Application of Hierarchical/Multilevel Models and Quality of Reporting (2010-2020): A Systematic Review.

Introduction: Multilevel models have gained immense popularity across almost every discipline due to the presence of hierarchy in most data and phenomena. In this paper, we present a systematic review on the adoption and application of multilevel models and the important information reported on the results generated from the use of these models. Methods: The review was performed by searching Google Scholar for original research articles on the application of multilevel models published between 2010 and 2020. The search strategy involved topics such as "multilevel models," "hierarchical linear models," and "mixed models with hierarchy." The search placed more emphasis on the application of hierarchical models in any discipline but excluded software methodological development and related articles. Results: A total of 121 articles were initially obtained from the search results. However, 65 articles met the inclusion criteria for the review. Out of the 65 articles reviewed, 46.2% were related to health/epidemiology, 15.4% to education and psychology, and 16.9% to social life. The majority of the articles (78.5%) were two-level models, and most of these studies modelled univariate responses. However, the few that modelled more than one response modelled them separately. Moreover, 83.1% were cross-sectional design, and 9.2% and 6.2% were longitudinal and repeated measures, respectively. Moreover, a little over half (55.4%) of articles reported on the intraclass correlation measure, and all articles indicated the response variable distribution where most (47.7%) were normally distributed. Only 58.5% of articles reported on the estimation methods used as Bayesian (20%) and MLE (18.5%). Again, model validation measures and statistical software were reported in 70.8% and 90.8% articles, respectively. Conclusion: There is an increase in the utilization of multilevel modelling in the last decade, which could be attributed to the presence of clustered and hierarchically correlated data structures. There is a need for improvement in the area of measurement and reporting on the intraclass correlation, parameter estimation, and variable selection measures to further improve the quality of the application of multilevel models. The integration of spatial effects into multilevel models is very limited and needs to be explored in the future.

Mapping the incidence rate of typhoid fever in sub-Saharan Africa.

BACKGROUND: With more than 1.2 million illnesses and 29,000 deaths in sub-Saharan Africa in 2017, typhoid fever continues to be a major public health problem. Effective control of the disease would benefit from an understanding of the subnational geospatial distribution of the disease incidence. METHOD: We collated records of the incidence rate of typhoid fever confirmed by culture of blood in Africa from 2000 to 2022. We estimated the typhoid incidence rate for sub-Saharan Africa on 20 km × 20 km grids by exploring the association with geospatial covariates representing access to improved water and sanitation, health conditions of the population, and environmental conditions. RESULTS: We identified six published articles and one pre-print representing incidence rate estimates in 22 sites in 2000-2022. Estimated incidence rates showed geospatial variation at sub-national, national, and regional levels. The incidence rate was high in Western and Eastern African subregions followed by Southern and Middle African subregions. By age, the incidence rate was highest among 5-14 yo followed by 2-4 yo, > 14 yo, and 0-1 yo. When aggregated across all age classes and grids that comprise each country, predicted incidence rates ranged from 43.7 (95% confidence interval: 0.6 to 591.2) in Zimbabwe to 2,957.8 (95% CI: 20.8 to 4,245.2) in South Sudan per 100,000 person-years. Sub-national heterogeneity was evident with the coefficient of variation at the 20 km × 20 km grid-level ranging from 0.7 to 3.3 and was generally lower in high-incidence countries and widely varying in low-incidence countries. CONCLUSION: Our study provides estimates of 20 km × 20 km incidence rate of typhoid fever across sub-Saharan Africa based on data collected from 2000 through 2020. Increased understanding of the subnational geospatial variation of typhoid fever in Africa may inform more effective intervention programs by better targeting resources to heterogeneously disturbed disease risk.

Fever in focus: Symptoms, diagnoses and treatment of febrile children in Ghana-A longitudinal hospital study.

BACKGROUND: Healthcare resources are often limited in areas of sub-Saharan Africa. This makes accurate and timely diagnoses challenging and delays treatment of childhood febrile illness. We explored longitudinal characteristics related to symptoms, diagnosis and treatment of hospitalised febrile children in a rural area of Ghana highly endemic for malaria. METHODS: Febrile children under 15 years, admitted to the study hospital paediatric ward, were recruited to the study and clinical data were collected throughout hospitalisation. Descriptive statistics were reported for all cases; for longitudinal analyses, a subset of visits with limited missing data was used. RESULTS: There were 801 hospitalised children included in longitudinal analyses. Malaria (n = 581, 73%) and sepsis (n = 373, 47%) were the most prevalent suspected diagnoses on admission. One-third of malaria suspected diagnoses (n = 192, 33%) were changed on the discharge diagnosis, compared to 84% (n = 315) of sepsis suspected diagnoses. Among malaria-only discharge diagnoses, 98% (n/N = 202/207) received an antimalarial and 33% (n/N = 69/207) an antibiotic; among discharge diagnoses without malaria, 28% (n/N = 108/389) received an antimalarial and 83% (n/N = 324/389) an antibiotic. CONCLUSIONS: Suspected diagnoses were largely based on clinical presentation and were frequently changed; changed diagnoses were associated with lingering symptoms, underscoring the need for faster and more accurate diagnostics. Medications were over-prescribed regardless of diagnosis stability, possibly because of a lack of confidence in suspected diagnoses. Thus, better diagnostic tools are needed for childhood febrile illnesses to enhance the accuracy of and confidence in diagnoses, and to cut down unjustified medication use, reducing the risk of antimicrobial and malaria resistance.

Awareness of and participation in mass drug administration programs used for onchocerciasis control in the Atwima Nwabiagya North District, Ghana.

BACKGROUND: Studies on Mass drug administration (MDA) in Ghana targeting various diseases, have mostly focused on factors that affect coverage and compliance to MDA with limited focus on evidence regarding awareness and community perception of the program. Therefore, this study sought to provide empirical evidence on the knowledge of onchocerciasis, and awareness of and participation in the MDA among community members. METHODS: A community-based cross-sectional survey was conducted from August to October 2019 in communities within the Atwima Nwabiagya North District, Ghana. Data was collected from 2,008 respondents. Bivariate and multivariate logistic regression analyses were performed to measure the associations between socio-demographics, having heard of onchocerciasis and its prevention, and levels of awareness of the MDA program. RESULTS: A total of 1268 respondents (63.2%) were aware of the MDA program. The majority ofMost respondents (74.4%) were of the view that the information given about the program was not enough and 45.4% of the respondents had no idea about the relevance of the MDA program. Respondents who had ever heard about onchocerciasis prevention and persons who had previously participated in the MDA program were more likely to be aware of the MDA program during implementation (AOR = 2.32; 95% CI 1.79-3.01 and AOR = 9.31; 95% CI 7.06-12.26, respectively). CONCLUSIONS: We observed a significant association between being aware of MDA campaigns and knowledge of onchocerciasis and its preventive methods, and participation in previous MDA campaigns. We recommend intensification and improvement of prevention campaigns regarding the onchocerciasis MDA program as key to ensuring increased MDA program participation.

Validation of prevalent diabetes risk scores based on non-invasively measured predictors in Ghanaian migrant and non-migrant populations - The RODAM study.

Background: Non-invasive diabetes risk models are a cost-effective tool in large-scale population screening to identify those who need confirmation tests, especially in resource-limited settings. Aims: This study aimed to evaluate the ability of six non-invasive risk models (Cambridge, FINDRISC, Kuwaiti, Omani, Rotterdam, and SUNSET model) to identify screen-detected diabetes (defined by HbA1c) among Ghanaian migrants and non-migrants. Study design: A multicentered cross-sectional study. Methods: This analysis included 4843 Ghanaian migrants and non-migrants from the Research on Obesity and Diabetes among African Migrants (RODAM) Study. Model performance was assessed using the area under the receiver operating characteristic curves (AUC), Hosmer-Lemeshow statistics, and calibration plots. Results: All six models had acceptable discrimination (0.70 ≤ AUC <0.80) for screen-detected diabetes in the overall/combined population. Model performance did not significantly differ except for the Cambridge model, which outperformed Rotterdam and Omani models. Calibration was poor, with a consistent trend toward risk overestimation for screen-detected diabetes, but this was substantially attenuated by recalibration through adjustment of the original model intercept. Conclusion: Though acceptable discrimination was observed, the original models were poorly calibrated among populations of African ancestry. Recalibration of these models among populations of African ancestry is needed before use.

Determinants of modern contraceptive use among married women and those living with a partner in Ghana.

The objective of the study was to ascertain the determinants of modern contraceptive use in Ghana among married women and those living with a partner. Secondary data from the Performance Monitoring and Accountability 2020 Ghana 2015 survey were used for the study. A multivariate logistic regression analysis was used. Modern contraceptive use was 25.5%. The significant predictors of modern contraceptive use were exposure to the media (AOR 2.07, 95% CI 1.20 - 3.55), residence in the Upper East region (AOR 0.26, 95% CI 0.10 - 0.71), final decision makers on contraceptive method either by themselves or jointly (AOR 0.26, 95% CI 0.14 -0.92), return to provider (AOR 6.96, 95% CI 3.59 - 13.49), refer relative or friend to provider (AOR 2.67, 95% CI 1.27 - 5.68), and parity of 5 or more (AOR 4.42, 95% CI 1.49 - 13.12). Media exposure on contraceptives and client satisfaction has the potential to improve modern contraceptive uptake in Ghana.

Subgroups of adult-onset diabetes: a data-driven cluster analysis in a Ghanaian population.

Adult-onset diabetes mellitus (here: aDM) is not a uniform disease entity. In European populations, five diabetes subgroups have been identified by cluster analysis using simple clinical variables; these may elucidate diabetes aetiology and disease prognosis. We aimed at reproducing these subgroups among Ghanaians with aDM, and establishing their importance for diabetic complications in different health system contexts. We used data of 541 Ghanaians with aDM (age: 25-70 years; male sex: 44%) from the multi-center, cross-sectional Research on Obesity and Diabetes among African Migrants (RODAM) Study. Adult-onset DM was defined as fasting plasma glucose (FPG) ≥ 7.0 mmol/L, documented use of glucose-lowering medication or self-reported diabetes, and age of onset ≥ 18 years. We derived subgroups by cluster analysis using (i) a previously published set of variables: age at diabetes onset, HbA1c, body mass index, HOMA-beta, HOMA-IR, positivity of glutamic acid decarboxylase autoantibodies (GAD65Ab), and (ii) Ghana-specific variables: age at onset, waist circumference, FPG, and fasting insulin. For each subgroup, we calculated the clinical, treatment-related and morphometric characteristics, and the proportions of objectively measured and self-reported diabetic complications. We reproduced the five subgroups: cluster 1 (obesity-related, 73%) and cluster 5 (insulin-resistant, 5%) with no dominant diabetic complication patterns; cluster 2 (age-related, 10%) characterized by the highest proportions of coronary artery disease (CAD, 18%) and stroke (13%); cluster 3 (autoimmune-related, 5%) showing the highest proportions of kidney dysfunction (40%) and peripheral artery disease (PAD, 14%); and cluster 4 (insulin-deficient, 7%) characterized by the highest proportion of retinopathy (14%). The second approach yielded four subgroups: obesity- and age-related (68%) characterized by the highest proportion of CAD (9%); body fat-related and insulin-resistant (18%) showing the highest proportions of PAD (6%) and stroke (5%); malnutrition-related (8%) exhibiting the lowest mean waist circumference and the highest proportion of retinopathy (20%); and ketosis-prone (6%) with the highest proportion of kidney dysfunction (30%) and urinary ketones (6%). With the same set of clinical variables, the previously published aDM subgroups can largely be reproduced by cluster analysis in this Ghanaian population. This method may generate in-depth understanding of the aetiology and prognosis of aDM, particularly when choosing variables that are clinically relevant for the target population.

Characterization of Typhoid Intestinal Perforation in Africa: Results From the Severe Typhoid Fever Surveillance in Africa Program.

Background: Typhoid intestinal perforation (TIP) remains the most serious complication of typhoid fever. In many countries, the diagnosis of TIP relies on intraoperative identification, as blood culture and pathology capacity remain limited. As a result, many cases of TIP may not be reported as typhoid. This study demonstrates the burden of TIP in sites in Burkina Faso, Democratic Republic of Congo (DRC), Ethiopia, Ghana, Madagascar, and Nigeria. Methods: Patients with clinical suspicion of nontraumatic intestinal perforation were enrolled and demographic details, clinical findings, surgical records, blood cultures, tissue biopsies, and peritoneal fluid were collected. Participants were then classified as having confirmed TIP, probable TIP, possible TIP, or clinical intestinal perforation based on surgical descriptions and cultures. Results: A total of 608 participants were investigated for nontraumatic intestinal perforation; 214 (35%) participants had surgically-confirmed TIP and 33 participants (5%) had culture-confirmed typhoid. The overall proportion of blood or surgical site Salmonella enterica subspecies enterica serovar Typhi positivity in surgically verified TIP cases was 10.3%. TIP was high in children aged 5-14 years in DRC, Ghana, and Nigeria. We provide evidence for correlation between monthly case counts of S. Typhi and the occurrence of intestinal perforation. Conclusions: Low S. Typhi culture positivity rates, as well as a lack of blood and tissue culture capability in many regions where typhoid remains endemic, significantly underestimate the true burden of typhoid fever. The occurrence of TIP may indicate underlying typhoid burden, particularly in countries with limited culture capability.

Sleep and Happiness in Urban-Dwelling Older Adults in Ghana: A Serial Multiple Mediation Model of Generalized Anxiety and Depressive Symptoms.

OBJECTIVE: Sleep problems (SP) are highly prevalent and seriously affect health and well-being in old age. The aim of this study was to examine the association between SP and happiness in an urban-dwelling older sample. The authors further explore the effects of generalized anxiety and depressive symptoms in the SP-happiness link using serial mediating modeling. METHODS: Data came from the 2016 to 2018 Aging, Health, Psychological Well-being, and Health-seeking Behavior Study in Ghana (n = 661). The authors measured happiness with the cross-culturally validated item on a five-point scale. The GAD-7 and the CESD-8, respectively, assessed generalized anxiety and depressive symptoms. Participants reported nighttime and daytime SP in the last 30 days. The SPSS-based Hayes' PROCESS macro program (Model 6) was constructed to quantify the hypothesized mediation effect. RESULTS: The analysis included 661 adults aged greater than or equal to 50 years (mean age = 65.53 [SD] = 11.89 years; 65.20% women). After full adjustment, path models showed that SP was negatively associated with happiness (ß = -0.1277, 95%CI = -0.15950 to -0.096). Bootstrapping estimates revealed that the SP-happiness link was serially mediated via generalized anxiety representing 8.77%, depressive symptoms yielding 18.95%, and anxiety symptoms→depressive symptoms accounting for 26.70% of the total effect. CONCLUSION: Generalized anxiety and depressive symptoms may explain the negative association between SP and happiness in urban-dwelling older adults in the sub-Saharan African (SSA) context. Interventions, social and clinical, to improve happiness through sleep quality should include ways to improve mental health. Longitudinal and cross-cultural data are warranted to assess the bi-directionality of this relationship.

Examining the risk factors for overweight and obesity among women in Ghana: A multilevel perspective.

Overweight/obesity prevalence is on the increase in epidemic proportions across Low- and Middle-Income countries (LMICs). The public health burden associated with obesity/overweight cannot be underestimated due to its association with chronic health outcomes. This study investigated the individual- and community level risk factors for obesity/overweight among reproductive women. The data used consist of 4393 reproductive women and form part of the 2014 Ghana Demographic and Health Survey (GDHS). Information on these women are clustered within 427 communities. A 2-tier random intercept multilevel logistic model was used to assess the effect of individual- and community level factors on the likelihood of a woman to be obese/overweight. The obesity/overweight prevalence among reproductive women was estimated to be 35.5% (95% CI: 34.04, 36.90%), which significantly differed across clusters. Most at risk were women from middle-income households (aOR = 2.85; 95% CI: 2.28, 3.56), upper-income households (aOR = 5.019, 95% CI: 3.85, 6.55), attaining secondary education (aOR = 1.74; 95% CI: 1.41, 2.16), and higher (aOR = 1.63; 95% CI: 1.14, 2.33), old age (20-29 years (aOR = 4.26; 95% CI: 3.142,5.78); 30-39 years (aOR = 8.59; 95% CI: 6.15, 12.00); 40-49 years (aOR = 12.81; 95% CI: 9.10, 18.16)). Significant differences in the probability of being overweight/obese between different communities were observed (MOR = 1.39). The high prevalence of overweight/obesity requires urgent public health interventions to prevent future public health crises. Efforts to strengthen the healthcare system, encourage lifestyle modification, and public health education are needed to solidify the gains of ensuring a healthy population by 2030 (SDG 3).

An exploration of stakeholder views and perceptions on taxing tobacco, alcohol and sugar-sweetened beverages in Ghana.

BACKGROUND: Non-communicable diseases (NCDs) account for nearly 43% of Ghana's all-cause mortality. Unhealthy commodities (such as alcohol, sugar and tobacco) are an important factor in the growing NCD burden in the region of sub-Saharan Africa (SSA). Despite health taxes on tobacco, alcohol and sugar-sweetened beverages (SSBs) gaining renewed attention, adoption and implementation in SSA remain limited. This study aims to unpack the contextual politics and to examine current perceptions of opportunities and barriers for health taxes in Ghana. METHODS: Semistructured qualitative interviews (n=19) conducted with purposively sampled stakeholders representing four sectors: government, civil society, media and international organisations, and two group interviews with nine industry stakeholders, informed by a review of relevant literature and policy/advocacy documents. RESULTS: Stakeholders had a general belief that such taxes are primarily useful for revenue generation (for health spending) rather than for reducing consumption and improving health. There do appear to be opportunities for health taxes with stakeholders broadly supportive of taxing SSBs. This support could be strengthened via 'health' framing of any new tax proposals, the generation of Ghana-specific evidence about the potential impacts of such taxes and greater public awareness. Industry actors and some government representatives opposed health taxes, citing concerns about the potential to increase illicit trade and economic harm. Some stakeholders also believed that links between politicians and affected industries represent an important barrier. CONCLUSION: These findings identify opportunities to introduce health taxes but also underline the potential resistance from affected industry stakeholders. Nevertheless, a strategic approach that focuses on achieving policy coherence (between central government, health and economic ministries), combined with efforts to strengthen stakeholder and public support, may weaken the lobbying position of industry. Such efforts could be supported by research to help demonstrate the value of different designs of health taxes for achieving Ghana's health goals and to better understand industry-political links.

Extent of illicit cigarette market from single stick sales in Ghana: findings from a cross-sectional survey.

OBJECTIVE: This study aims to measure the extent of illicit cigarette consumption from single stick sales, to determine the nature and types of illicit cigarettes present in Ghana, and to identify the factors associated with illicit cigarette consumption in Ghana. DESIGN: A cross-sectional study using empty cigarette packs generated by 1 day's single stick cigarette sales collected from cigarette vendors. SETTING: Five large cities (Accra, Kumasi, Takoradi, Tamale and Bolgatanga) and three border towns (Aflao, Paga/Hamele and Elubo) in the northern, middle and coastal belt of Ghana. PROCEDURE AND PARTICIPANTS: Ten areas were randomly selected in each city/town, and all shops selling cigarettes within 1 km of the central point were surveyed. OUTCOME MEASURES: (1) Estimates of the share of illicit cigarette packs in the total cigarette sales from vendors selling single stick cigarettes in Ghana; (2) nature and types of illicit cigarette packs; (3) factors associated with illicit cigarette sales in Ghana. RESULTS: Of a total of 4461 packs, about 20% (95% CI 18.3 to 20.7) were found to be illicit. Aflao (Ghana-Togo border) and Tamale (Ghana-Burkina Faso border) had the highest percentage of illicit cigarette sales at 99% and 46%, respectively (p<0.001). Over half of the illicit packs originated from Togo (51%), followed by Nigeria (15%) and then Cote d'Ivoire (10%). Adjusted and unadjusted logistic regression models indicated that convenience stores, border towns, pack price and the northern zone had higher odds of illicit cigarette sales. CONCLUSION: To effectively tackle illicit cigarettes, market surveillance and strengthening supply chain control are required, particularly at the border towns and the northern region of the country.

Cardiovascular Risk Estimation Based on Country-of-Birth- and Country-of-Residence-Specific Scores among Migrants in the Netherlands: The HELIUS Study.

BACKGROUND: Regional and country-specific cardiovascular risk algorithms have been developed to improve CVD risk prediction. But it is unclear whether migrants' country-of-residence or country-of-birth algorithms agree in stratifying the CVD risk of these populations. We evaluated the risk stratification by the different algorithms, by comparing migrant country-of-residence-specific scores to migrant country-of-birth-specific scores for ethnic minority populations in the Netherlands. METHOD: data from the HELIUS study was used in estimating the CVD risk scores for participants using five laboratory-based (Framingham, Globorisk, Pool Cohort Equation II, SCORE II, and WHO II) and three nonlaboratory-based (Framingham, Globorisk, and WHO II) risk scores with the risk chart for the Netherlands. For the Globorisk, WHO II, and SCORE II risk scores, we also computed the risk scores using risk charts specified for the migrant home country. Risk categorization was first done according to the specification of the risk algorithm and then simplified to low (green), moderate (yellow and orange), and high risk (red). RESULTS: we observed differences in risk categorization for different risk algorithms ranging from 0% (Globorisk) to 13% (Framingham) for the high-risk category, as well as differences in the country-of-residence- and country-of-birth-specific scores. Agreement between different scores ranged from none to moderate. We observed a moderate agreement between the Netherlands-specific SCORE II and the country-of-birth SCORE II for the Turkish and a nonagreement for the Dutch Moroccan population. CONCLUSION: disparities exist in the use of the country-of-residence-specific, as compared to the country-of-birth, risk algorithms among ethnic minorities living in the Netherlands. Hence, there is a need for further validation of country-of-residence- and country-of-birth-adjusted scores to ascertain appropriateness and reliability.

Pathogens associated with hospitalization due to acute lower respiratory tract infections in children in rural Ghana: a case-control study.

Respiratory infections are one of the most common causes of death among children under the age of five years. Data on prevalence and relevance of specific organisms in African children are still lacking. This case-control-study investigated prevalence and relevance of specific organisms in Ghanaian children admitted to hospital with symptoms of lower respiratory tract infection (LRTI). Pharyngeal swabs were taken and tested by PCR for 19 respiratory isolates. Adjusted odds ratios (aORs) were calculated to estimate associations between isolates and admission with LRTI. Population attributable fractions (PAFs) were calculated to assess the proportion of LRTI cases due to a particular pathogen. The study included 327 cases and 562 controls. We found associations between detection and admission for LRTI for influenza (aOR 98.6; 95% confidence interval (CI) 20.0-1789.6), respiratory syncytial virus (aOR 40.2; 95% CI 7.2-758.6), H. influenzae (aOR 4.1; 95% CI 2.2-7.9) and S. pneumoniae (aOR 2.4; 95% CI 1.7-3.4). PAFs ≥ 10% were observed for S. pneumoniae (30%; 95% CI 26-42), H. influenzae (10%; 95% CI 2-19) and influenza (10%; 95% CI 2-18). This study highlights the need for heightened surveillance and development of effective vaccines for respiratory pathogens other than SARS-CoV-2 in the future.

Cohort profile: Research on Obesity and Diabetes among African Migrants in Europe and Africa Prospective (RODAM-Pros) cohort study.

PURPOSE: The Research on Obesity and Diabetes among African Migrants (RODAM) prospective (RODAM-Pros) cohort study was established to identify key changes in environmental exposures and epigenetic modifications driving the high burden of cardiovascular disease (CVD) risk among sub-Saharan African migrants. PARTICIPANTS: All the participants in the RODAM cross-sectional study that completed the baseline assessment (n=5114) were eligible for the follow-up of which 2165 participants (n=638 from rural-Ghana, n=608 from urban-Ghana, and n=919 Ghanaian migrants in Amsterdam, the Netherlands) were included in the RODAM-Pros cohort study. Additionally, we included a subsample of European-Dutch (n=2098) to enable a comparison to be made between Ghanaian migrants living in the Netherlands and the European-Dutch host population. FINDINGS TO DATE: Follow-up data have been collected on demographics, socioeconomic status, medical history, psychosocial environment, lifestyle factors, nutrition, anthropometrics, blood pressure, fasting blood, urine and stool samples. Biochemical analyses included glucose metabolism, lipid profile, electrolytes and renal function, liver metabolism and inflammation. In a subsample, we assessed DNA methylation patterns using Infinium 850K DNA Methylation BeadChip. Baseline results indicated that migrants have higher prevalence of CVD risk factors than non-migrants. Epigenome-wide association studies suggest important differences in DNA methylation between migrants and non-migrants. The follow-up study will shed further light on key-specific environmental exposures and epigenetic modifications contributing to the high burden of CVD risk among sub-Saharan African migrants. FUTURE PLANS: Follow-up is planned at 5-year intervals, baseline completed in 2015 and first follow-up completed in 2021.

A two-mediator serial mediation chain of the association between social isolation and impaired sleep in old age.

Poor sleep is a long-term public health issue that has become increasingly prevalent among socially isolated older adults. However, research on the mechanisms explaining the link between social isolation and impaired sleep (IS) remains limited, particularly in low- and middle-income countries. This study explored the serial mediating effects of loneliness and mental distress on the association of social isolation with IS among Ghanaian older adults. We analyzed data from 1201 adults aged ≥ 50 from Ghana's AgeHeaPsyWel-HeaSeeB study (mean age = 66.14, SD = 11.85, age range = 50-111; women = 63.28%). Measures included the UCLA 3-item Loneliness Scale, modified Berkman-Syme Social Network Index, Sleep Quality Scale, and Mental Distress Questionnaire. We used bootstrapping techniques from Hayes' PROCESS macro program to estimate the hypothesized serial mediation. Social isolation was significantly associated with IS (ß = 0.242, p < 0.001). Crucially, social isolation indirectly predicted IS via three significant mediating pathways. Loneliness accounted for 17.6% (ß = 0.054, CI = 0.096, 0.016), mental distress accounted for 6.5% (ß = 0.020, 95% CI = 0.004, 0.040), and loneliness and mental distress accounted for 32.2% (ß = 0.099, 95% CI = 0.065, 0.138) of the overall effect. The total mediating effect was 56.4%. These findings suggest that the social isolation-sleep link is respectively and serially explained by loneliness and mental distress. Social integrative interventions for sleep quality in old age should target mental and emotional well-being.

Using drones to transport suspected COVID-19 samples; experiences from the second largest testing centre in Ghana, West Africa.

BACKGROUND: The declaration of COVID-19 as a pandemic on March 11 2020, by the World Health Organisation prompted the need for a sustained and a rapid international response. In a swift response, the Government of Ghana, in partnership with Zipline company, launched the use of Unmanned Automated Vehicles (UAV) to transport suspected samples from selected districts to two foremost testing centres in the country. Here, we present the experiences of employing this technology and its impact on the transport time to the second largest testing centre, the Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR) in Kumasi, Ghana. METHODS: Swab samples collected from suspected COVID-19 patients were transported to the Zipline office by health workers. Information on the samples were sent to laboratory personnel located at KCCR through a WhatsApp platform to get them ready to receive the suspected COVID-19 samples while Zipline repackaged samples and transported them via drone. Time of take-off was reported as well as time of drop-off. RESULTS: A total of 2537 COVID-19 suspected samples were received via drone transport from 10 districts between April 2020 to June 2021 in 440 deliveries. Ejura-Sekyedumase District Health Directorate delivered the highest number of samples (765; 30%). The farthest district to use the drone was Pru East, located 270 km away from KCCR in Kumasi and 173 km to the Zipline office in Mampong. Here, significantly, it took on the average 39 minutes for drones to deliver samples compared to 117 minutes spent in transporting samples by road (p<0.001). CONCLUSION: The use of drones for sample transport during the COVID-19 pandemic significantly reduced the travel time taken for samples to be transported by road to the testing site. This has enhanced innovative measures to fight the pandemic using technology.

Effectiveness of school-based interventions for preventing tobacco smoking initiation among young people in low- and middle-income countries: a systematic review protocol.

BACKGROUND: Despite the commendable progress made globally in tobacco control, the world is falling short of achieving a 30% relative reduction in current tobacco use by 2025. The African region remains the least in the efforts in fighting the tobacco epidemic and is most exploited by the tobacco industry. Schools have been continuously used for over three decades as a setting for delivering youth smoking prevention programmes; however, the evidence of the effectiveness of those school-based interventions provides varying outcomes. Also, interventions that proved to be effective, in high-income countries (HICs), may not necessarily be effective in the African region as a result of cultural differences and other contrasting factors. An existing systematic review that explored school-based tobacco prevention programmes among the youth in African countries from 2000 to 2016 showed partial effectiveness. This review will address the gap by updating the 2016 review to examine studies in LMICs to generate findings to help target resources which have the potential to save lives by preventing smoking initiation among young people. METHODS: The JBI methodology for systematic reviews of effectiveness will guide the conduct of this review. A comprehensive strategic search will be developed to retrieve both published and unpublished studies that evaluate school-based interventions to prevent tobacco smoking initiation among in-school young people in LMICs compared to non-intervention programmes. Published studies would be from databases such as MEDLINE via Ovid, CINAHL via EBSCO, Embase, PsycINFO, PsycEXTRA, and the Cochrane Central Register of Controlled Trials. Sources of grey literature would be ProQuest Dissertations and Theses, MedNar, EBSCO Open Dissertations, Open Access Theses and Dissertations, and Trove. The databases will be searched for published studies in the English language. The processes of study selection, critical appraisal, data extraction, and data synthesis will be in accordance with the JBI approach for reviews of effectiveness with a minimum of two reviewers at each stage. The primary outcome of the review will be the non-initiation of tobacco smoking by the youth. DISCUSSION: The review will provide synthesized evidence on the effectiveness of school-based smoking initiation prevention among young people in LMICs. The findings of the review would support policymakers and programme implementers to develop targeted interventions for effective tobacco control initiatives. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021246206.

Detection of Salmonella Typhi nucleic acid by RT-PCR and anti-HlyE, -CdtB, -PilL, and -Vi IgM by ELISA at sites in Ghana, Madagascar and Ethiopia.

BACKGROUND: We aimed to assess the prevalence of Salmonella Typhi through DNA and IgM-antibody detection methods as a prelude to extended surveillance activities at sites in Ghana, Madagascar, and Ethiopia. METHODS: We performed species-specific real-time polymerase reaction (RT-PCR) to identify bacterial nucleic acid, and enzyme-linked immunosorbent assay (ELISA) for detecting HlyE/STY1498-, CdtB/STY1886-, pilL/STY4539- and Vi-antigens in blood and biopsy specimens of febrile and non-febrile subjects. We generated antigen-specific ELISA proxy cut-offs by change-point analyses, and utilized cumulative sum as detection method coupled with 1000 repetitive bootstrap analyses. We computed prevalence rates in addition to odds ratios to assess correlations between ELISA outcomes and participant characteristics. RESULTS: Definitive positive RT-PCR results were obtained from samples of febrile subjects originating from Adama Zuria/Ethiopia (1.9%, 2/104), Wolayita Sodo/Ethiopia (1.0%, 1/100), Diego/Madagascar (1.0%, 1/100), and Kintampo/Ghana (1.0%, 1/100), and from samples of non-febrile subjects from Wolayita Sodo/Ethiopia (1%, 2/201). While IgM antibodies against all antigens were identified across all sites, prevalence rates were highest at all Ethiopian sites, albeit in non-febrile populations. Significant correlations in febrile subjects aged < 15 years versus ≥ 15 years were detected for Vi (Odds Ratio (OR): 8.00, p = 0.034) in Adama Zuria/Ethiopia, STY1498 (OR: 3.21, p = 0.008), STY1886 (OR: 2.31, p = 0.054) and STY4539 (OR: 2.82, p = 0.022) in Diego/Madagascar, and STY1498 (OR: 2.45, p = 0.034) in Kintampo/Ghana. We found statistical significance in non-febrile male versus female subjects for STY1498 (OR: 1.96, p = 0.020) in Adama Zuria/Ethiopia, Vi (OR: 2.84, p = 0.048) in Diego/Madagascar, and STY4539 (OR: 0.46, p = 0.009) in Kintampo/Ghana. CONCLUSIONS: Findings indicate non-discriminatory stages of acute infections, though with site-specific differences. Immune responses among non-febrile, presumably healthy participants may mask recall and/or reporting bias leading to misclassification, or asymptomatic, subclinical infection signs induced by suppression of inflammatory responses. As most Ethiopian participants were ≥ 15 years of age and not at high-risk, the true S. Typhi burden was likely missed. Change-point analyses for generating ELISA proxy cut-offs appeared robust, though misclassification is possible. Our findings provided important information that may be useful to assess sites prior to implementing surveillance for febrile illness including Salmonella disease.

Effect of fear appeal mobile phone messaging on health behaviors of caregivers with children under-five in Ghana.

Social and Behavior Change Communication is a vital strategy in the control of malaria. However, the effectiveness of fear appeal tactic as a preventive strategy remains uncertain. This study examined the influence of a fear appeal mobile phone-based intervention, guided by Witte's Extended Parallel Process model, on malaria prevention among caregivers with children under-five. We conducted a quasi-experimental study of a 12-month intervention using a sample of 324 caregivers from two rural districts, assigned to either an intervention or control group. The intervention group received fear appeal voice Short Message Service (SMS), once a week for twelve (12) months, while caregivers in the control group received none. The results showed that exposure to the messages was associated with an increased odds of positive attitude [adjusted Odds ratio (aOR) = 2.58; 95% CI 1.61-4.15] and behavioral changes (aOR = 2.03, 95% CI 1.29-3.19). The intervention group exhibited lower odds of defensive avoidance (aOR = 0.44, 95% CI 0.29-0.68) and message minimization (aOR = 0.51, 95% CI 0.33-0.78) compared with the control group. These findings highlight the importance of communicating health messages via mobile phones using fear appeal for improving the health behaviors of caregivers. This strategy, however, may not be useful for influencing the intention of caregivers to engage in positive health practices to protect their children from malaria.