Biobehavioral survey using time location sampling among female sex workers living in Ghana in 2020.

Background: The HIV epidemic in Ghana is characterized as a mix of a low-level generalized epidemic with significant contributions from transmission among female sex workers (FSW) and their clients. This study seeks to identify and describe key characteristics and sexual behaviors of FSW and estimate the prevalence of HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus (HBV) among FSW in Ghana. Method: A total of 7,000 FSW were recruited for the study using Time Location Sampling (TLS) approach with 5,990 (85.6%) participants completing both biological and the behavioral aspects of the study. A structured questionnaire was administered to respondents to assess several factors, such as background characteristics, sexual risk behaviors, condom usage, HIV/AIDS knowledge, opinions, and attitudes. Trained staff conducted face-to-face interviews using mobile data collection software (REDCap) after provision of specimens for HIV and STI testing. Descriptive statistics such as medians, ranges, charts, and percentages are performed and presented. Also included, are bivariate analyses to establish relationships between FSW type and other relevant characteristics of the study. Results: Among the 7,000 (100%) FSW sampled from all regions, 6,773 took part in the behavioral and 6,217 the biological. There were 783 (11.2%) respondents who took part only in the behavioral and 227 (3.2%) only in the biological. Most were young, with a median age of 26 years, majority had never been married or were widowed/divorced and a quarter had no education or had only primary education. Majority (74.8%) of FSW first sold sex at age 25 years or less with a median age of 20 years. Most (84.8%) of the FSW indicated that they entered sex work for money, either for self or family and had an average of eleven (11) sexual partners per week. More than half (55.2%) of the FSW were new entrants who had been in sex work for less than 5 years before the study. Consistent condom use with paying clients was generally unsatisfactory (71%), and was however, very low (24%) with their intimate partners or boyfriends. Only about half (54.6%) of FSW have been exposed to HIV prevention services in the last three months preceding the survey, and this varies across regions. Overall, comprehensive knowledge about HIV and AIDS was low. Only 35% of FSW had comprehensive knowledge. HIV prevalence was 4.6% and was higher among seaters (brothel-based) and older FSW who had been sex work for a longer period. The HIV prevalence from the previous bio-behavioral survey (BBS) in 2015 and 2011 were estimated to be 6.9 and 11.1%, respectively. Conclusion: Compared to the results from the previous studies, the findings give an indication that Ghana is making significant progress in reducing the burden of HIV among FSW in the country. However, risky behaviors such as low consistent condom use, low coverage of HIV services across the regions, and low comprehensive knowledge could reverse the gains made so far. Immediate actions should be taken to expand coverage of HIV services to all locations. Efforts must be made to reach out to the new entrants while also addressing strongly held myths and misconceptions about HIV.

Correlates of prevalent HIV infection among adolescents, young adults, and older adult female sex workers in Ghana: Analysis of data from the Ghana biobehavioral survey.

BACKGROUND: Human immunodeficiency virus infection remains a high burden among key populations such as female sex workers in the world. We aimed to provide distribution of prevalence and correlates of Human immunodeficiency virus infection among adolescent, young, and older adult FSWs in Ghana. METHODS: This data was obtained from the biobehavioral survey of female sex workers (2020) in Ghana based on a time location sampling approach for the selection of respondents. A sampling frame was developed taking into consideration list of venues, days, and time that sex workers operate across all the regions of Ghana. These lists were derived from a sampling universe which was obtained during a mapping exercise. All sex workers aged 16 years and above and eligible on the day of visit participated. Human immunodeficiency virus testing was done based on First Response and Oraquick. To obtain estimates for sex workers, sampling weights were calculated and applied to the dataset. Inferential analyses using Bayesian regression models were applied with interaction effects. RESULTS: A total of 5,990 participants completed both the biological and behavioral aspects of the study. The HIV prevalence among female sex workers in Ghana was 4.67% (CI: 4.05%, 5.40%). About 70% of the respondents who tested positive for Human immunodeficiency virus were among the older adults (= >25 years) group. Generally, there was a high prevalence variation across the 16 regions of Ghana, from 0.00% to 8.40%. Respondents' age was a significant contributor to the prevalence of HIV. Respondents who were forced into having sex had higher odds (38%) of being positive in the combined analysis. Respondents who had comprehensive knowledge of HIV had lower odds (39%) of testing positive. CONCLUSION: The findings suggest a low prevalence of HIV among sex workers in 2020 compared to the 2011 and 2015 biobehavioral survey results but higher than the general population. Specifically, older adults have a higher prevalence of HIV. There is generally low level of comprehensive knowledge among sex workers. Interventions geared towards increasing FSW knowledge on risky behavior should be vigorously pursued.

Continuity of care among diabetic patients in Accra, Ghana.

Introduction: Diabetes mellitus is a fast-rising non-contagious disease of global importance that remains a leading cause of indisposition and death. Evidence shows that effective management of diabetes has a close link with continuity of care which is known to be the integral pillar of quality care. This study, therefore, sought to determine the extent of continuity of care between diabetic patients and their care providers as well as factors associated with relational continuity of care. Methodology: This cross-sectional, facility-based study was conducted among diabetics in Accra, Ghana. We sampled 401 diabetic patients from three diabetic clinics in the region using a stratified and systematic random sampling technique. Data were collected using a structured questionnaire containing information on socio-demographic characteristics, the four dimensions of continuity of care, and patients' satisfaction. A 5-point Likert scale was used to measure patient's perception of relational, flexible, and team continuity, while most frequent provider continuity was used to measure longitudinal continuity of care. Scores were added for each person and divided by the highest possible score for each domain to estimate the continuity of care index. Data were collected and exported to Stata 15 for analysis. Results: The results show that team continuity was the highest (0.9), followed by relational and flexibility continuity of care (0.8), and longitudinal continuity of care was the least (0.5). Majority of patients experienced high team (97.3%), relational (68.1%), and flexible (65.3%) continuity of care. Most patients (98.3%) were satisfied with the diabetes care they received from healthcare providers. Female subjects had higher odds of experiencing relational continuity of care as compared to male subjects. Furthermore, participants with higher educational levels were five times more likely to experience relational continuity of care than those with lower educational background. Conclusion: The study demonstrated that the majority of diabetics had team continuity of care being the highest experienced among the four domains, followed by flexible and longitudinal being the least experienced. Notably, team and flexible continuity of care had a positive association with relational continuity of care. Higher educational level and being female were associated with relational continuity of care. There is therefore the need for policy action on the adoption of multidisciplinary team-based care.

Exploring factors influencing acceptability of online capacity building platform for HIV and AIDS monitoring and evaluation in Ghana.

Introduction: Ghana's multi-sectoral approach towards the management of HIV and AIDS has resulted in many community-level activities and programs aimed at stopping HIV infections and reducing the impact of HIV and AIDS. This study seeks to investigate whether Monitoring & Evaluation (M&E) officers in Ghana will be willing to join in an electronic learning platform which is web-based as a means of building M&E capacity. Methods: 123 out of 130 participants were involved in the study. Continuous and categorical variables were analysed using means and proportions. Structural equation Modelling technique was used to determine the factors associated with acceptability/intention to use. Results: The results showed that Attitude toward usage had a positive significant influence on acceptability/intention to use (AITU). In addition, experience with online learning and Internet discussion also had a positive influence on perceived usefulness and perceived ease of use respectively. The overall model shows 71% of variation of M&E officers' attitude toward usage on acceptability/intention to use online M&E platform as observed by the covariates in the model. Conclusions: Attitude toward usage was observed to be the strongest determinant of the AITU online HIV/AIDS M&E platform for monitoring and evaluation activities.

Behavioural Risk for HIV, Hepatitis B, and Hepatitis C Infections among a Population of Drug Users and Injectors across Four Regions in Ghana.

Background: Blood borne infections such as HIV, Hepatitis B (HBV), and Hepatitis C (HCV) are of great importance to governments and their implementing partners, especially among people who use drugs (PWUD) and people who inject drugs (PWID). Prevalence and determinants of HIV, HBV, and HCV among PWUD and PWID in Ghana are not well established, the significance of this study. Method: This assessment was a cross-sectional study implemented via the respondent driven sampling approach. A team of community advisory boards that comprised former users, current users, and civil society organizations were constituted to help in the implementation of the study. The study was conducted in four regions in Ghana. The assessment was based on a representation of populations of PWID and PWUD from the four regions. Efforts were made by the team to ensure adequate representation of women where feasible. A quantitative questionnaire was developed and used to obtain information on the respondents' sociodemographics, sexual behavior, substance use, and biological characteristics. The prevalence of HIV, HBV, and HCV among PWID and PWUD was determined using blood samples. First response and oral quick test for confirmation of HIV positivity were carried out, while SD bioline was used to test for the presence of HBV and HBC. Data were analyzed using the Bayesian generalized linear model via the binomial family of distributions under the logit link function with weak Cauchy and Normal distribution as prior. Results: A total of 323 PWUD and PWID participants were interviewed across four regions of Ghana. The overall median age of the respondents was 36 (28, 43) years. The prevalence of HIV, HBV, and HCV infection in the study was 2.5%, 4.6%, and 5.9%, respectively. The prevalence of HIV, HBV, and HCV among drug users was 2.5% (95% CI: 0.7%-4.2%), 4.1% (95% CI: 1.8%-6.2%), and 6.7% (95% CI: 3.9%-9.4%), respectively. Most drug injectors and users started using and injecting drugs at ages less than 20 years and between 20 and 29 years, respectively. Drug users who identified themselves as part of the general population were 66% less likely to be tested HIV positive (POR = 0.34, CrI: 0.12-0.81) compared to sex workers. Part time employment respondents had fivefold odds (POR = 5.50, CrI: 1.20-16.16) of being HBV positive as against full-time employment. Conclusion: Most of the injectors and users started drugs at an early age. Drug users and injectors are at higher risk of these infections because of associated risky sexual behaviors and risky injection practices. Harm reduction programs to help addicts who are willing to quit the practice are recommended.

Sexual and reproductive health education and its association with ever use of contraception: a cross-sectional study among women in urban slums, Accra.

BACKGROUND: Sexual and reproductive health education among girls and women has several reproductive health benefits, including improved contraceptive knowledge, contraception use at first intercourse, increased chance of contraceptive use in a lifetime, and effective usage of contraceptives. It is however not clear whether women/girls in urban slums who have had sexual and reproductive health education would likely utilize contraception. This study sets out to test the hypothesis that Accra slum women who have had sex education have higher chances of ever using contraception. METHODS: A cross-sectional survey was conducted among reproductive aged women in two slums (i.e. Agbogbloshie and Old Fadama) in Accra, Ghana. A sample size of 691, made up of respondents who provided responses to the question on ever used contraception, sex education as well as those with complete information on all the other variables of interest was considered in this study. Binary logistic regression models were fitted to examine association between sexual and reproductive health education and ever use of contraception. Crude odds ratios (cOR) and adjusted odds ratios (aOR) at p-value less than 0.05 were used to assess the strength of the association between the outcome and independent variables. RESULTS: More than half (56.73%) of the women have never received sexual and reproductive health education. Most of the respondents (77.28%) had ever used contraceptives. Women who had no form of sexual and reproductive health education had lower odds of ever using contraception (OR = 0.641, 95% CI 0.443, 0.928) and this persisted after controlling for the effect of demographic factors (AOR = 0.652, 95% CI 0.436, 0.975] compared to those who have ever received any form of sex education. Non-married women as well as women who were exposed to media (newspapers/radio/television) were also more likely to use contraceptives in slums in Accra, Ghana. CONCLUSION: The study revealed a relatively low prevalence of sex education among women in urban slums in Accra. However, sex education was found to increase the odds of ever use of contraception. These findings call for intensified sexual and reproductive health education among reproductive aged girls and women in urban slums in Accra using existing informal social networks and local media platforms.

Sexual and reproductive health education among girls and women has several reproductive health benefits, including improved contraceptive knowledge, contraception use at first intercourse, increased chance of contraceptive use in a lifetime, and effective usage of contraceptives. It is however not clear whether women/girls in urban slums who have had some form of sex education would likely utilize contraception more than those who have not. This study sets out to test the hypothesis that Accra slum women who have had sex education have higher chances of ever using contraception. A cross-sectional survey was conducted among reproductive aged women in two slums (i.e. Agbogbloshie and Old Fadama) in Accra, Ghana. A sample size of 691 girls/women aged 15­49 was considered. More than half (56.73%) of the women had never received some form of sex education. Most of the respondents (77.28%) had ever used contraceptives. Women who had no form of sex education had lower odds of ever using contraception and this persisted after controlling for the effect of demographic factors compared to those who have ever received any form of sex education. Non-married women as well as women who were exposed to media (newspapers/radio/television) were also more likely to use contraceptives in slums in Accra, Ghana. In sum, the study revealed that while prevalence of sex education was relatively low among urban slum women, sex education generally increased the chances of ever use of contraception. These findings call for more and targeted sexual and reproductive health education among reproductive aged girls and women in urban slums in Accra using existing informal social networks and local media platforms.

Fragmentation of care during pregnancy in the Volta Region of Ghana: A social network analysis approach.

To determine the extent of care fragmentation during pregnancy and delivery in the Volta Region of Ghana. The National Health Insurance Claims Data for the Volta Region for the period January -December 2013 was used. Pregnant women who delivered at a health facility and made at least 3 visits were included in the study. Social network analysis (SNA) approach was used to determine care fragmentation. Fragmentation of care during delivery was defined to be any delivery at a facility different from the woman's most frequently visited antenatal care (ANC) facility. Network metrics (weighted in-degree and weighted out-degree) were used to determine extent of care fragmentation and also the key facilities contributing to the fragmentation. Overall, 14,474 pregnant women were included in the study with 15% (2,185) having cesarean section (CS). A total of 6,025 (42%) of all the pregnant women visited more than one facility during ANC and delivery, out of which 960 (16%) had CS. About 26% (3,769) of all deliveries and 32% (696) of all CS deliveries were fragmented. Fragmentation among those that had CS was significantly higher compared to those that had vaginal delivery (VD) (32% versus 25%, x²=45.88, p<0.001). Among those who visited multiple facilities, 63% (73% CS and 61% VD, x²=49.22, p<0.001) were fragmented. In addition, 15% of all deliveries (36% among those who visited multiple facilities) and 20% of all CS deliveries (45% among those who visited multiple facilities) were performed at facilities that the pregnant women never received ANC services from. There is high level of care fragmentation during the critical period of delivery among pregnant women who visited more than one facility. This fragmentation is particularly higher among those that had CS compared to vaginal delivery. This calls for policy to ensure coordination and continuity of care during pregnancy.

Testing the effect of an integrated-intervention to promote access to sexual and reproductive healthcare and rights among women with disabilities in Ghana: a quasi-experimental study protocol.

BACKGROUND: There is evidence that women with disabilities (WWDs) experience the most difficulty accessing and using sexual and reproductive health and rights (SRHRs) services and information worldwide. However, there are currently no workable interventions to reach WWDs with essential SRHR services. This study aims to test the effect of an integrated health facility and individual-level intervention on access to SRHRs information and services among sexually active WWDs aged 15-49 years in Ghana. METHODS: A quasi-experimental study design with four arms will be implemented in four districts in the Northern region of Ghana to test the effect of three inter-related interventions. The inventions are (1) capacity building in disability-centred SRHRs information and service delivery for healthcare providers, (2) support for WWDs to access disability-unfriendly healthcare infrastructure, and (3) one-on-one regular SRHRs education, information provision, and referral. The first two interventions are at the health-facility level while the third one is at the individual/family level. The first arm of the experiment will expose eligible WWDs to all three interventions. In the second arm, WWDs will be exposed to only the two-health facility-level interventions. The third arm will expose WWDs to only the individual level intervention. The forth arm will constitute the control group. A total of 680 (170 in each arm) sexually active women with physical disability and visual impairments will take part in the study over a period of 12 months. To assess the effect of the interventions on key study outcomes (i.e. awareness about, and use of modern contraceptive, ANC attendance, and skilled delivery among parous women), pre- and post-intervention surveys will be conducted. Difference-in-Difference analysis will be used to examine the effect of each intervention in comparison to the control group, while controlling for confounders. Cost-effectiveness analyses will also be conducted on the three-intervention arms vis a vis changes in key outcome measures to identify which of the three interventions is likely to yield greater impact with lower costs. DISCUSSION: Lack of access to SRHRs information and services for WWDs is not only a violation of their right to appropriate and quality SRH care but could also undermine efforts to achieve equitable healthcare access as envisaged under SDG 3. This research is expected to generate evidence to inform local health programmes to increase access to SRHRs among WWDs by strengthening local health system capacity to provide disability-sensitive SRHRs services. Trial registration Name of the registry: Pan African Clinical Trials Registry (PACTR). Trial ID: 14591. Date of registration: 02/01/2020. URL of trial registry record: https://pactr.samrc.ac.za/Researcher/TrialRegister.aspx?TrialID=14591.

Women with disabilities (WWDs) experience a lot of difficulty accessing sexual and reproductive health and rights (SRHRs) services and information worldwide. However, there are currently no workable specific interventions to reach WWDs with essential SRHRs services. We propose to implement three interventions to enable WWDs in Ghana who are aged 15­49 years gain better access to SRHRs services and information. Our aim is show whether these interventions have beneficial effects by helping many more WWDs access and use SRHRs services and information like modern contraceptives. To achieve this objective, we will (1) train healthcare providers in ways to better provide SRHRs information and service to WWDs; (2) support WWDs to access disability-unfriendly healthcare infrastructure by creating access ramps at health facilities; (3) train and deploy community health volunteers to undertake one-on-one regular home visits to educate WWDs on SRHRs, provide information on SRHRs and refer WWDs to healthcare providers. A total of 680 sexually active women with physical and visual impairments will take part in the study over a period of 12 months. We will divide the women into four groups (170 in each group). The first group will be exposed to all the three interventions. The second group will be exposed to only interventions 1 and 2. The third group will be exposed to only intervention 3. The fourth group will not be exposed to any of the three interventions. Our study is expected to strengthen the local health system capacity to provide disability-sensitive SRHRs services.

Determinants of Higher-Risk Sexual Behavior in Some Selected African Countries.

BACKGROUND: Although higher-risk sexual behavior (H-RSB) is a major contributor to the rapid rising rate of new HIV infections, there exists paucity of comprehensive evidence across the sub-Saharan African region. The purpose of this study was to determine the prevalence of H-RSB and its determinants across sub-Saharan Africa to inform policy. METHOD: Data were obtained from the Demographic and Health Survey (DHS) of ten sub-Saharan African (SSA) countries with their three most current DHS surveys from 2000 to 2016. Only participants who ever had sexual encounters in their lifetime were included in the study. Weighted adjusted Cox regression with robust variance and constant time was used to investigate disparities of H-RSB among the ten SSA countries. Relationships between sociodemographic, socioeconomic, knowledge, mass media, and H-RSB were investigated. RESULTS: The trend and prevalence of higher-risk sexual behavior show that Lesotho experienced a decreasing trend of the prevalence of H-RSB from 8.92 in period one to 6.42 in period three. Ghana experienced a marginal increase from 6.22 in period one to 6.76 in period two and then to 6.43 in the third period. However, Malawi, Zambia, and Zimbabwe obtained a marginal increasing trend in the prevalence of H-RSB from period one to three: 2.75 to 3.74, 4.33 to 6.24, and 6.11 to 7.99, respectively. Meanwhile, the prevalence of H-RSB in Namibia and Uganda decreased in period two to 1.84 and 5.76 but increased in period three to 2.01 and 6.83, respectively. Generally, determinants of H-RSB among the countries include age, sex, religious affiliation, marital status, educational level, employment status, economic status, age at first sex, and status of circumcision. CONCLUSION: Trend of relatively high prevalence of H-RSB has been found across majority of the countries with key sociodemographic factors influencing H-RSB. Therefore, different targeted interventional approaches are needed in all the countries to help reduce H-RSB and the overall HIV incidence. If issues regarding sexual behavior and sexual health are not addressed adequately, H-RSB can negate all the appreciable efforts aimed at ending the HIV pandemic by 2030.

National and subnational size estimation of female sex workers in Ghana 2020: Comparing 3-source capture-recapture with other approaches.

BACKGROUND: Key Population size estimation (PSE) is instrumental for HIV/STI preventive, treatment and care services planning, implementation and delivery. The objective was to estimate the overall population of female sex workers (FSW) in all the 16 regions of Ghana using different PSE methods. METHOD: Mapping of venues and complete enumeration of seaters was conducted at the formative stage prior to the bio-behavioral survey (BBS). Three PSE methods were used to derive the size estimates of FSW in the 16 regions. These include: Capture-recapture (CRC), service multiplier and three-source capture recapture (3SCRC) methods. The final choice of the estimation method used to estimate the roamer population was 3SCRC. This method was chosen because of its perfect record-linkage-hierarchic combination of three names that minimizes overmatching as well as the addition of an interaction term in the model which corrects for the dependencies in CRC. RESULTS: The total population size estimate of the female sex workers in the country obtained for roamers using capture re-capture was 41,746 (95% CI: 41,488-41,932). Using the service multiplier, the total population for both the roamers and seaters was 41,153 (95% CI: 37,242-45,984). The 3-source capture re-capture yielded 55,686 roamers FSW (95% CI: 47,686-63,686). The seater population was 4,363 FSW based on census/complete enumeration. The total population size estimate of FSW (seaters and roamers) in Ghana was 60,049 when 3SCRC and census were added. This represents about 0.76% of all estimated adult females aged 15-49yrs in Ghana. CONCLUSION: We report population size estimates (PSE) for FSW in Ghana. These estimates are the results of 3SCRC. These findings provide a valid and reliable source of information that should be referenced by government officials and policymakers to plan, implement and provide HIV/STI preventive, treatment, and care services for FSW in Ghana.

Comprehensive Knowledge of HIV and AIDS among Ghanaian Adults from 1998 to 2014: A Multilevel Logistic Regression Model Approach.

BACKGROUND: In order for stakeholders of HIV and AIDS to effectively plan HIV prevention programs, it is expedient to assess the level of individuals' knowledge on the most common preventive methods and misconceptions of the HIV virus. This study examines the trends and determinants of comprehensive knowledge (CK) of HIV and AIDS among Ghanaians from 1998-2014. METHOD: The data used for this study were drawn from the Ghana Demographic Health Surveys (GDHS), 1998-2014. A separate analysis was performed on each survey-year data and GDHS pooled dataset. Additionally, both the male and female datasets were combined. The samples used for the study were 6,389, 10706, 9484, and 13784 representing 1998, 2003, 2008, and 2014, respectively. The pooled dataset consisted of 40363 responses. The Pearson chi-square test and multilevel binary logistic regression analysis were carried out to assess the association between the study variables and CK of HIV and AIDS. RESULTS: CK of HIV and AIDS was found to be lower in women than men (29.24% vs. 37.7%) using the pooled dataset. The Greater Accra region recorded the highest percentage of CK of HIV and AIDS (44.18%), whereas the Northern region recorded the lowest (17.87%) among the 10 administrative regions in Ghana. Comprehensive knowledge of HIV and AIDS was also found to be less likely with an OR of 0.72 (95% CI; 0.65, 0.79, p < 0.001) among persons living in rural areas even after controlling for other study variables. There is also a decrease of CK of HIV and AIDS from 37.35% in 2008 to 32.5% in 2014. The lowest percentage (10.75%) of CK of HIV and AIDS among the four survey years was recorded in 1998. CONCLUSION: There are generally low levels of comprehensive knowledge among the Ghanaian adult population more especially among women. Those residing in rural areas have lower prevalence of CK of HIV and AIDS. To address some of these challenges, there is the need to intensify educational interventions more especially among women and people leaving in rural areas to reverse some of the knowledge gaps and correct the local misconceptions of HIV and AIDS.

Capacity for optimal performance of healthcare supply chain functions: competency, structural and resource gaps in the Northern Region of Ghana.

PURPOSE: The study drew on capacity framework around the individual, organisational, health system and wider context to explore gaps in health supply chain (HSC) workers capacity and competency to perform supply chain (SC) functions and the lessons for workforce development. DESIGN/METHODOLOGY/APPROACH: A mixed-method study was conducted across the Northern Region of Ghana. Qualitative data were collected from in-depth interviews with 34 key SC managers at the regional, district and facility levels. A semi-structured questionnaire was administered through the RedCap mobile app to 233 core HSC workers and non-core workers (clinicians with additional responsibilities in SC). Data were managed and analysed inductively and deductively for themes. FINDINGS: Weak knowledge and competency in SC functions attributed to poor training exposure and organisational support for capacity building, undermined the capacity to perform basic SC functions, especially by the non-core category. The policy and regulatory environment of the HSC marketplace were described as fluid and with complexity of demands. Both worker categories, therefore, requested functional, technical, managerial and customer care competencies to anticipate and manage complexities. Structural characteristics of the health system giving narrow decision space to HSC workers cascaded the capacity for innovation and initiative and promoted frustrations among mid-level managers. Infrastructural deficits and shortfalls in operational resources scaled back the capacity to efficiently manage inventory and ensure that commodities reach clients in good quality. ORIGINALITY/VALUE: Finding suggest that capacity building of HSC workers, strengthening of health institutions structural and resource capacity, and leveraging on technology will enable optimal performance of HSC functions.

Longitudinal continuity of care during antenatal and delivery in the Volta Region of Ghana.

OBJECTIVE: To determine the extent of longitudinal continuity of care (CoC) during pregnancy and delivery in the Volta Region of Ghana. METHODS: Longitudinal data were used from the National Health Insurance Claims Dataset for the period January to December 2013 for pregnant women who sought antenatal and delivery care in the region. Pregnant women who delivered at a health facility with at least three visits were included in the study. Five CoC indices were calculated for each pregnant woman. RESULTS: Of the 14 474 pregnant women included in the study, 58.4% had perfect CoC. Mean CoC indices were: most frequent provider continuity (MFPC) 0.82 ± 0.25; modified, modified continuity index (MMCI) 0.86 ± 0.20; continuity of care index (COCI) 0.76 ± 0.30; sequential continuity index (SECON) 0.80 ± 0.28; and place of delivery continuity (PDC) 0.68 ± 0.41. CONCLUSION: There are relatively medium to high levels of CoC indices during pregnancy and delivery, with place of delivery CoC having the lowest score, an indication that more pregnant women switched providers during delivery. There is a need for policy to ensure CoC during pregnancy.

Capacity building for implementation research: a methodology for advancing health research and practice.

BACKGROUND: Implementation research is increasingly being recognised as an important discipline seeking to maximise the benefits of evidence-based interventions. Although capacity-building efforts are ongoing, there has been limited attention on the contextual and health system peculiarities in low- and middle-income countries. Moreover, given the challenges encountered during the implementation of health interventions, the field of implementation research requires a creative attempt to build expertise for health researchers and practitioners simultaneously. With support from the Special Programme for Research and Training in Tropical Diseases, we have developed an implementation research short course that targets both researchers and practitioners. This paper seeks to explain the course development processes and report on training evaluations, highlighting its relevance for inter-institutional and inter-regional capacity strengthening. METHODS: The development of the implementation research course curriculum was categorised into four phases, namely the formation of a core curriculum development team, course content development, internal reviews and pilot, and external reviews and evaluations. Five modules were developed covering Introduction to implementation research, Methods in implementation research, Ethics and quality management in implementation research, Community and stakeholder engagement, and Dissemination in implementation research. Course evaluations were conducted using developed tools measuring participants' reactions and learning. RESULTS: From 2016 to 2018, the IR curriculum has been used to train a total of 165 researchers and practitioners predominantly from African countries, the majority of whom are males (57%) and researchers/academics (79.4%). Participants generally gave positive ratings (e.g. integration of concepts) for their reactions to the training. Under 'learnings', participants indicated improvement in their knowledge in areas such as identification of implementation research problems and questions. CONCLUSION: The approach for training both researchers and practitioners offers a dynamic opportunity for the acquisition and sharing of knowledge for both categories of learners. This approach was crucial in demonstrating a key characteristic of implementation research (e.g. multidisciplinary) practically evident during the training sessions. Using such a model to effectively train participants from various low- and middle-income countries shows the opportunities this training curriculum offers as a capacity-building tool.

Design and evaluation of a subcutaneous contraceptive implant training simulator.

OBJECTIVE: To design and fabricate a subcutaneous contraceptive implant insertion simulator, and to characterize the performance of nursing students trained with and without the simulator. METHOD: A cross-sectional study was conducted on nursing students in Ghana who had no previous training in the insertion of contraceptive implants. They were given standardized training in insertion of implants from 25 April to 26 April, 2016, and then were randomly assigned to an intervention or control group. The control group watched insertions of live implants while the intervention group practiced using the simulator. Local materials were used to fabricate the simulator. The performance of both groups was assessed after the training. RESULTS: The participants consisted of 50 nursing students. Those in the intervention group were more likely to: insert the implant accurately (95.2% vs 78.4%, P<0.001); take less time to complete an insertion (mean of 33.6 seconds vs 42.2 seconds, P<0.001); and commit fewer errors (1.9 vs 2.5, P=0.005) compared to the control group. In addition, participants rated the simulator high on 11/11 of the product requirements with the teaching (93.2%), learning (91.4%), and skill acquisition (88.6%) requirements being the highest rated. CONCLUSION: A low-cost, locally fabricated simulator is an effective tool for augmenting the current training protocol by improving insertion skills of contraceptive implants.

Factors influencing unmet need for family planning among Ghanaian married/union women: a multinomial mixed effects logistic regression modelling approach.

BACKGROUND: Unmet need for family planning is high (30%) in Ghana. Reducing unmet need for family planning will reduce the high levels of unintended pregnancies, unsafe abortions, maternal and neonatal morbidity and mortality. The purpose of this study was to examine factors that are associated with unmet need for family planning to help scale up the uptake of family planning services in Ghana. METHODS: This cross sectional descriptive and inferential study involved secondary data analysis of women in the reproductive age (15-49 years) from the Ghana Demographic and Health Survey 2014 data. The outcome variable was unmet need for family planning which was categorized into three as no unmet need, unmet need for limiting and unmet need for spacing. Chi-squared test statistic and bivariate multilevel multinomial mixed effects logistic regression model were used to determine significant variables which were included for the multivariable multilevel multinomial mixed effects logistic regression model. All significant variables (p < 0.05) based on the bivariate analysis were included in the multinomial mixed effects logistic regression model via model building approach. RESULTS: Women who fear contraceptive side effects were about 2.94 (95% CI, 2.28, 3.80) and 2.58 (95% CI, 2.05, 3.24) times more likely to have an unmet need for limiting and spacing respectively compared to those who do not fear side effects. Respondents' age was a very significant predictor of unmet need for family planning. There was very high predictive probability among 45-49 year group (0.86) compared to the 15-19 year group (0.02) for limiting. The marginal predictive probability for spacing changed significantly from 0.74 to 0.04 as age changed from 15 to 19 to 45-49 years. Infrequent sexual intercourse, opposition from partners, socio-economic (wealth index, respondents educational level, respondents and partner's occupation) and cultural (religion and ethnicity) were all significant determinants of both unmet need for limiting and spacing. CONCLUSIONS: This study reveals that fear of side effect, infrequent sex, age, ethnicity, partner's education and region were the most highly significant predictors of both limiting and spacing. These factors must be considered in trying to meet the unmet need for family planning.

Modern contraceptive use among women of reproductive age in Ghana: analysis of the 2003-2014 Ghana Demographic and Health Surveys.

BACKGROUND: Contraceptives are used in family planning to space or limit pregnancies and are categorized into modern and traditional methods. The modern methods have been proven to be more scientifically effective at preventing unwanted pregnancies than the traditional methods. With data from three (3)-different Demographic and Health Surveys, the aim of this study is to assess the trends and identify factors that consistently influence modern contraceptives' use among women of the reproductive age group in Ghana. METHODS: The study used secondary data from the 2003, 2008, and 2014 Ghana Demographic Health Surveys (GDHS). The trends of determinants of modern contraceptives use among women of reproductive age in Ghana were determined. A bivariate approach was used to select significant predictors. The Cox proportional hazards model analysis was employed via a multilevel modelling approach. RESULTS: Out of the total respondents of 2229, 2356, and 4469, 18.75%, 15.75% and 21.53% were modern contraceptives users for 2003, 2008 and 2014 respectively. The multiple cox proportional hazards model analysis identified place of residence and the educational level of a woman as strong predictors of modern contraceptives use in Ghana. Modern contraceptive use is increasing among rural residence. Women who are in formal occupations (professional, clerical, services) are more likely to use modern contraceptives than their colleagues in less formal occupations (manual, agricultural, sales). CONCLUSION: This study highlights the trends of determinants on modern contraceptive use in Ghana from 2003 to 2014. The most persistent determinants of modern contraceptive use in Ghana during this time period are place of residence and a woman's educational level. Women working in Agriculture and Sales are the least users of modern contraceptives in Ghana over the period.

Knowledge and use of information and communication technology by health sciences students of the University of Ghana.

BACKGROUND: Studies have shown that ICT adoption contributes to productivity and economic growth. It is therefore important that health workers have knowledge in ICT to ensure adoption and uptake of ICT tools to enable efficient health delivery. OBJECTIVE: To determine the knowledge and use of ICT among students of the College of Health Sciences at the University of Ghana. METHODS: This was a cross-sectional study conducted among students in all the five Schools of the College of Health Sciences at the University of Ghana. A total of 773 students were sampled from the Schools. Sampling proportionate to size was then used to determine the sample sizes required for each school, academic programme and level of programme. Simple random sampling was subsequently used to select students from each stratum. RESULTS: Computer knowledge was high among students at almost 99%. About 83% owned computers (p < 0.001) and self-rated computer knowledge was also 87 % (p <0.001). Usage was mostly for studying at 93% (p< 0.001). CONCLUSIONS: This study shows students have adequate knowledge and use of computers. It brings about an opportunity to introduce ICT in healthcare delivery to them. This will ensure their adequate preparedness to embrace new ways of delivering care to improve service delivery. FUNDING: Africa Build Project, Grant Number: FP7-266474.