior to the start of mining activities, a cross-sectional survey was conducted in 2006/2007 to determine malaria epidemiology, including malaria parasitaemia and anaemia among children < 5 years and monthly malaria transmission in a mining area of Ghana. RESULTS: A total of 1,671 households with a child less than five years were selected. About 50% of the household heads were males. The prevalence of any malaria parasitaemia was 22.8% (95% CI 20.8-24.9). Plasmodium falciparum represented 98.1% (95% CI 96.2-99.2) of parasitaemia. The geometric mean P. falciparum asexual parasite count was 1,602 (95% CI 1,140-2,252) and 1,195 (95% CI 985-1,449) among children < 24 months and ≥ 24 months respectively. Health insurance membership (OR 0.60, 95% CI 0.45-0.80, p = 0.001) and the least poor (OR 0.57, 95% CI 0.37-0.90, p = 0.001) were protected against malaria parasitaemia. The prevalence of anaemia was high among children < 24 months compared to children ≥ 24 months (44.1% (95% CI 40.0-48.3) and 23.8% (95% CI 21.2-26.5) respectively. About 69% (95% CI 66.3-70.9) of households own at least one ITN. The highest EIRs were record in May 2007 (669 ib/p/m) and June 2007 (826 ib/p/m). The EIR of Anopheles gambiae were generally higher than Anopheles funestus. CONCLUSION: The baseline malaria epidemiology suggests a high malaria transmission in the mining area prior to the start of mining activities. Efforts at controlling malaria in this mining area have been intensified but could be enhanced with increased resources and partnerships between the government and the private sector.

Clustering of childhood mortality in the Kintampo Health and Demographic Surveillance System in Ghana.

BACKGROUND: Childhood mortality in Ghana has generally declined in the last four decades. However, estimates tend to conceal substantial variability among regions and districts. The lack of population-based data in Ghana, as in other less developed countries, has hindered the development of effective programmes targeted specifically at clusters where mortality levels are significantly higher. OBJECTIVE: This paper seeks to test for the existence of statistically significant clusters of childhood mortality within the Kintampo Health and Demographic Surveillance System (KHDSS) between 2005 and 2007. DESIGN: In this study, mortality rates were generated using mortality data extracted from the health and demographic surveillance database of the KHDSS and exported into STATA. The spatial and spatio-temporal scan statistic by Kulldorff was used to identify significant clusters of childhood mortality within the KHDSS. RESULTS: A significant cluster of villages with high under-five mortality in the south-eastern part of the KHDSS in 2006 was identified. This is a remote location where poverty levels are relatively higher, health facilities are more sparse and these are compounded by poor transport services in case of emergencies. CONCLUSION: This study highlights the potential of the surveillance platform to demonstrate the spatial dimensions of childhood mortality clustering. It is apparent, though, that further studies need to be carried out in order to explore the underlying risk factors for potential mortality clusters that could emerge later.

Community perceptions of malaria and malaria treatment behaviour in a rural district of Ghana: implications for artemisinin combination therapy.

BACKGROUND: Artesunate-amodiaquine (AS-AQ) was introduced in Ghana as the first line drug for treatment of uncomplicated malaria in 2004. We report the perceptions of malaria and malaria treatment behaviour, the community awareness of and perceptions about AS-AQ two years after the introduction of this ACT treatment for malaria. METHODS: Two surveys were conducted; a cross-sectional survey of 729 randomly selected household heads (urban-362, rural-367) and 282 women with children < 5 years (urban-121, rural-161) was conducted in 2006. A district wide survey was conducted in 2007 to assess awareness of AS-AQ. These were complemented with twenty-eight focus group discussions (FGDs) and 16 key informant interviews (KII) among community members and major stakeholders in the health care delivery services. All nine (9) health facilities and five (5) purposively selected drug stores were audited in order to identify commonly used anti-malarials in the study area at the time of the survey. RESULTS: Majority of respondents ( > 75%) in the sampled survey mentioned mosquito bites as the cause of malaria. Other causes mentioned include environmental factors (e.g. dirty surroundings) and standing in the sun. Close to 60% of the household heads and 40% of the care-givers interviewed did not know about AS-AQ. The community respondents who knew about and had ever taken AS-AQ perceived it to be a good drug; although they mentioned they had experienced some side effects including headaches and body weakness. Co-blistered AS-AQ was available in all the government health facilities in the study area. Different formulations of ACTs were however found in urban chemical shops but not in rural chemical stores where monotherapy antimalarials were predominant. CONCLUSION: The knowledge of fever as a symptom of malaria is high among the study population. The awareness of AS-AQ therapy and its side-effect was low in the study area. Community education and sensitization, targeting all categories of the population, has to be intensified to ensure an efficient implementation process.

Effect of vitamin A supplementation in women of reproductive age on maternal survival in Ghana (ObaapaVitA): a cluster-randomised, placebo-controlled trial.

BACKGROUND: A previous trial in Nepal showed that supplementation with vitamin A or its precursor (betacarotene) in women of reproductive age reduced pregnancy-related mortality by 44% (95% CI 16-63). We assessed the effect of vitamin A supplementation in women in Ghana. METHODS: ObaapaVitA was a cluster-randomised, double-blind, placebo-controlled trial undertaken in seven districts in Brong Ahafo Region in Ghana. The trial area was divided into 1086 small geographical clusters of compounds with fieldwork areas consisting of four contiguous clusters. All women of reproductive age (15-45 years) who gave informed consent and who planned to remain in the area for at least 3 months were recruited. Participants were randomly assigned by cluster of residence to receive a vitamin A supplement (25 000 IU retinol equivalents) or placebo capsule orally once every week. Randomisation was blocked and based on an independent, computer-generated list of numbers, with two clusters in each fieldwork area allocated to vitamin A supplementation and two to placebo. Capsules were distributed during home visits undertaken every 4 weeks, when data were gathered on pregnancies, births, and deaths. Primary outcomes were pregnancy-related mortality and all-cause female mortality. Cause of death was established by verbal post mortems. Analysis was by intention to treat (ITT) with random-effects regression to account for the cluster-randomised design. Adverse events were synonymous with the trial outcomes. This trial is registered with ClinicalTrials.gov, number NCT00211341. FINDINGS: 544 clusters (104 484 women) were randomly assigned to vitamin A supplementation and 542 clusters (103 297 women) were assigned to placebo. The main reason for participant drop out was migration out of the study area. In the ITT analysis, there were 39 601 pregnancies and 138 pregnancy-related deaths in the vitamin A supplementation group (348 deaths per 100 000 pregnancies) compared with 39 234 pregnancies and 148 pregnancy-related deaths in the placebo group (377 per 100 000 pregnancies); adjusted odds ratio 0.92, 95% CI 0.73-1.17; p=0.51. 1326 women died in 292 560 woman-years in the vitamin A supplementation group (453 deaths per 100 000 years) compared with 1298 deaths in 289 310 woman-years in the placebo group (449 per 100 000 years); adjusted rate ratio 1.01, 0.93-1.09; p=0.85. INTERPRETATION: The body of evidence, although limited, does not support inclusion of vitamin A supplementation for women in either safe motherhood or child survival strategies. FUNDING: UK Department for International Development, and USAID.

Diagnostic accuracy of verbal autopsies in ascertaining the causes of stillbirths and neonatal deaths in rural Ghana.

This study evaluated the diagnostic accuracy of a verbal autopsy (VA) tool in ascertaining the causes of stillbirths and neonatal deaths in rural Ghana and was nested within a community-based maternal vitamin A supplementation trial (ObaapaVitA trial). All stillbirths and neonatal deaths between 1 January 2003 and 30 June 2004 were prospectively included. Community VAs were carried out within 6 months of death and were classified with a primary cause of death by three experienced paediatricans. The reference standard diagnosis was obtained by the study paediatrician in 4 district hospitals in the study area. There were 20,317 deliveries, 661 stillbirths and 590 neonatal deaths with a VA diagnosis in the study population. A total of 311 stillbirths and 191 neonatal deaths had both a VA and a hospital reference standard diagnosis. The VA performed poorly for stillbirth diagnoses such as congenital abnormalities and maternal haemorrhage. Accuracy was higher for intrapartum obstetric complications and antepartum maternal disease. For neonatal deaths, sensitivity was >60% for all major causes; specificity was 76% for birth asphyxia but >85% for prematurity and infection. Overall, VA diagnostic accuracy was higher than expected in this rural African setting. Our classification system was based on the expected public health importance of the individual causes of death, differing implications for intervention and the ability to distinguish between the individual causes in low-resource settings. We believe this system was easier to use than traditional approaches and resulted in high precision and accuracy. However, further simplifications are needed to allow use of the World Health Organisation VA in routine child health programmes. The diagnostic accuracy of the VA tool should also be assessed in other regions and in multicentre studies.