Malaria Prevalence and Macroeconomic Output in Ghana, 1990 to 2019.

In Ghana, malaria remains the number 1 reason for outpatient department visits, making it a major public health problem. Thus, there could be significant lost productivity days as a result of malaria morbidity and mortality, which could negatively affect economic output at the macrolevel. Nonetheless, there is a dearth of empirical evidence of the effect of malaria on macroeconomic output in Ghana. This study therefore aims to provide the foremost empirical evidence regarding the effect of malaria prevalence on macroeconomic output in Ghana using a time series design with data spanning the period 1990 to 2019. Gross Domestic Product (GDP), serving as a proxy for macroeconomic output, is the dependent variable, while the prevalence of malaria (overall, among only males and among only females) serves as the main independent variable. The Ordinary Least Square (OLS) regression is used as the baseline estimation technique and the Instrumental Variable Two-Stage Least Square (IV2SLS) regression is employed as the robustness check estimator due to its ability to deal with endogeneity. The IV2SLS regression results show that a percentage increase in the overall prevalence of malaria is associated with a 1.16% decrease in macroeconomic output at 1% significance level. We also find that the effect of malaria in males on macroeconomic output is slightly higher relative to females. The findings from the OLS regression are not qualitatively different from the IV2SLS regression estimates. There is therefore the need to strengthen efforts such as quality case management, larval source management, mass distribution of long-lasting insecticide-treated bed nets, social behavior change, surveillance (both epidemiological and entomological), intermittent preventive treatment of malaria in pregnancy, research among others, which are important toward eliminating malaria.

A qualitative study of infection prevention and control practices in the maternal units of two Ghanaian hospitals.

INTRODUCTION: Healthcare-associated infections (HAIs) remain a common challenge in healthcare delivery, with a significant burden in low- and middle-income countries. Preventing HAIs has gained enormous attention from policy makers and healthcare managers and providers, especially in resource-limited settings. Despite policies to enforce infection prevention and control (IPC) measures to prevent HAIs, IPC compliance remains a challenge in hospital settings. In this study, we explore the experiences of healthcare providers and women in the post-natal phase and investigate factors influencing IPC practices in two hospitals in Ghana. METHODS: The study used a qualitative approach involving semi-structured interviews, focus group discussions, and observations among healthcare providers and women in the postnatal phase in two maternity units from January 2019 to June 2019. Interviews were recorded and transcribed verbatim for thematic analysis. The data sets were uploaded into the qualitative software NVivo 12 to facilitate coding and analysis. FINDINGS: Healthcare providers were driven by the responsibility to provide medical care for their patients and at the same time, protect themselves from infections. IPC facilitators include leadership commitment and support, IPC training and education. Women were informed about IPC in educational talks during antenatal care visits, and their practices were also shaped by their background and their communities. IPC barriers include the poor documentation or 'invisibility' of HAIs, low prioritization of IPC tasks, lack of clear IPC goals and resources, discretionary use of guidelines, and communication-related challenges. The findings demonstrate the need for relevant power holders to position themselves as key drivers of IPC and develop clear goals for IPC. Hospital managers need to take up the responsibility of providing the needed resources and leadership support to facilitate IPC. Patient engagement should be more strategic both within the hospital and at the community level.

An Ethnographic Study of Multiple Factors Influencing Perceptions, Attitudes, and Observance of COVID-19 Preventive Measures among Rural and Urban Slum Dwellers in Ghana.

Background: The COVID-19 pandemic and government-led interventions to tackle it have had life-changing effects on vulnerable populations, especially rural and urban slum dwellers in developing countries. This ethnographic study explored how the Ghanaian government's management of COVID-19, socio-cultural factors, infrastructural challenges, and poverty influenced community perceptions, attitudes, and observance of COVID-19 prevention measures in Ghana. Methods: The study employed focused ethnography using in-depth interviews (IDIs), focus group discussions (FGDs), and nonparticipant observations to collect data from an urban slum and a rural community as well as from government officials, from October 2020 to January 2021. The data were triangulated and analyzed thematically with the support of qualitative software NVivo 12. All ethical procedures were followed. Results: The Ghanaian government's strategy of communicating COVID-19-related information to the public, health-related factors such as health facilities failing to follow standard procedures in testing and tracing persons who came into contact with COVID-19-positive cases, poverty, and lack of social amenities contributed to the poor observance of COVID-19 preventive measures. In addition, the government's relaxation of COVID-19 restrictions, community and family values, beliefs, and misconceptions contributed to the poor observance of COVID-19 preventive measures. Nevertheless, some aspects of the government's intervention measures and support to communities with COVID-19 prevention items, support from nongovernmental organizations (NGOs), and high knowledge of COVID-19 and its devastating effects contributed to positive attitudes and observance of COVID-19 preventive measures. Conclusion: There is a need for the government to use the existing community structures to engage vulnerable communities so that their concerns are factored into interventions to ensure that appropriate interventions are designed to suit the context. Moreover, the government needs to invest in social amenities in deprived communities. Finally, the government has to be consistent with the information it shares with the public to enhance trust relations.

The role of community engagement toward ensuring healthy lives: a case study of COVID-19 management in two Ghanaian municipalities.

Introduction: Community engagement is one of the important requirements for strengthening health delivery in communities in a bid to achieve sustainable development goal 3, target 3.3 (SDG 3.3). The World Health Organization has strongly encouraged the use the five levels of community engagement, which are informing, consulting, planning, collaborating, and empowering communities in order to build resilience and to enable them contribute to the fight against diseases and for the uptake of health interventions. This study sought to explore and describe from the view of government institutions in Ghana how they engaged communities in COVID- 19 management and vaccine acceptance and how the communities within two municipalities also perceived the engagement process as well as the lessons that can be learned in engaging communities to deal with other health challenges and interventions toward the attainment of SDG 3 target 3.3. Materials and methods: This case study qualitative research project employed in-depth interviews among 36 respondents composed of government officials (the Ghana Health Service (GHS), the Information Services Department (ISD), the National Commission on Civic Education (NCCE) and two Municipal Assemblies), and community leaders and 10 focus group discussions among 87 men and women most of whom were natives and some migrants in two administrative municipalities in Ghana. Data were collected from June to September 2021. Audio interviews were transcribed and uploaded to Nvivo 12 to support triangulation, coding, and thematic analysis. Ethical approval was obtained from the University of Health and Allied Sciences' Research Ethics Committee and all COVID-19 restrictions were observed. Results: The findings revealed that all the four government institutions educated and informed the communities within their municipalities on COVID-19 management and vaccine acceptance. However, the Ghana Health Service was the most effective in the engagement spectrum of the other four; consulting, involving, collaborating, and empowering communities in the process of COVID-19 management and vaccine acceptance. The GHS achieved that through its CHPS program, which ensured a decentralized health service provision system with multiple programs and leveraging on its multiple programs to reach out to the communities. Government institutions such as the NCCE and the ISD faced challenges such as limited funding and support from the government to be able to carry out their tasks. Additionally, they were not involved with the communities prior to the pandemic and for that matter, they did not have access to community systems such as committees, and existing groups to facilitate the engagement process. Discussion: Using communities to support Ghana's attainment of the SDG 3 target 3.3 is possible; however, the government needs to provide funds and resources to the institutions responsible to enable them to carry out community engagement effectively. Also, promoting decentralization among institutions can strengthen community engagement processes. It is important that state institutions continue to strategize to empower communities in order to promote their participation in healthcare interventions and in the fight against infectious diseases in Ghana.

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

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

Malaria in pregnancy control and pregnancy outcomes: a decade's overview using Ghana's DHIMS II data.

BACKGROUND: Malaria in pregnancy control interventions have been implemented through antenatal care services for more than 2 decades in Ghana. The uptake of these interventions has seen steady improvement over the years. This has occurred within the context of decreasing global trends of malaria infection confirmed by decreasing malaria in pregnancy prevalence in Ghana. However, not much is known about how these improvements in interventions uptake and reduction in malaria infection prevalence have impacted pregnancy outcomes in the country. This study aimed at describing trends of maternal anaemia and low birth weight prevalence and uptake of malaria in pregnancy control interventions over the last decade using data from Ghana's District Health Information Management System (DHIMS II). METHODS: Data from Ghana's DHIMS II on variables of interest covering the period 2012 to 2021 was analysed descriptively using Microsoft Excel 365. Results were computed as averages and percentages and presented in tables and graphs. RESULTS: The prevalence of maternal anaemia at booking and at term and low birth weight increased marginally from 31.0%, 25.5% and 8.5% in 2012 to 36.6%, 31.9% and 9.5% in 2021 respectively. Severe anaemia prevalence at booking and at term remained under 2% over the study period. Women making at least 4 ANC visits, receiving at least 3 doses of intermittent preventive treatment of malaria and an insecticide-treated net increased from 77.0%, 41.4% and 4.1% in 2012 to 82%, 55.0% and 93.3% in 2021, respectively. Malaria test positivity rate reduced from 54.0% to 34.3% between 2014 and 2021 while women receiving iron and folate supplementation for 3 and 6 months rose from 43.0% and 25.5% to 89.7% and 61.8%, respectively between 2017 and 2021. CONCLUSION: Maternal anaemia and low birth weight prevalence showed marginal upward trends over the last decade despite reduced malaria infection rate and improved uptake of malaria in pregnancy control interventions. There is room for improvement in current intervention implementation levels but the complex and multi-factorial aetiologies of maternal anaemia and low birth weight need urgent investigation and quantification to inform policy and practice.

The socio-economic and health effects of COVID-19 among rural and urban-slum dwellers in Ghana: A mixed methods approach.

BACKGROUND: Vulnerable populations such as rural and urban-slum dwellers are more likely to suffer greatly from the deleterious effects of the novel Coronavirus disease 2019 (COVID-19). However, in Ghana, most COVID-19 mitigating packages are not focused on vulnerable populations. METHODS: Concurrent mixed methods design was used to examine the socio-economic and health effects of COVID-19 among rural and urban-slum dwellers in Ghana. Four hundred respondents were sampled for the quantitative arm of the study, while 46 In-depth Interviews (IDIs) were conducted with community members and government officials. Sixty-four community members participated in Focus Group Discussions (FGDs) and non-participant observation was carried out for three months. Quantitative data were analysed using frequencies, percentages, Pearson Chi2 and ordered logistic regression. Interviews were recorded using digital recorders and later transcribed. Transcribed data (IDIs, FGDs) and observation notes were uploaded onto a computer and transferred to qualitative software NVivo 12 to support thematic coding and analysis. RESULTS: Majority of the respondents confirmed the deleterious socio-economic and health effects of COVID-19 on jobs and prices of food. Other effects were fear of visiting a health facility even when unwell, depression and anxiety. Young people (18-32 years), males, urban-slum dwellers, married individuals, the employed and low-income earners (those who earn GHC10/$1.7 to GHC100/ $17), were more likely to suffer from the socio-economic and health effects of COVID-19. Urban-slum dwellers coped by relying on family and social networks for food and other basic necessities, while rural dwellers created locally appropriate washing aids to facilitate hand washing in the rural communities. CONCLUSION: COVID-19 and the government's mitigation measures had negative socio-economic and health effects on vulnerable communities. While vulnerable populations should be targeted for the government's COVID-19 mitigating packages, special attention should be given to young people (18-32 years), males, urban-slum dwellers, married individuals and low-income earners. Communities should be encouraged to maintain coping strategies adopted even after COVID-19.

Motivators and demotivators to accessing malaria in pregnancy interventions in sub-Saharan Africa: a meta-ethnographic review.

BACKGROUND: Despite the introduction of efficacious interventions for malaria control, sub-Saharan Africa continues to bear the highest burden of malaria and its associated effects on vulnerable populations, such as pregnant women and children. This meta-ethnographic review contributes to literature on malaria in pregnancy interventions in sub-Saharan Africa by offering insights into the multiple factors that motivate or demotivate women from accessing MiP interventions. METHODS: A meta-ethnographic approach was used for the synthesis. Original qualitative research articles published from 2010 to November 2021 in English in sub-Saharan Africa were searched for. Articles focusing on WHO's recommended interventions such as intermittent preventive treatment with sulfadoxine-pyrimethamine, long-lasting insecticidal nets and testing and treatment of Malaria in Pregnancy (MiP) were included. Selected articles were uploaded into Nvivo 11 for thematic coding and synthesis. RESULTS: Twenty-seven original qualitative research articles were included in the analysis. Main factors motivating uptake of MiP interventions were: (1) well organized ANC, positive attitudes of health workers and availability of MiP services; (2) Women's knowledge of the effects of malaria in pregnancy, previous experience of accessing responsive ANC; (3) financial resources and encouragement from partners, relatives and friends and (4) favourable weather condition and nearness to a health facility. Factors that demotivated women from using MiP services were: (1) stock-outs, ANC charges and health providers failure to provide women with ample education on the need for MiP care; (2) perception of not being at risk and the culture of self-medication; (3) fear of being bewitched if pregnancy was noticed early, women's lack of decision-making power and dependence on traditional remedies and (4) warm weather, long distances to health facilities and the style of construction of houses making it difficult to hang LLINs. CONCLUSIONS: Health system gaps need to be strengthened in order to ensure that MiP interventions become accessible to women. Additionally, health managers need to involve communities in planning, designing and implementing malaria interventions for pregnant women. It is important that the health system engage extensively with communities to facilitate pregnant women and communities understanding of MiP interventions and the need to support pregnant women to access them.

"Our Work, Our Health, No One's Concern": Domestic Waste Collectors' Perceptions of Occupational Safety and Self-Reported Health Issues in an Urban Town in Ghana.

Domestic waste collectors face major public health hazards that result in injuries and morbidity globally. This study explored domestic waste collectors' perceptions of occupational safety and self-reported health issues in a city in Ghana using a phenomenological qualitative research design. In-depth interviews and focus group discussions were held with 64 domestic waste collectors from two waste companies. The transcribed data were imported into NVivo 11.0 software (QSR International, Burlington, MA, USA) for coding, and a content analysis was applied to analyze all the transcribed data using the processes of induction and deduction. The consensual views from the domestic waste collectors showed the waste-company employers' non-interest in the domestic waste collectors' occupational safety and health. Poor communication from employers to domestic waste collectors and huge workloads were identified as the causes of the poor implementation of occupational safety practices, which exposed the domestic waste collectors to occupational health hazards. The domestic waste collectors reported that they suffered from occupational injuries, psychosocial disorders, work-related stress, and frequent burnout. The domestic waste collectors adopted coping strategies, such as self-medication, to deal with these occupational hazards, since most of them were not covered by guaranteed health insurance. In addition, the study revealed the non-compliance and non-enforcement of occupational health and safety policies by the employers to guide health and safety training and practices among the domestic waste collectors. In conclusion, the findings suggest that DWCs are exposed to occupational safety and health hazards in their work. Waste-company employers should extend welfare benefits to DWCs, such as health insurance and social security benefits, to ensure their security, health, and well-being. The findings could inform the design of intervention programs and policies to guide training and practices for domestic waste collectors.

Mixed effect analysis of factors influencing the use of insecticides treated bed nets among pregnant women in Ghana: evidence from the 2019 Malaria Indicator Survey.

BACKGROUND: Malaria during pregnancy is a major cause of maternal morbidity globally and leads to poor birth outcomes. The World Health Organization has recommended the use of insecticide treated bed nets (ITN) as one of the effective malaria preventive strategies among pregnant women in malaria endemic areas. This study, therefore, seeks to examine the individual and household factors associated with the use of ITNs among pregnant women in Ghana. METHODS: Data for this study was obtained from the 2019 Ghana Malaria Indicator Survey (GMIS) conducted between September 25 and November 24, 2019. The weighted sample comprised 353 pregnant women aged 15-49 years. Data was analyzed with SPSS version 22 using both descriptive and multilevel logistics regression modelling. Statistically significant level was set at p < 0.05. RESULTS: The study found that 49.2% of pregnant women in Ghana use ITN to prevent malaria. Pregnant women aged 35-49 years (AOR = 3.403, CI: 1.191-9.725), those with no formal education (AOR = 5.585, CI = 1.315-23.716), and those who had secondary education (AOR = 3.509, CI = 1.076-11.440) had higher odds of using ITN. Similarly, higher odds of ITN usage was found among who belonged to the Akan ethnic group (AOR = 7.234, CI = 1.497-34.955), dwell in male-headed households (AOR = 2.232, CI = 1.105-4.508) and those whose household heads are aged 60-69 years (AOR = 4.303, CI = 1.160-15.966). However, pregnant women who resided in urban areas (AOR = 0.355, CI = 0.216-0.582), those whose household heads aged 40-49 years (AOR = 0.175, CI = 0.066-0.467) and those who belonged to richer (AOR =0.184, CI = 0.050-0.679) and richest (AOR = 0.107, CI = 0.021-0.552) households had lower odds of using ITN for malaria prevention. CONCLUSIONS: Individual socio-demographic and household factors such as pregnant women's age, educational level, place of residence, ethnicity, sex and age of household head, and household wealth quintile are associated with the use of ITN for malaria prevention among pregnant women. These factors ought to be considered in strengthening malaria prevention campaigns and develop new interventions to help increase ITN utilization among vulnerable population living in malaria- endemic areas.

COVID-19 vaccine hesitancy among the adult population in Ghana: evidence from a pre-vaccination rollout survey.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has already claimed over four million lives globally and over 800 deaths in Ghana. The COVID-19 vaccine is a key intervention towards containing the pandemic. Over three billion doses of the vaccine have already been administered globally and over 800,000 doses administered in Ghana, representing less than 5% vaccination coverage. Fear, uncertainty, conspiracy theories and safety concerns remain important threats to, a successful rollout of the vaccine if not managed well. OBJECTIVE: Ascertain the predictors of citizens' probability of participating in a COVID-19 vaccine trial and subsequently accept the vaccine when given the opportunity. METHODOLOGY: The study was an online nation-wide survey among community members (n = 1556) from 18th September to 23rd October, 2020 in the 16 regions in Ghana. Binary probit regression analysis with marginal effect estimations was employed to ascertain the predictors of community members' willingness to participate in a COVID-19 vaccine trial and uptake the vaccine. RESULTS: Approximately 60% of respondents said they will not participate in a COVID-19 vaccine trial; 65% will take the vaccine, while 69% will recommend it to others. Willingness to voluntarily participate in COVID-19 vaccine trial, uptake the vaccine and advise others to do same was higher among adults aged 18-48 years, the unmarried and males (p < 0.05). Significant predictors of unwillingness to participate in the COVID-19 vaccine trial and uptake of the vaccine are: married persons, females, Muslims, older persons, residents of less urbanised regions and persons with lower or no formal education (p < 0.05). Predominant reasons cited for unwillingness to participate in a COVID-19 vaccine trial and take the vaccine included fear, safety concerns, lack of trust in state institutions, uncertainty, political connotations, spiritual and religious beliefs. CONCLUSION: The probability of accepting COVID-19 vaccine among the adult population in Ghana is high but the country should not get complacent because fear, safety and mistrust are important concerns that have the potential to entrench vaccine hesitancy. COVID-19 vaccine rollout campaigns should be targeted and cognisant of the key predictors of citizens' perceptions of the vaccine. These lessons when considered will promote Ghana's efforts towards vaccinating at least 20 million people to attain herd immunity.

An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context.

BACKGROUND: Intermittent preventive treatment of malaria among pregnant women with sulfadoxine-pyrimethamine (IPTp-SP), is one of the three recommended interventions for the prevention of malaria in pregnancy (MiP) in sub-Sahara Africa. The World Health Organisation recommended in 2012 that SP be given at each scheduled ANC visit except during the first trimester and can be given a dose every month until the time of delivery, to ensure that a high proportion of women receive at least three doses of SP during pregnancy. Despite implementation of this policy, Ghana did not attain the target of 100% access to IPTp-SP by 2015. Additionally, negative outcomes of malaria infection in pregnancy are still recurring. This ethnographic study explored how health system, individual and socio-cultural factors influence IPTp-SP uptake in two Ghanaian regions. METHODS: The study design was ethnographic, employing non-participant observation, case studies and in depth interviews in 8 health facilities and 8 communities, from April 2018 to March 2019, in two Ghanaian regions. Recommended ethical procedures were observed. RESULTS: Health system factors such as organization of antenatal care (ANC) services and strategies employed by health workers to administer SP contributed to initial uptake. Women's trust in the health care system contributed to continued uptake. Inadequate information provided to women accessing ANC, stock-outs and fees charged for ANC services reduced access to IPTp-SP. Socio-cultural factor such as encouragement from social networks influenced utilization of ANC services and IPTp-SP uptake. Individual factors such as refusing to take SP, skipping ANC appointments and initiating ANC attendance late affected uptake. CONCLUSION: Health system, socio-cultural and individual factors influence uptake of optimum doses of IPTp-SP. Consequently, interventions that aim at addressing IPTp-SP uptake should focus on regular and sufficient supply of SP to health facilities, effective implementation of free ANC, provision of appropriate and adequate information to women and community outreach programmes to encourage early and regular ANC visits.

Managing urban solid waste in Ghana: Perspectives and experiences of municipal waste company managers and supervisors in an urban municipality.

Increased population growth and rapid urbanization have resulted in the generation of large quantities of solid waste across major urban cities in Ghana, outstripping local authorities' ability to manage and dispose of waste in a sanitary manner. This study explored the perspectives and experiences of municipal waste company managers and supervisors in the Ho municipality of Ghana on solid waste management practices. A qualitative inquiry was conducted by adopting a phenomenological approach, using in-depth interviews and focus group discussions for data collection. A total of 35 participants, made up of 12 managers and 23 supervisors took part in the study. Transcribed data were imported into NVivo 11.0 software for coding. Content analysis was applied to analyze all transcribed data using processes of induction and deduction. The results showed that organizational capacity, resources, and expertise; community factors such as socio-cultural beliefs and a low sense of responsibility towards solid waste management among urban residents; contextual factors such as regulations, and weak enforcement all influence and shape the level of efficiency and effectiveness of solid waste management practices in the study setting. The findings suggest that policy frameworks and procedures implemented to curb poor urban waste management practices should be systematic and thorough in order to tackle the issue of solid waste in the study setting and Ghana in general. The nature of the identified issues and challenges requires multidimensional and multilevel interventions to provide sustainable solutions for managing urban waste in Ghana.

Urban health nexus with coronavirus disease 2019 (COVID-19) preparedness and response in Africa: Rapid scoping review of the early evidence.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 also called coronavirus disease 2019 was first reported in the African continent on 14 February 2020 in Egypt. As at 18 December 2020, the continent reported 2,449,754 confirmed cases, 57,817 deaths and 2,073,214 recoveries. Urban cities in Africa have particularly suffered the brunt of coronavirus disease 2019 coupled with criticisms that the response strategies have largely been a 'one-size-fits-all' approach. This article reviewed early evidence on urban health nexus with coronavirus disease 2019 preparedness and response in Africa. METHODS: A rapid scoping review of empirical and grey literature was done using data sources such as ScienceDirect, GoogleScholar, PubMed, HINARI and official websites of World Health Organization and Africa Centres for Disease Control and Prevention. A total of 26 full articles (empirical studies, reviews and commentaries) were synthesised and analysed qualitatively based on predefined inclusion criteria on publication relevance and quality. RESULTS: Over 70% of the 26 articles reported on coronavirus disease 2019 response strategies across Africa; 27% of the articles reported on preparedness towards coronavirus disease 2019, while 38% reported on urbanisation nexus with coronavirus disease 2019; 40% of the publications were full-text empirical studies, while the remaining 60% were either commentaries, reviews or editorials. It was found that urban cities remain epicentres of coronavirus disease 2019 in Africa. Even though some successes have been recorded in Africa regarding coronavirus disease 2019 fight, the continent's response strategies were largely found to be a 'one-size-fits-all' approach. Consequently, adoption of 'Western elitist' mitigating measures for coronavirus disease 2019 containment resulted in excesses and spillover effects on individuals, families and economies in Africa. CONCLUSION: Africa needs to increase commitment to health systems strengthening through context-specific interventions and prioritisation of pandemic preparedness over response. Likewise, improved economic resilience and proper urban planning will help African countries to respond better to future public health emergencies, as coronavirus disease 2019 cases continue to surge on the continent.

Perspectives and practices of healthcare providers and caregivers on healthcare-associated infections in the neonatal intensive care units of two hospitals in Ghana.

Healthcare-associated infections (HAIs) remain a serious threat to patient safety worldwide, particularly in low- and middle-income countries. Reducing the burden of HAIs through the observation and enforcement of infection prevention and control (IPC) practices remains a priority. Despite growing emphasis on HAI prevention in low- and middle-income countries, limited evidence is available to improve IPC practices to reduce HAIs. This study examined the perspectives of healthcare providers (HPs) and mothers in the neonatal intensive care unit on HAIs and determined the major barriers and facilitators to promoting standard IPC practices. This study draws on data from an ethnographic study using 38 in-depth interviews, four focus group discussions and participant observation conducted among HPs and mothers in neonatal intensive care units of a secondary- and tertiary-level hospital in Ghana. The qualitative data were analysed using a grounded theory approach, and NVivo 12 to facilitate coding. HPs and mothers demonstrated a modest level of understanding about HAIs. Personal, interpersonal, community, organizational and policy-level factors interacted in complex ways to influence IPC practices. HPs sometimes considered HAI concerns to be secondary in the face of a heavy clinical workload, a lack of structured systems and the quest to protect professional authority. The positive attitudes of some HPs, and peer interactions promoted standard IPC practices. Mothers expressed interest in participation in IPC activities. It however requires systematic efforts by HPs to partner with mothers in IPC. Training and capacity building of HPs, provision of adequate resources and improving communication between HPs and mothers were recommended to improve standard IPC practices. We conclude that there is a need for institutionalizing IPC policies and strengthening strategies that acknowledge and value mothers' roles as caregivers and partners in IPC. To ensure this, HPs should be better equipped to prioritize communication and collaboration with mothers to reduce the burden of HAIs.

Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions.

BACKGROUND: Malaria in pregnancy (MiP) is an important public health problem across sub-Saharan Africa. The package of measures for its control in Ghana in the last 20 years include regular use of long-lasting insecticide-treated bed nets (LLINs), directly-observed administration (DOT) of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and prompt and effective case management of MiP. Unfortunately, Ghana like other sub-Saharan African countries did not achieve the reset Abuja targets of 100% of pregnant women having access to IPTp and 100% using LLINs by 2015. METHODS: This ethnographic study explored how healthcare managers dealt with existing MiP policy implementation challenges and the consequences on IPTp-SP uptake and access to maternal healthcare. The study collected date using non-participant observations, conversations, in-depth interviews and case studies in eight health facilities and 12 communities for 12 months in two Administrative regions in Ghana. RESULTS: Healthcare managers addressed frequent stock-outs of malaria programme drugs and supplies from the National Malaria Control Programme and delayed reimbursement from the NHIS, by instituting co-payment, rationing and prescribing drugs for women to buy from private pharmacies. This ensured that facilities had funds to pay creditors, purchase drugs and supplies for health service delivery. However, it affected their ability to enforce DOT and to monitor adherence to treatment. Women who could afford maternal healthcare and MiP services and those who had previously benefitted from such services were happy to access uninterrupted services. Women who could not maternal healthcare services resorted to visiting other sources of health care, delaying ANC and skipping scheduled ANC visits. Consequently, some clients did not receive the recommended 5 + doses of SP, others did not obtain LLINs early and some did not obtain treatment for MiP. Healthcare providers felt frustrated whenever they could not provide comprehensive care to women who could not afford comprehensive maternal and MiP care. CONCLUSION: For Ghana to achieve her goal of controlling MiP, the Ministry of Health and other supporting institutions need to ensure prompt reimbursement of funds, regular supply of programme drugs and medical supplies to public, faith-based and private health facilities.

Health system, socio-cultural, economic, environmental and individual factors influencing bed net use in the prevention of malaria in pregnancy in two Ghanaian regions.

BACKGROUND: Improving maternal health remains a priority to the Ghanaian government. Consequently, it has implemented the World Health Organization recommendation of distributing free long-lasting insecticidal nets (LLINs) to pregnant women-one of the effective strategies to combating malaria in pregnancy. However, the burden of negative outcomes of malaria in pregnancy such as low birth weight and miscarriages is still high. This may be related to the health system, socio-cultural and economic dynamics that influence LLIN use, but their role is not well understood. This ethnographic study sought to understand health system, socio-cultural, economic and environmental dynamics in utilization of LLINs among pregnant women in two Ghanaian regions. METHODS: An ethnographic study design was used. In-depth interviews and conversations were conducted among health workers, pregnant women and opinion leaders. Observations were conducted in 12 communities and eight health facilities. Ethical clearance was obtained from the University of Health and Allied Sciences' Research Ethics Committee. Nvivo 11 was used to support data coding. Data were triangulated and analysed using a thematic approach. RESULTS: Findings suggest health system, socio-cultural, economic, environmental and individual factors influenced LLIN use. Health facility readiness in stocking LLINs influenced ownership and use. Receiving appropriate information from health providers and encouragement from public officials improved LLIN use. Women with a history of LLIN use prior to becoming pregnant and women who had young children remained consistent users. Experiencing irritating effects of LLINs and preference for traditional methods to wade off mosquitoes, reduced LLIN use. Pregnant women whose household and family members used LLINs were influenced positively to use them. Gender power relations between husbands and wives influenced women's use of LLINs. The type of housing and weather conditions contributed to inconsistent use. Staying out late for business purposes and to converse, exposed pregnant women to mosquito bites. CONCLUSION: Giving out LLINs at facility level should be accompanied with comprehensive information, which is relevant to the socio-cultural context that women live in. Mass distribution should factor in individual and public information to promote community acceptance and proper use of ITNs. Facilities should be encouraged to constantly maintain LLINs stock in order to ensure that ANC registrants receive LLINs for use.

Leadership styles in two Ghanaian hospitals in a challenging environment.

Hospital managers' power to exercise effective leadership in daily management can affect quality of care directly as well as through effects on frontline workers' motivation. This paper explores the influence of contextual factors on hospital managers' leadership styles and the motivation of frontline workers providing maternal and new born care in two public district hospitals in Ghana. It draws on data from an ethnographic study that involved participant observation, conversations and in-depth interviews conducted over 20 months, with frontline health workers and managers. Qualitative analysis software Nvivo 11 was used to facilitate coding, and common patterns emerging from the codes were grouped into themes. Ethical clearance was obtained from the Ghana Health Service Ethical Review Committee. Contextual factors such as institutional rules and regulations and funding constrained managers' power, and influenced leadership styles and responses to expressed and observed needs of frontline workers and clients. The contextual constraints on mangers' responses were a source of demotivation to both managers and frontline workers, as it hampered quality health service provision. Knowing what to do, but sometimes constrained by context, managers described 'feeling sick' and frustrated. On the other hand in the instances where managers' were able to get round the constraints and respond effectively to frontline health workers and clients' needs, they felt encouraged and motivated to work harder. Effective district hospital management and leadership is influenced by contextual factors; and not just individual manager's knowledge and skills. Interventions to strengthen management and leadership of public sector hospitals in low- and middle-income countries like Ghana need to consider context and not just individual managers' skills and knowledge strengthening.

'I Used to Fight with Them but Now I Have Stopped!': Conflict and Doctor-Nurse-Anaesthetists' Motivation in Maternal and Neonatal Care Provision in a Specialist Referral Hospital.

BACKGROUND AND OBJECTIVES: This paper analyses why and how conflicts occur and their influence on doctors and nurse-anaesthetists' motivation in the provision of maternal and neonatal health care in a specialist hospital. METHODOLOGY: The study used ethnographic methods including participant observation, conversation and in-depth interviews over eleven months in a specialist referral hospital in Ghana. Qualitative analysis software Nvivo 8 was used for coding and analysis of data. Main themes identified in the analysis form the basis for interpreting and reporting study findings. ETHICS STATEMENT: Ethical clearance was obtained from the Ghana Health Service Ethics Review board (approval number GHS-ERC:06/01/12) and from the University of Wageningen. Written consent was obtained from interview participants, while verbal consent was obtained for conversations. To protect the identity of the hospital and research participants pseudonyms are used in the article and the part of Ghana in which the study was conducted is not mentioned. RESULTS: Individual characteristics, interpersonal and organisational factors contributed to conflicts. Unequal power relations and distrust relations among doctors and nurse-anaesthetists affected how they responded to conflicts. Responses to conflicts including forcing, avoiding, accommodating and compromising contributed to persistent conflicts, which frustrated and demotivated doctors and nurse-anaesthetists. Demotivated workers exhibited poor attitudes in collaborating with co-workers in the provision of maternal and neonatal care, which sometimes led to poor health worker response to client care, consequently compromising the hospital's goal of providing quality health care to clients. CONCLUSION: To improve health care delivery in health facilities in Ghana, health managers and supervisors need to identify conflicts as an important phenomenon that should be addressed whenever they occur. Effective mechanisms including training managers and health workers on conflict management should be put in place. Additionally promoting communication and interaction among health workers can foster team spirit. Also resolving conflicts using the collaborating response may help to create a conducive work environment that will promote healthy work relations, which can facilitate the delivery of quality maternal and neonatal health care. However, such an approach requires that unequal power relations, which is a root cause of the conflicts is addressed.

'Your health our concern, our health whose concern?': perceptions of injustice in organizational relationships and processes and frontline health worker motivation in Ghana.

Taking a perspective of frontline health workers as internal clients within health systems, this study explored how perceived injustice in policy and organizational matters influence frontline health worker motivation and the consequent effect on workers' attitudes and performance in delivering maternal and neonatal health care in public hospitals. It consisted of an ethnographic study in two public hospitals in Southern Ghana. Participant observation, conversation and in-depth interviews were conducted over a 16-month period. Ethical approval and consent were obtained from relevant persons and authorities. Qualitative analysis software Nvivo 8 was used for coding and analysis of data. Main themes identified in the analysis form the basis for interpreting and reporting study findings. Findings showed that most workers perceived injustice in distributive, procedural and interactional dimensions at various levels in the health system. At the national policy level this included poor conditions of service. At the hospital level, it included perceived inequity in distribution of incentives, lack of protection and respect for workers. These influenced frontline worker motivation negatively and sometimes led to poor response to client needs. However, intrinsically motivated workers overcame these challenges and responded positively to clients' health care needs. It is important to recognize and conceptualize frontline workers in health systems as internal clients of the facilities and organizations within which they work. Their quality needs must be adequately met if they are to be highly motivated and supported to provide quality and responsive care to their clients. Meeting these quality needs of internal clients and creating a sense of fairness in governance arrangements between frontline workers, facilities and health system managers is crucial. Consequently, intervention measures such as creating more open door policies, involving frontline workers in decision making, recognizing their needs and challenges and working together to address them are critical.