Exploring the knowledge, attitude, and practices of over-the-counter medical sellers in Ghana.

Background: Rural areas in sub-Saharan Africa face a high prevalence and morbidity of skin disease while also lacking access to dermatologists. In Ghana, where approximately 25 licensed dermatologists are available for 25 million people, community pharmacies, called over-the-counter medical sellers (OTCMS), were established to respond to accessibility inequities, albeit without equitable training. Objective: Our study evaluates the dermatologic knowledge, attitudes, and practices (KAP) of OTCMS in Ghana's Ashanti Region. Methods: To assess dermatologic KAP, we created a standardized questionnaire and recorded 13 interviews with OTCMS in seven communities. Interviews were completed with help from Ghanaian translators and transcripts were transcribed verbatim, then analyzed qualitatively to determine common themes for analysis. Results: This analysis identified six major themes: i) prescriber qualifications; ii) diagnostics; iii) therapeutics; iv) economics; v) health systems integration; vi) care-seeking behavior. Analysis of these themes outlined many cultural roles and challenges of OTCMS, including serving as the primary contact for dermatologic conditions in rural communities. While possibly necessary due to the lack of accessible dermatologists, this raises concerns for potential harm in diagnostic error and misuse of therapeutics due to the lack of formal dermatology training. Conclusion: In rural parts of Ghana, the KAP of OTCMS play a pivotal role in assessing and treating skin disease for those who might otherwise lack access to adequate dermatologic management. Furthermore, although our study identifies potential issues related to the roles played by OTCMS, it also suggests strategies to improve the dermatologic health of many Ghanaians by enhancing education and healthcare delivery in rural areas.

Strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low- and middle-income countries: a narrative review.

BACKGROUND: Skilled attendance at birth is considered key to accomplishing Sustainable Development Goal (SDG) 3.1 aimed at reducing maternal mortality. Many maternal deaths can be prevented if a woman receives care by skilled health personnel. Maternal utilization of skilled health delivery services in rural areas in low- and middle-income countries is 70% compared to 90% in urban areas. Previous studies have found community-based interventions may increase rural maternal uptake of skilled health delivery services, but evidence is lacking on which strategies are most effective. OBJECTIVE: To review the effectiveness of community-based strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low-and middle-income countries. METHODS: We conducted a narrative review. PubMed, CINAHL, Cochrane Library, and PsycINFO databases were searched for articles from database inception through 13 November 2019. Key search terms were pre-determined. Information was extracted on studies meeting our inclusion criteria: cluster and randomized trials, rural setting, reproductive aged women, community engagement, low- and middle-income countries. Studies were considered effective if statistically significant (p < 0.05). A narrative synthesis was conducted. RESULTS: Ten cluster randomized trials out of 5,895 candidate citations met the inclusion criteria. Strategies included home-based visits, women's groups, and combined approaches. Out of the ten articles, only three studies were found to significantly increase maternal uptake of skilled health personnel for delivery, and each used a different strategy. The results are inconclusive as to which strategies are most effective. Limitations of this review include heterogeneity and generalizability of studies. CONCLUSIONS: This research suggests that different strategies may be effective at improving maternal utilization of skilled health personnel for delivery in certain rural settings while ineffective in others. More research is warranted to better understand the context in which strategies may be effective and under what conditions.

A Qualitative Analysis of Factors Impacting Comprehensive Cleft Lip and Palate Care in Ghana.

OBJECTIVE: The objective of this study was to examine practices regarding cleft lip and palate (CLP) among medical professionals and caregivers of children with CLP and to identify barriers and facilitators to comprehensive CLP care at a hospital in West Africa. DESIGN: Qualitative methods used consisted of individual semistructured interviews with caregivers of children with CLP and one focus group with CLP team members. SETTING: A majority of the interviews took place in the hospital, with some occurring during home visits. The focus group was conducted in the same hospital. PARTICIPANTS: Forty-five caregivers of children with CLP and 1 adult with CLP completed an interview. Additionally, 2 of the caregivers had CLP and completed an interview from their perspective. The focus group consisted of 13 CLP team members from a comprehensive CLP team in Ghana. INTERVENTIONS: Interviews consisted of semistructured, open-ended questions, and the focus group relied on a discussion guide. Line-by-line coding was used to identify common themes regarding barriers and facilitators to CLP care. RESULTS: Barriers to CLP care that were consistent across caregiver interviews and the focus group were lack of knowledge regarding CLP, stigma and cultural beliefs surrounding CLP, transportation, financial, and feeding/nutrition issues. Barriers to care identified in the interviews and focus group were similar; however, facilitators to care varied greatly between the 2. CONCLUSIONS: Two different qualitative methods provided unique perspectives on barriers and facilitators to CLP care. However, patients and caregivers continue to face substantial barriers to obtaining care.

Point prevalence of asymptomatic Plasmodium infection and the comparison of microscopy, rapid diagnostic test and nested PCR for the diagnosis of asymptomatic malaria among children under 5 years in Ghana.

BACKGROUND: Plasmodium infection among children is a serious public health problem. Asymptomatic malaria infection among humans serves as a significant reservoir for transmitting Plasmodium to uninfected Anopheles mosquitoes, fueling malaria endemicity and asymptomatic malaria may progress to clinical malaria. Therefore, prompt and accurate diagnosis of malaria infection is crucial for the management and control of malaria, especially in endemic areas. This study assessed the point prevalence of asymptomatic malaria infection and evaluated the performance of malaria Rapid Diagnostic Tests (RDT), light microscopy and nested PCR (nPCR) for the diagnosis of asymptomatic malaria infection in a paediatric population in the Atwima Nwabiagya North district, Ghana. METHODS: This cross-sectional study enrolled 500 asymptomatic children aged ≤ 5 years. After consent was obtained from a parent, blood samples were collected from each participant to assess for Plasmodium infection based on histidine rich protein-2 (pfHRP-2)-based malaria RDT, light microscopy and nPCR. RESULTS: The point prevalence of asymptomatic malaria by microscopy, RDT, and nPCR were 116/500 (23.2%), 156/500 (31.2%), and 184/500 (36.8%), respectively. Using nPCR as the reference, RDT presented with a perfect sensitivity (100.0%), specificity (100.0%), accuracy (100.0%), and reliability (100.0%) in detecting asymptomatic P. falciparum infection. Likewise, microscopy presented with an excellent specificity and high accuracy in detecting both P. falciparum (100.0%; 85.6%) and P. malariae (100.0%; 100.0%). However, the sensitivity (56.4%) and reliability (56.4%) of microscopy was low for both P. falciparum. CONCLUSION: The findings of this study indicate a high point prevalence of asymptomatic Plasmodium infection among children in Atwima Nwabiagya North district, Ghana. In the absence of the more sensitive PCR, pfHRP-2-based malaria RDT provides substantial diagnostic sensitivity, specificity, accuracy and reliability and is superior to microscopy.

Abortion in rural Ghana: Cultural norms, knowledge and attitudes.

Using qualitative methodology, semi-structured questionnaires were administered to participants in the Barakese subdistrict of Ghana in order to understand the extent to which men and women have knowledge of family planning services and in what ways cultural norms, practices, and attitudes toward abortion affect the decision to abort. Women in the community pursue abortion using unsafe methods, despite fear of shame, bleeding, infection, or death, as the perceived cost of maintaining the pregnancy is greater. Protective factors that were reported to dissuade women from pursuing unsafe abortion include fear of social disgrace, divine retribution, and death. Women reported the inability to control the timing of their pregnancies, despite harboring knowledge of family planning. Concerned about perceived side effects of modern family planning methods, respondents chose to use fertility awareness methods or to use no contraception. There remains a gap between knowledge of the benefits of and the actual use of family planning methods, leading to unwanted pregnancy and seeking unsafe abortion. Intensified health promotion and education regarding side effects to combat misconceptions related to contraception, as well as expanding alternative contraceptive options to all regions of Ghana, are critical to improve uptake.

Social Deterministic Factors to Participation in the National Health Insurance Scheme in the Context of Rural Ghanaian Setting.

The primary purpose of this study is to identify predictors of complete household enrollment into the National Health Insurance Scheme (NHIS) among inhabitants of the Barekese sub-district in the Ashanti Region of Ghana. Heads of households in 20 communities from the Barekuma Collaborative Community Project site were interviewed to gather data on demographic, socioeconomic status (SES) indicators and complete household subscription in the NHIS. Logistic regression model was used to predict enrollment in the NHIS. Of the 3228 heads of households interviewed, 60 percent reported having all members of their respective households enrolled in the NHIS. Residents in the classified Middle and High SES brackets had 1.47 (95% CI: 1.21-1.77) and 1.66 (95% CI: 1.27-2.16) times higher odds, respectively, of complete household enrollment compared to their counterparts in the Low SES category. The odds of enrolling in the program tend to increase progressively with the highest level of education attained by the head of the family unit. Eight years after the introduction of the national health insurance policy in Ghana, the reported subscription rate for complete households was about 60 percent in the 20 rural communities that participated in the study. This finding calls for the need to step up further national strategies that will help increase enrollment coverage, especially among the poor and less educated in the rural communities.

Spatial Analysis of Factors Associated with Household Subscription to the National Health Insurance Scheme in Rural Ghana.

The use of health insurance schemes in financing healthcare delivery and to minimize the poverty gap is gaining considerable recognition among the least developed and resource challenged countries around the world. With the implementation of the socialized health insurance scheme, Ghana has taken the lead in Sub-Saharan Africa and now working out further strategies to gain universal coverage among her citizenry. The primary goal of this study is to explore the spatial relationship between the residential homes and demographic features of the people in the Barekese subdistrict in Ghana on the probability to enroll the entire household unit in the National Health Insurance Scheme (NHIS). Household level data were gathered from 20 communities on the enrollment status into the NHIS alongside demographic and socioeconomic indicators and the spatial location of every household that participated in the study. Kulldorff's purely spatial scan statistic was used to detect geographic clusters of areas with participatory households that have either higher or lower enrollment patterns in the insurance program. Logistic regression models on selected demographic and socioeconomic indicators were built to predict the effect on the odds of enrolling an entire household membership in the NHIS. Three clusters significantly stood out to have either high or low enrollment patterns in the health insurance program taking into accounts the number of households in those sub-zones of the study region. Households in the Cluster 1 insurance group have very high travel expenses compared to their counterparts in the other idenfied clusters. Travel cost and time to the NHIS registration center to enroll in the program were both significant predictors to participation in the program when controlling for cluster effect. Residents in the High socioeconomic group have about 1.66 [95% CI: 1.27-2.17] times the odds to enroll complete households in the insurance program compared to their counterparts in the Low socioeconomic group. The study demonstrated the use of spatial analytical tools to identify clusters of household enrollment pattern in the NHIS among residents in rural Ghana. In the face of limited resources, policy makers can therefore use the findings as guideline to strategically channel interventions to areas of most need. Furthermore, these analyses can be repeated annually to assess progress on improving insurance coverage.

Forming a supplement intervention using a multi-theoretical behavior model.

OBJECTIVES: To identify behavior theory-based strategies to improve compliance with daily multiple micronutrient supplementation (MMS) among rural Ghanaian women. METHODS: Components of a multi-theoretical framework were investigated in focus groups of reproductive-aged women in 6 communities. RESULTS: Participants were generally unaware of MMS' purpose. Perceived benefits included better health and stimulated appetite, which some believe escalates food purchases and financial constraints. Cost, forgetfulness, and unsustainability were also perceived barriers. Facilitators for compliance incorporated initial visual reminders and daily announcements with reinforcement using the 'keeper' system. CONCLUSIONS: Application of a tailored health behavioral model can effectively guide the design, implementation and evaluation of community-based MMS interventions.

The burden and correlates of hypertension in rural Ghana: a cross-sectional study.

AIM: Cardiovascular diseases (CVDs), of which hypertension is a major risk factor, are predicted to account for four times as many deaths as from communicable diseases by the year 2020. Hypertension, once rare, is rapidly becoming a major public health burden in sub-Saharan Africa (SSA). However, data on its prevalence, awareness, treatment and control are paltry, especially for rural communities. This study was done to determine the burden and correlates of adult hypertension in the rural Barekese sub-district of Ghana. METHODS: A cross-sectional survey was conducted on 425 adults aged ≥ 35 in the Barekese sub district (estimated population 18,510). Socio-demographic characteristics, modifiable and non-modifiable risk factors, blood pressure (BP) and anthropometric measurements were collected using standardized protocols. RESULTS: Overall, the proportion of hypertension and isolated systolic hypertension is 44.7% and 32.7% respectively in the study population. However, 64.9% of these were on treatment, with only 8.9% having controlled blood pressure (<140/90 mmHg). The mean systolic and diastolic BP were 134.38 mmHg (standard deviation, SD: 21.46) and 84.32 mmHg (SD: 12.44). Obesity (Body Mass Index, BMI>30 kg/m²) was found in 37 (10.4% of the population), out of whom 7 (15.9%) were extremely obese (BMI> 40 kg/m²). Increasing age and level of education were positively correlated with increasing blood pressure. CONCLUSION: The high burden of hypertension in this population along with the considerable less detection, treatment and control is of great concern. There is the need to promote health education measures that will foster prevention and early detection of hypertension.

Development and validation of the Indian Adolescent Health Questionnaire.

The period of adolescence is a critical time of development. There is an urgent need to better assess adolescent health worldwide, particularly in India, a country with the world's largest adolescent population. Validated screening tools are needed to evaluate health-related risks and behaviors in this growing demographic. We developed, validated and administered a school-based health assessment, the Indian Adolescent Health Questionnaire, which can be used as a comprehensive health-screening tool among Indian adolescents in secondary school.

Impact of early and concurrent stunting on cognition.

Undernutrition is associated with poor cognitive development, late entry into school, decreased years of schooling, reduced productivity and smaller adult stature. We use longitudinal data from 1674 Peruvian children participating in the Young Lives study to assess the relative impact of early stunting (stunted at 6-18 months of age) and concurrent stunting (stunted at 4.5-6 years of age) on cognitive ability. Anthropometric data were longitudinally collected for children at 6-18 months of age and 4.5-6 years of age at which time verbal and quantitative ability were also assessed. We estimate that an increase in concurrent height-for-age z-scores (HAZ) by one standard deviation was associated with an increase in a child's score on the Peabody Picture Vocabulary Test (PPVT) by 2.35 points [confidence interval (CI): 1.55-3.15] and a 0.16 point increase on the cognitive development assessment (CDA) (CI: 0.05-0.27). Furthermore, we report that the estimate for concurrent HAZ and PPVT is significantly higher than the estimate for early stunting and PPVT. We found no significant difference between early and concurrent estimates for HAZ and CDA. Children from older mothers, children whose mothers had higher education levels, children living in urban areas, children who attended pre-school, children with fewer siblings and children from wealthier backgrounds scored higher on both assessments. Cognitive skills of children entering school were associated with early stunting but the strongest association was found with concurrent stunting suggesting that interventions preventing linear growth faltering should not only focus on the under 2s but include children up to 5 years of age.

Family planning in a sub-district near Kumasi, Ghana: side effect fears, unintended pregnancies and misuse of a medication as emergency contraception.

The Barekuma Collaborative Community Development Project (BCCDP) performed a study regarding family planning in communities in the Barekese sub-district near Kumasi, Ghana in July 2010. Eighty-five women, ages 15-49 years, in three communities were interviewed with a modified version of the 2008 Ghana Demographic and Health Survey. While virtually all women recognized at least one family planning method, half of all recent or current pregnancies were unintended and 20 percent of women had a previous abortion. Unexpectedly, 27 percent of women had misused norethisterone tablets (Primolut N or "N-tablets"), a synthetic progesterone, as emergency contraception. Women had a variety of concerns about family planning methods, including one-third having a fear of side effects for hormonal methods (particularly heart palpitations), as well as unfamiliarity with and particular aspects they did not like for most methods. However, women were interested in learning more about side effects as well as modern fertility awareness-based methods. There is an urgent need for interventions aimed at regulating and implementing the correct use of Primolut N tablets, addressing real and perceived side effects of family planning practices through properly trained community health nurses and introducing modern methods of fertility awareness such as Standard Days Method and the Two-day Method in the Barekese sub-district.

Verbal autopsy: an analysis of the common causes of childhood death in the Barekese sub-district of Ghana.

The availability of mortality data for any society plays an essential role in health monitoring and evaluation, as well as in the design of health interventions. However, most resource-poor countries such as Ghana have no reliable vital registration system. In these instances, verbal autopsy (VA) may be used as an alternative method to gather mortality data. In rural Ghana, the research team utilized a VA questionnaire to interview caretakers who were present with a child under the age of five prior to death. The data was given to two physicians who independently assigned the most probable cause of death for the child. A third, blinded physician analyzed the data in the cases where the first two physicians disagreed. When there was agreement between physicians, this was assigned as the cause of death for the individual child. During the study period, we recorded 118 deaths from 92 households. Twenty-nine (24.6%) were neonatal deaths with the leading causes of death being neonatal sepsis, birth asphyxia and pneumonia. The remaining 89 (75.4%) were post-neonatal deaths with the most common causes of death being pneumonia, malaria and malnutrition. While 63/118 (53.4%) deaths occurred in the home, there is no statistically significant relationship between the location of the home and the time of travel to the nearest health facility (P=0.132). VA is an important epidemiological tool for obtaining mortality data in communities that lack reliable vital registration systems. Improvement in health care is necessary to address the large number of deaths occurring in the home.

Verbal Autopsy: an Analysis of the Common Causes of Childhood Death in the Barekese Sub-District of Ghana

The availability of mortality data for any society plays an essential role in health monitoring and evaluation; as well as in the design of health interventions. However; most resource-poor countries such as Ghana have no reliable vital registration system. In these instances; verbal autopsy (VA) may be used as an alternative method to gather mortality data. In rural Ghana; the research team utilized a VA questionnaire to interview caretakers who were present with a child under the age of five prior to death. The data was given to two physicians who independently assigned the most probable cause of death for the child. A third; blinded physician analyzed the data in the cases where the first two physicians disagreed. When there was agreement between physicians; this was assigned as the cause of death for the individual child. During the study period; we recorded 118 deaths from 92 households. Twenty-nine (24.6) were neonatal deaths with the leading causes of death being neonatal sepsis; birth asphyxia and pneumonia. The remaining 89 (75.4) were post-neonatal deaths with the most common causes of death being pneumonia; malaria and malnutrition. While 63/118 (53.4) deaths occurred in the home; there is no statistically significant relationship between the location of the home and the time of travel to the nearest health facility (P=0.132). VA is an important epidemiological tool for obtaining mortality data in communities that lack reliable vital registration systems. Improvement in health care is necessary to address the large number of deaths occurring in the home

Children who recover from early stunting and children who are not stunted demonstrate similar levels of cognition.

Stunting is associated with adverse cognitive development in childhood and adolescence, fewer years of schooling, decreased productivity, and reduced adult stature. Recovery from early stunting is possible; however, few studies explore whether those who demonstrate linear catch-up growth experience long-term cognitive deficits. Using longitudinal data on 1674 Peruvian children from the Young Lives study, we identified factors associated with catch-up growth and assessed whether children who displayed catch-up growth have significantly lower cognition than children who were not stunted during infancy and childhood. Based on anthropometric data for children 6-18 mo of age and again for the same children when they were 4.5-6 y of age, we categorized participants as not stunted, stunted in infancy but not childhood (catch-up), stunted in childhood, and stunted in infancy and childhood. Children who had grandparents in the home, had less severe stunting in infancy, and had taller mothers were more likely to demonstrate catch-up growth by round 2. Children who experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted (P = 0.6 and P = 0.7, respectively). Those stunted in childhood as well as those stunted in infancy and childhood scored significantly lower on both assessments than children who were not stunted. Based on findings from this study, policy makers and program planners should consider redoubling efforts to prevent stunting and promote catch-up growth over the first few years of life as a way of improving children's physical and intellectual development.

Pregnancy and Village Outreach Tibet: a descriptive report of a community- and home-based maternal-newborn outreach program in rural Tibet.

OBJECTIVE: The Pregnancy and Village Outreach Tibet (PAVOT) program, a model for community- and home-based maternal-newborn outreach in rural Tibet, is presented. METHODS: This article describes PAVOT, including the history, structure, content, and activities of the program, as well as selected program outcome measures and demographic characteristics, health behaviors, and pregnancy outcomes of women who recently participated in the program. RESULTS: The PAVOT program was developed to provide health-related services to pregnant rural Tibetan women at risk of having an unattended home birth. The program involves training local healthcare workers and laypersons to outreach pregnant women and family members. Outreach includes basic maternal-newborn health education and simple obstetric and neonatal life-saving skills training. In addition, the program distributes safe and clean birth kits, newborn hats, blankets, and maternal micronutrient supplements (eg, prenatal vitamins and minerals). More than 980 pregnant women received outreach during the study period. More than 92% of outreach recipients reported receiving safe pregnancy and birth education, clean birthing and uterine massage skills instruction, and clean umbilical cord care training. Nearly 80% reported basic newborn resuscitation skills training. Finally, nearly 100% of outreach recipients received maternal micronutrient supplements and safe and clean birth kits. CONCLUSION: The PAVOT program is a model program that has been proven to successfully provide outreach to rural-living Tibetans by delivering maternal-newborn health education, skills training, and resources to the home.

Exploring the relationship between chronic undernutrition and asymptomatic malaria in Ghanaian children.

BACKGROUND: A moderate association has been found between asymptomatic parasitaemia and undernutrition. However, additional investigation using the gold standard for asymptomatic parasitaemia confirmation, polymerase chain reaction (PCR), is needed to validate this association. Anthropometric measurements and blood samples from children less than five years of age in a rural Ghanaian community were used to determine if an association exists between chronic undernutrition and PCR-confirmed cases of asymptomatic malaria. METHODS: This was a descriptive cross-sectional study of 214 children less than five years of age from a community near Kumasi, Ghana. Blood samples and anthropometric measurements from these children were collected during physical examinations conducted in January 2007 by partners of the Barekuma Collaborative Community Development Programme. RESULTS: Findings from the logistic model predicting the odds of asymptomatic malaria indicate that children who experienced mild, moderate or severe stunting were not more likely to have asymptomatic malaria than children who were not stunted. Children experiencing anaemia had an increased likelihood (OR = 4.15; 95% CI: 1.92, 8.98) of asymptomatic malaria. Similarly, increased spleen size, which was measured by ultrasound, was also associated with asymptomatic malaria (OR = 2.17; 95% CI: 1.44, 3.28). Fast breathing, sex of the child, and age of the child were not significantly associated with the asymptomatic malaria. CONCLUSIONS: No significant association between chronic undernutrition and presence of asymptomatic malaria was found. Children who experience anaemia and children who have splenomegaly are more likely to present asymptomatic malaria. Programmes aimed at addressing malaria should continue to include nutritional components, especially components that address anaemia.