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Background: The World Health Organization has set ambitious goals to eliminate cervical cancer, necessitating evidence on increasing coverage and access to screening and treatment in high-burden areas. We implemented a pilot program to assess the feasibility of obtaining self-collected specimens for high-risk human papillomavirus (hr-HPV) testing in Nzulezo stilt village, a hard-to-reach community in Ghana, and inviting only hr-HPV-positive women to a central location for colposcopy and possible treatment. Subsequently, this study aimed to investigate the prevalence of hr-HPV infection and cervical lesions among the women and to explore factors potentially associated with hr-HPV infection among them., Methods: This pilot community-based cross-sectional study utilized data from screening sessions held from 2 to 20 November 2021 with specimens collected by participants using Evalyn brushes. HPV DNA testing was performed using the Sansure MA-6000 platform, while visual inspection utilized the Enhanced Visual Assessment (EVA) mobile colposcope. Univariate and multivariable nominal logistic regression was employed to explore factors associated with hr-HPV positivity., Results: Among 100 women screened (mean age, 43.6 ± 14.5 years), the overall hr-HPV prevalence rate was 39.0% (95% CI, 29.4-49.3). The prevalence rates of hr-HPV genotypes were stratified as follows: HPV16-8.0% (95% CI, 3.5-15.2), HPV18-5.0% (95% CI, 1.6-11.2), and other genotype(s) - 31.0% (95% CI, 22.1-41.0). Single-genotype infections with HPV16 and HPV18 were found in 4.0% (95% CI, 1.1-9.9) and 3.0% (95% CI, 0.6-8.5) of women, respectively. Mixed infections were observed in 1.0% (95% CI, 0.0-5.4) for HPV16 + 18, 3.0% (95% CI, 0.6-8.5) for HPV16 + other type(s), and 1.0% (95% CI, 0.0-5.4) for HPV18 + other type(s). The prevalence of cervical lesions among hr-HPV-positive women screened via colposcopy was 11.4% (95% CI, 3.2-26.7). In the multivariable model, reliance on other sources for medical bill payment was associated with hr-HPV infection (aOR, 0.20; 95% CI, 0.04-0.93), whereas age was not (aOR, 1.02; 95% CI, 0.99-1.05)., Conclusions: A high hr-HPV infection prevalence was recorded among the women. Utilizing technologies such as self-sampling, HPV DNA testing, and mobile colposcopy enables screening and treatment in remote and hard-to-reach communities where access to cervical cancer screening and treatment would otherwise be limited. Further research is warranted to assess the value and scalability of this approach in similar remote areas and its potential implementation in future programs., (© 2024. The Author(s).)

Background: The COVID-19 pandemic had socioeconomic effects in Africa. This study assessed the social and economic determinants of healthcare utilization during the first wave of COVID-19 among adults in Ghana., Methods: Information about individuals residing in Ghana was derived from a survey conducted across multiple countries, aiming to evaluate the impact of the COVID-19 pandemic on the mental health and overall well-being of adults aged 18 and above. The dependent variable for the study was healthcare utilization (categorized as low or high). The independent variables were economic (such as financial loss, job loss, diminished wages, investment/retirement setbacks, and non-refunded travel cancellations) and social (including food scarcity, loss of financial support sources, housing instability, challenges affording food, clothing, shelter, electricity, utilities, and increased caregiving responsibilities for partners) determinants of health. A multinomial logistic regression was conducted to identify factors associated with healthcare utilization after adjusting for confounders (age, gender, access to medical insurance, COVID-19 status, educational background, employment, and marital status of the participants)., Results: The analysis included 364 responses. Individuals who encountered a loss of financial support (AOR: 9.58; 95% CI: 3.44-26.73; p < 0.001), a decrease or loss of wages (AOR: 7.44, 95% CI: 3.05-18.16, p < 0.001), experienced investment or retirement setbacks (AOR: 10.69, 95% CI: 2.60-43.88, p = 0.001), and expressed concerns about potential food shortages (AOR: 6.85, 95% CI: 2.49-18.84, p < 0.001) exhibited significantly higher odds of low healthcare utilization during the initial phase of the pandemic. Contrastingly, participants facing challenges in paying for basic needs demonstrated lower odds of low healthcare utilization compared to those who found it easy to cover basic expenses (AOR: 0.19, 95% CI: 0.06-0.67, p = 0.001)., Conclusion: Economic and social factors were associated with low healthcare utilization in Ghana during the first wave of the pandemic. Investment or retirement loss and financial support loss during the pandemic had the largest effect on healthcare utilization. Further research is needed to understand the connection between concerns about food shortages, welfare losses during pandemics and healthcare utilization during pandemics in Ghana., (© 2024. The Author(s).)

Background: The World Health Organization recommended the Test, Treat and Track (T3) strategy for malaria control that, every suspected malaria case should be tested prior to treatment with Artemisinin-based combination therapy (ACT) and tracked. We assessed the performance and challenges in the implementation of T3 strategy among children under-five years in Volta and Oti Regions of Ghana., Method: A descriptive cross-sectional study was carried in 69 health facilities. Exit interviews were conducted for caregivers of children with fever using a semi-structured questionnaire. Clinicians were interviewed at the out-patient department in each facility. Descriptive statistics was conducted, Chi-square test and logistic regression were used to determine the associations between completion of T3 and independent variables., Results: Most children, 818/900 (90.9%) were tested for malaria and 600/818 (73.4%) were positive for malaria parasitaemia using rapid diagnostic test. Of those testing positive for malaria, 530/600 (88.3%) received treatment with ACTs. Half, (109/218) of the children testing negative for malaria also received ACTs. Also, 67/82 (81.7%) of children not tested for malaria received ACTs. Only 408/900 (45.3%) children completed T3 with Community Health-based Planning Services (CHPS) compound having the highest completion rate 202/314 (64.3%). CHPS Compounds were 6.55 times more likely to complete T3 compared to the hospitals [(95% CI: 3.77, 11.35), p<0.001]. Health facilities with laboratory services were 2.08 times more likely to complete T3 [(95% CI: 1.55, 2.79), p<0.001] The main challenge identified was clinicians' perception that RDTs do not give accurate results., Conclusion: Testing fever cases for malaria before treatment and treating positive cases with ACTs was high. Treating negative cases and those not tested with ACTs was also high. Health facilities having laboratory services and facility being CHPS compounds were key predictors of completing T3. Clinician's not trusting RDT results can affect the T3 strategy in malaria control. Periodic training/monitoring is required to sustain adherence to the strategy., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Kweku et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Good menstrual hygiene practice is critical to the health of adolescent girls and women. In Ghanaian public schools, the School Health Education Program which includes menstrual health education has been instituted to equip adolescents with knowledge on menstruation and its related good hygiene practices. However, in most communities, menstruation is scarcely discussed openly due to mostly negative social and religious beliefs about menstruation. In this study, we examined socio-cultural factors associated with knowledge, attitudes and menstrual hygiene practices among Junior High School adolescent girls in the Kpando Municipality of Ghana., Materials and Methods: A mixed method approach was employed with 480 respondents. A survey was conducted among 390 adolescent girls using interviewer-administered questionnaires to collect data on knowledge of menstruation and menstrual hygiene practices. Focus Group Discussions (FGDs) using a discussion guide were conducted among 90 respondents in groups of 9 members. The FGD was used to collect data on socio-cultural beliefs and practices regarding menstruation. Descriptive and inferential statistics and content analysis were used to analyze the quantitative and qualitative data respectively., Results: Most (80%) of the study participants had good knowledge of menstruation. Also, most (82%) of the participants practiced good menstrual hygiene. Attending a public (AOR = 0.24, 95% CI = 0.12-0.48, p<0.001) and rural (AOR = 0.40, 95% CI = 0.21-0.75, p<0.01) school was significantly associated with reduced odds of practicing good menstrual hygiene. Good knowledge of menstruation was associated with increased odds of good hygiene practices (AOR = 4.31, 95% CI = 2.39-7.90, p<0.001). Qualitative results showed that teachers provided adolescents with more detailed biological information on menstruation than key informants (family members) did at menarche. However, both teachers and family members spoke positively of menstruation to adolescent girls. Social and religious beliefs indicate that menstruation is evil and unclean. Such beliefs influenced community members' attitudes towards adolescent girls and led to practices such as isolating menstruating girls and limiting their ability to interact and participate in certain community and religious activities., Conclusion: Despite the prominence of negative social and religious beliefs about menstruation, good menstrual hygiene practice was high among study participants. Knowledge of menstruation; place of residents; and type of school were the major factors associated with good menstrual hygiene practice. It is therefore, necessary to intensify the School Health Education Program in both rural and urban public and intensively involve private schools as well to ensure equal access to accurate information on menstruation and good menstrual hygiene practices among adolescent girls., Competing Interests: The authors have declared that no competing interests exist.

Objective: To examine the contribution of lower-level health facilities in increasing access to cervical cancer screening in the North Tongu District., Design: A descriptive cross-sectional study design was used. The Cervical Cancer Prevention and Training Centre (CCPTC) of the Catholic Hospital, Battor, served as the hub, and six health facilities (3 health centres and 3 CHPS compounds) served as the spokes. From April 2018 to September 2019, the well-resourced CCPTC trained 6 nurses at selected Community-based Health Planning and Services (CHPS) / Health Centres (HCs) (spokes) to provide cervical cancer screening services. The nurses, after training, started screening with VIA and HPV DNA testing., Participants: A total of 3,451women were screened by the trained nurses. This comprised 1,935 (56.1%) from the hub and 1,516 (43.9%) from the spokes., Main Outcome Measure: The detection of screen positives., Results: The screen positives were 19.4% (375/1935) at the hub and 4.9% (74/1516) at the spokes., Conclusion: We have demonstrated that a hub and spokes model for cervical cancer screening is possible in limited resource settings. Designating and resourcing a 'hub' that supports a network of 'spokes' could increase women's access to cervical cancer screening. This approach could create awareness about cervical cancer screening services and how they can be accessed., Funding: None declared., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

Background: Malaria is a preventable disease that causes huge morbidity and mortality in malaria-endemic areas, especially among children and pregnant women. The malaria control programme focuses on the prevention of mosquito bites using insecticide-treated nets (ITNs) and mosquito aerosol sprays and coils, as well as prevention of severe disease among those infected through prompt and adequate treatment. The success of the malaria control programme in Ghana is dependent on the malaria prevention practices of people in the community. Therefore, this study evaluated the malaria prevention practices of participants in four districts of the Volta Region of Ghana., Methods: This was a cross-sectional study conducted in Ketu South, Nkwanta South, Hohoe Municipality and Ho West districts of the Volta Region of Ghana. Questionnaire were administered to adults who consented to each household visited. Questions were asked on the socio-demographics and malaria prevention practices of the households. Data analysis was done using SPSS version 23 with frequency distribution done for all the variables. Pearson chi-square was used to determine the significant association between socio-demographics and malaria prevention practices, and Multivariate nominal logistic regression analysis was used to model the relationship between dichotomous dependent variables (ITN ownership and usage) and independent variables., Results: Out of the 2493 participants; 2234 (89.6%) owned ITN and 1528 (68.4%) used ITN a night before this study, 768 (30.8%) used mosquito aerosol spray and 368 (15%) used mosquito coil. More females significantly owned ITN than males (1293, 92.4%, p ≤ 0.001). Participants from Ketu South had 1.5 times higher odds of owning an ITN compared to Ho West whose odds are not different from Nkwanta South or Hohoe (AOR, 1.56 [95% 1.09-2.22]; p = 0.01). In terms of ITN usage, participants in Nkwanta South were less likely to use ITN compared to the other districts; AOR, 0.434 [95% CI 0.31-0.62, p < 0.001]. Also, of the 668 participants that had a fever within the past 3 days, 268 (40.1%) visited a patent medicine store and 156 (23.4%) visited health facilities., Conclusion: There is high ownership of ITNs, but relatively low utilization among the community members. Education on malaria prevention practices should be intensified and continuous among the population of the Volta Region to ensure the success of malaria control in the region., (© 2021. The Author(s).)

Background: Children need good nutrition to develop proper immune mechanisms and psychosocial maturity, but malnutrition can affect their ability to realize this. Apart from the national demographic and health survey, which is carried out every 5 years, there have not been enough documented studies on child breastfeeding and weaning practices of caregivers in the Volta Region. We, therefore, examined child breastfeeding and weaning practices of mothers in the Volta Region of Ghana., Methods: A sub-national survey method was adopted and a semi-structured questionnaire was used to collect data from 396 mothers and their children. Descriptive and inferential statistics comprising frequency, percentage, chi-square, and logistic regression were employed in analysing the data. We defined exclusive breastfeeding as given only breast milk to an infant from a mother or a wet nurse for six months of life except drops or syrups consisting of vitamins, minerals, supplements, or medicines on medical advice, and prolonged breastfeeding as breastfeeding up to 24 months of age., Results: The prevalence of exclusive breastfeeding (EBF) was 43.7%. Mothers constituting 61.1% started breastfeeding within an hour of giving birth. In addition to breast milk, 5.1% gave fluids to their children on the first day of birth. About 66.4% started complementary feeding at 6 months, 22.0% breastfed for 24 months or beyond, while 40.4% fed their children on-demand. Child's age (AOR: 0.23, 95% CI:0.12-0.43, p<0.0001), prolonged breastfeeding (AOR: 0.41, 95%CI: 0.12-0.87, p = 0.001), mother's religion (AOR: 3.92, 95%CI: 1.23-12.61, p = 0.021), feeding practices counselled on (AOR: 1.72, 95%CI: 1.96-3.09, p = 0.023), mother ever heard about EBF (AOR: 0.43, 95%CI: 1.45-2.41, p = 0.039), child being fed from the bottle with a nipple (AOR: 1.53, 95%CI: 1.94-2.48, p = 0.003), and age at which complementary feeding was started (AOR: 17.43, 95%CI: 3.47-87.55, p = 0.008) were statistically associated with EBF., Conclusion: Breastfeeding education has been ongoing for decades, yet there are still gaps in the breastfeeding practices of mothers. To accelerate progress towards attainment of the sustainable development goal 3 of ensuring healthy lives and promoting well-being for all at all ages by the year 2030, we recommend innovative policies that include extensive public education to improve upon the breastfeeding and weaning practices of mothers., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Over the past two decades, there have been several global interventions including the Sustainable Development Goals (SDGs), aimed at improving health outcomes. Despite efforts by countries to achieve the SDG targets, mental health challenges remain major public health concerns globally. We examined the prevalence and predictors of depression, anxiety, and stress as well as the comorbidities of these mental health issues among adults., Materials and Methods: This was a community-based cross-sectional study conducted among 2456 adults in four districts of the Volta Region of Ghana using data from the UHAS-Yonsei University Partnership Project. We analysed the data using frequency, percentage, mean, standard deviation, correlation, and binary logistic regression., Results: Overall, 51.8% of the participants had at least one of the mental health issues examined. The prevalence of a mental health issue was 25.2%, 53.3%, and 9.7% for depression, anxiety, and stress respectively. Participants constituting 8.3% experienced all three mental health issues as comorbidities. Participants' level of formal education and income significantly predicted depression, anxiety, and stress respectively at the multivariable level. Adults with a tertiary level of education were, for instance, 68% (AOR = 0.32, 95%CI = 0.15-0.66), 65% (AOR = 0.35, 95%CI = 0.17-0.73), and 50% (AOR = 0.50, 95%CI = 0.33-0.76) less likely to experience depression, anxiety, and stress, respectively compared with those who had no formal education., Conclusion: The majority of our study participants either experienced depression, anxiety, or stress. There were quite high comorbidities of the mental health issues among the adult population. To accelerate progress towards the achievement of SDG 3.4 target of promoting mental health and wellbeing for all by the year 2030, there is a need for effective implementation of the country's 2012 Mental Health Act which makes provisions for the establishment of a Mental Health Fund. This could improve the financial circumstances of indigenes as income has been realised in the present study as an important factor influencing depression, anxiety, and stress among the adult population., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Severely sick-children presenting at primary healthcare facilities need referral to higher level facilities for better care. Adherence to referrals and quality of care received by those referred could serve as critical steps towards their survival., Objective: To describe experiences with severely sick children referred to higher-level health facilities for care and reasons for non-adherence to referral; to explore healthcare provider's perspectives to referral., Methods: Referrals among 3046 young children were followed for adherence. Assessment of children referred from a PHC facility adhering to referral advice and reasons for non-adherence to referral was determined. Agreement on reported diagnoses at PHC centres and health-facilities receiving patients was assessed. Perspectives of healthcare providers were assessed., Results: 212 children were referred from PHC centres to various hospitals with 14.2% non-adherence. Reasons given: 48.3% of carers adhering felt child's condition was severe; 43.3% complied with healthcare provider directive. The main reasons for non-adherence to referral were no money for transport (50%) and child condition not serious (30.0%). 69.0% of anaemia cases diagnosed at PHC facilities and hospitals. 65.7% fever diagnosed at a PHC centres were confirmed as malaria at the hospitals. Healthcare providers referred patients for severity, perceivedcomplication and non-response to treatment., Conclusion: Adherence was generally good. The level of agreement in diagnosis of common diseases such as malaria and anaemia at PHC centres and district hospitals was high and low for rarer diseases. Capacity should be provided at PHC levels for adequate management of cases presented to reduce referrals carers have to make., Funding: This study did not receive funding from any external sources., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

Background: To strengthen the implementation of the Community-based Health Planning and Services (CHPS) programme which is Ghana's key primary health care delivery strategy, the CHPS+ Project was initiated in 2017. We examined community utilisation and satisfaction with CHPS services in two System Learning Districts (SLDs) of the project., Methods: This community-based descriptive study was conducted in the Nkwanta South Municipality and Central Tongu District of Ghana. Data were collected from 1008 adults and analysed using frequency, percentage, chi-square, and logistic regression models., Results: While the level of utilisation of CHPS services was 65.2%, satisfaction was 46.1%. Utilisation was 76.7% in Nkwanta South and 53.8% in Central Tongu. Satisfaction was also 55.2% in Nkwanta South and 37.1% in Central Tongu. Community members in Nkwanta South were more likely to utilise (AOR = 3.17, 95%CI = 3.98-9.76) and be satisfied (AOR = 2.77, 95%CI = 1.56-4.90) with CHPS services than those in Central Tongu. Females were more likely to utilise (AOR = 1.75, 95%CI = 1.27-2.39) but less likely to be satisfied [AOR = 0.47, 95%CI = 0.25-0.90] with CHPS services than males. Even though subscription to the National Health Insurance Scheme (NHIS) was just 46.3%, NHIS subscribers were more likely to utilise (AOR = 1.51, 95%CI = 1.22-2.03) and be satisfied (AOR = 1.45, 95%CI = 0.53-1.68) with CHPS services than non-subscribers., Conclusion: Ghana may not be able to achieve the goal of universal health coverage (UHC) by the year 2030 if current levels of utilisation and satisfaction with CHPS services persist. To accelerate progress towards the achievement of UHC with CHPS as the vehicle through which primary health care is delivered, there should be increased public education by the Ghana Health Service (GHS) on the CHPS concept to increase utilisation. Service quality should also be improved by the GHS and other stakeholders in Ghana's health industry to increase satisfaction with CHPS services. The GHS and the National Health Insurance Authority (NHIA) should also institute innovative strategies to increase subscription to the NHIS since it has implications for CHPS service utilisation and satisfaction.

Background: Breast and cervical cancers constitute the two leading causes of cancer deaths among women in Ghana. This study examined breast and cervical screening practices among adult and older women in Ghana., Methods: Data from a population-based cross-sectional study with a sample of 2749 women were analyzed from the study on global AGEing and adult health conducted in Ghana between 2007 and 2008. Binary and multivariable ordinal logistic regression analyses were performed to assess the association between socio-demographic factors, breast and cervical screening practices., Results: We found that 12.0 and 3.4% of adult women had ever had pelvic screening and mammography respectively. Also, 12.0% of adult women had either one of the screenings while only 1.8% had both screening practices. Age, ever schooled, ethnicity, income quantile, father's education, mother's employment and chronic disease status were associated with the uptake of both screening practices., Conclusion: Nationwide cancer awareness campaigns and education should target women to improve health seeking behaviours regarding cancer screening, diagnosis and treatment. Incorporating cancer screening as a benefit package under the National Health Insurance Scheme can reduce financial barriers for breast and cervical screening.

Background: In sub-Saharan Africa, there is high coverage of the recommended four or more times antenatal care (ANC) visits during pregnancy without complications; notwithstanding this achievement, the negative birth outcomes related to childbirth such as low birth weights and stillbirths are still high despite the increased access to antenatal services. Hence, the study assessed the association between antenatal attendance and birth weight in the Wa East District., Method: The cross-sectional study design was used with a semistructured questionnaire to collect data from mothers who delivered within a one-year period through a review of antenatal and birth records from health facilities where the women delivered and interviewed. The chi-squared test and univariate and multivariate logistic regression were performed to establish the association between normal birth weight and ANC services the woman received and other predictor variables, and p value < 0.05 was considered a significant association between dependent and independent variables., Result: The study involved 233 women. About 62.2% attended ANC clinics 4+ times before giving birth, 70.0% did not received the minimum ANC services required for every pregnant woman, 0.9% of pregnancies resulted in stillbirth, and 24.5% of babies born had a birth weight < 2.5 kg. Women marital status (legally married) [AOR: 2.05, 95% CI: 1.33-6.89, p = 0.044], religion (Islam) [AOR: 0.33, 95% CI: 0.08-0.39, p = 0.013], and educational level (SHS/tertiary) [AOR: 4.27, 95% CI: 0.08-0.88, p = 0.031] were the background characteristics associated with normal birth weight (2.5-40 kg). Also, women who had their urine tested at the ANC clinics [AOR: 6.59, 95% CI: 8.48-15.07, p < 0.001] and women who received a long-lasting insecticide-treated net [AOR: 2.17, 95% CI: 0.03-0.92, p = 0.039] from the ANC clinic were associated with normal birth weight., Conclusion: Notwithstanding the benefits of antenatal care services, only 62.2% of pregnant women attended 4 or more ANC visits before giving birth, while 70% did not received the services they need. These might have influence the 24.5% of babies born with a low birth weight. Therefore, there is a need for special attention from all stakeholders to reverse the trend., Competing Interests: The authors of this work declare that they have no competing interest regarding the study and the publication of this paper., (Copyright © 2020 Prince Kubi Appiah et al.)

Dihydroartemisinin-piperaquine has shown excellent efficacy and tolerability in malaria treatment. However, concerns have been raised of potentially harmful cardiotoxic effects associated with piperaquine. The population pharmacokinetics and cardiac effects of piperaquine were evaluated in 1,000 patients, mostly children enrolled in a multicenter trial from 10 sites in Africa. A linear relationship described the QTc-prolonging effect of piperaquine, estimating a 5.90-ms mean QTc prolongation per 100-ng/ml increase in piperaquine concentration. The effect of piperaquine on absolute QTc interval estimated a mean maximum QTc interval of 456 ms (50% effective concentration of 209 ng/ml). Simulations from the pharmacokinetic-pharmacodynamic models predicted 1.98 to 2.46% risk of having QTc prolongation of >60 ms in all treatment settings. Although piperaquine administration resulted in QTc prolongation, no cardiovascular adverse events were found in these patients. Thus, the use of dihydroartemisinin-piperaquine should not be limited by this concern. (This study has been registered at ClinicalTrials.gov under identifier NCT02199951.)., (Copyright © 2020 Wattanakul et al.)

Background: Community volunteerism is essential in the implementation of the Community-based Health Planning and Services (CHPS) in Ghana. We explored the responsibilities, motivations and challenges of community health management committees (CHMCs) in two CHPS+ Project districts in Ghana., Methods: We used a qualitative approach to collect data through 4 focus group discussions among a purposive sample of community health volunteers in December 2018 and analysed them thematically., Results: Community health management committees (CHMCs) were found to provide support in running the CHPS programme through resource mobilisation, monitoring of logistics, assisting the Community Health Officers (CHO) in the planning of CHPS activities, and the resolution of conflicts between CHOs and community members. The value, understanding and protective functions were the key motivations for serving on CHMCs. Financial, logistical and telecommunication challenges, lack of recognition and cooperation from community members, lack of motivation and lack of regular skill development training programmes for CHMC members who serve as traditional birth attendants (TBAs) were major challenges in CHMC volunteerism., Conclusion: Community health volunteerism needs to be prioritised by the Ghana Health Service and other health sector stakeholders to make it attractive for members to give off their best in the discharge of their responsibilities.

Background: In 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017., Methods: This exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed., Results: Negative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns., Conclusion: Health-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme., Competing Interests: The authors have declared that no competing interests exist.

Background: Febrile children seen in malaria hypo-endemic settings, such as the Greater Accra region (GAR) of Ghana are more likely to be suffering from a non-malarial febrile illness compared to those seen in hyper-endemic settings. The need for prescribers to rely on malaria test results to guide treatment practices in the GAR is even greater. This study was designed to investigate the factors associated with inappropriate artemisinin-based combination therapy (ACT) prescription., Methods: A survey was conducted in six health facilities in the region in 2015. Treatment practices for febrile outpatient department (OPD) patients were obtained from their records. Prescribers were interviewed and availability of malaria commodities were assessed. The primary outcome was the proportion of patients prescribed ACT inappropriately. Independent variables included patient age and access to care, prescriber factors (professional category, work experience, access to guidelines, exposure to training). Data were analysed using Stata at 95% CI (α-value of 0.05). Frequencies and means were used to describe the characteristics of patients and prescribers. To identify the predictors of inappropriate ACT prescription, regression analyses were performed accounting for clustering., Results: Overall, 2519 febrile OPD records were analysed; 45.6% (n = 1149) were younger than 5 years. Only 40.0% of patients were tested. The proportion of patients who were prescribed ACT inappropriately was 76.4% (n = 791 of 1036). Of these 791 patients, 141 (17.8%) were prescribed anti-malarial injections. Patients seen in facilities with rapid diagnostic tests (RDT) in stock were less likely to be prescribed ACT inappropriately, (AOR: 0.04, 95% CI 0.01-0.14, p < 0.001) compared to those seen in facilities with RDT stock-outs. Prescribers who had been trained on malaria case management within the past year were 4 times more likely to prescribe ACT inappropriately compared to those who had not been trained (AOR: 4.1; 95% CI (1.5-11.6); p < 0.01). Patients seen by prescribers who had been supervised were 8 times more likely to be  prescribed ACT inappropriately., Conclusion: Inappropriate ACT prescription to OPD febrile cases was high. Training and supervision of health workers appears not to be yielding the desired outcomes. Further research is needed to understand this observation.

Background: Anaemia among pregnant women and post-partum mothers is a public health challenge in Ghana, especially in the Volta Region. While literature abounds on anaemia among pregnant women, the same cannot be said for anaemia among post-partum mothers in the region. This study, therefore, examined the prevalence and associated risk factors of anaemia among women attending antenatal care and post-natal care., Methods: This descriptive cross-sectional survey recruited 409 pregnant women and 194 post-natal mothers attending antenatal and post-natal care, at the Hohoe Municipal Hospital. Background characteristics were collected using a semi-structured questionnaire, blood samples were analysed for the presence of anaemia and malaria parasitaemia and folders were reviewed for estimated blood loss., Results: We found the prevalence of anaemia among pregnant women and post-partum mothers to be 33 and 16% respectively. Higher malaria parasitaemia (2%) was found in pregnant women compared with postpartum mothers (1%). We found that 4% of post-partum mothers had abnormal blood loss (301mls-500mls) whereas 5% of them had postpartum haemorrhage (>500mls) during child birth. A univariate logistics regression of anaemia status on some risk factors in pregnant women showed no significant association between anaemia and any of the risk factors. Among post-partum mothers, only mothers' age was statistically significant in the univariate analysis [COR = 0.27 (95% CI:0.103, 0.72);0.008]. Mothers aged 20-29 were 73% less likely to be anaemic., Conclusion: The prevalence of anaemia among pregnant women found in this study points to a situation of moderate public health problem according to WHO cut-off values for the public health significance of anaemia. Strategies should therefore be put in place to encourage thorough health education and promotion programmes among both pregnant and post-partum women., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2019.)

Background: Human rabies, often contracted through dog bites, is a serious but neglected public health problem in the tropics, including Ghana. Due to its high fatality rate, adequate knowledge and vaccination of domestic dogs against the disease are very crucial in reducing its burden. We examined dog owners' knowledge level on rabies and factors that influenced anti-rabies vaccination of dogs in the Upper East Region of Ghana., Methods: This descriptive cross-sectional study was conducted among 260 randomly sampled dog owners in six communities from six Districts using a multistage sampling technique, in the Upper East Region of Ghana. An interviewer-administered questionnaire was used to collect data from the respondents. Descriptive and inferential analyses were done using STATA 14.1., Results: While knowledge about rabies was 199 (76.5%), that about anti-rabies vaccination was 137 (52.7%). District of residence (χ 2 = 112.59, p < 0.001), sex (χ 2 = 6.14, p = 0.013), education (χ 2 = 20.45, p < 0.001) as well as occupation (χ 2 = 11.97, p = 0.007) were significantly associated with rabies knowledge. District of residence (χ 2 = 57.61, p < 0.001), Educational level (χ 2 = 15.37, p = 0.004), occupation (χ 2 = 11.66, p = 0.009), religion (χ 2 = 8.25, p = 0.016) and knowledge on rabies (χ 2 = 42.13, p < 0.001) were also statistically associated with dog vaccination against rabies. Dog owners with good knowledge on rabies for instance, were more likely to vaccinate their dogs against rabies compared to those with poor knowledge [AOR = 1.99 (95% CI: 0.68, 5.86), p = 0.210]. Dog owners with tertiary level of education were also 76.31 times more likely (95% CI: 6.20, 938.49, p = 0.001) to have good knowledge about rabies compared to those with no formal education., Conclusions: Dog owners in the Upper East Region of Ghana had good knowledge about rabies. This, however, did not translate into correspondingly high levels of dog vaccination against the disease. Rabies awareness and vaccination campaigns should, therefore, be intensified in the region, especially among the least educated and female dog owners.

Background: Anaemia is one of the major causes of death among children under five years in Ghana. We examined the risk factors of anaemia among children under five years in the Hohoe Municipality, Ghana., Methods: This facility-based matched case control study recruited 210 children (70 cases and 140 controls) aged 6 to 59 months. Stratified and simple random sampling techniques were used to select mothers attending Child Welfare Clinic (CWC) for the screening of their children. Data were collected using a semistructured questionnaire. Finger prick blood was collected to estimate the haemoglobin (Hb) level and thick film was prepared to determine malaria parasitaemia. Axillary temperature was measured using an +electronic thermometer and anthropometric measurements were done using a weighing scale and inelastic tape measure. Continuous variables were presented as means and standard deviations and categorical variables as frequencies and proportions. Conditional logistic regression was used to determine the strength of association between the dependent and the independent variables. Statistical significance was considered at p value of <0.05., Results: The prevalence of anaemia was high (53.8%), while children whose mothers received iron supplementation during pregnancy were 7.64 times more likely to be anaemic compared with those who did not [AOR=7.64 (95% CI:1.41-41.20.93); p=0.018]. Children with poor dietary diversity were 9.15 times more likely to have anaemia [AOR=9.15 (95% CI: 3.13-26.82); p< 0.001]; and children whose mothers were farmers and traders were 83% [AOR = 0.17 (95% CI: 0.05-0.60); p=0.006] and 79% [AOR=0.21 (95% CI: 0.06-0.74); p=0.014], respectively, less likely to have anaemia., Conclusion: The biologic, intermediate, and underlying factors that were significantly associated with anaemia comprised maternal iron supplementation, poor dietary diversity, farmers, and traders. Given that iron supplementation during pregnancy did not protect children against anaemia, we recommend the child's nutritional dietary diversity is encouraged.

Background: Prompt diagnosis and effective treatment of malaria cases with efficacious drugs is an important strategy in the management and control of malaria in endemic populations. As part of a study investigating the factors modulating the development of Plasmodium falciparum gametocytes in the human host, we assessed the rate of RDT positivity of patients in different departments of the Ho Teaching Hospital and the relation with age and anaemia., Materials and Methods: Eight-hundred and ten individuals attending clinic at various departments within the Ho Teaching Hospital were screened for malaria antigenaemia using RDT as a point-of-entry investigation. RDT positive individuals were immediately treated for malaria whereas RDT negative individuals were treated for other ailments. Haematological analyses were performed for 69 of these patients and the relationship between RDT results and haemoglobin levels were investigated., Results: The overall RDT positivity rate was 19.8% (160/810) of all individuals screened. There was no significant difference in the haemoglobin levels of RDT-positive and RDT-negative individuals ( p value = 0.272). The highest number of attendees screened was children in the paediatric outpatient department and paediatric ward, 62% (507/810), with RDT positivity rate of 17% (91/507). We found the highest RDT positivity rate of 51% (19/37) in the male medical ward., Conclusions: This study shows that RDT is a useful tool in promoting prompt diagnosis and management of malaria and though children form a majority of hospital attendees and malaria infections, the frequency of malaria detection may be higher in adults as compared to children.

Background: There has been a growing realisation of the need to enhance men's inclusion in maternal and safe motherhood services, especially in low-income settings. However, empirical studies on the extent to which men are involved in maternal and safe motherhood services especially in poor inner-city communities are lacking. The purpose of this study was to describe the level of men's inclusion in maternal and safe-motherhood services in inner-city communities in Ghana, and to assess the barriers of men's involvement., Methods: A descriptive cross-sectional quantitative survey was conducted among a total of 256 randomly selected adult men in Chorkor, an inner-city fishing community in Accra, the capital city of Ghana. A multistage sampling strategy was used to select houses, households and respondents. Descriptive statistical techniques were used to analyse the data. Data analysis was done with the aid of SPSS version 20., Results: Although almost all (96.6%) respondents knew the meaning of family planning, as high as 236(92.2%) have never accompanied their wives/partners to clinics to seek family planning services. Also 242(94.5%) and 251(98%) of men, respectively, knew the importance of antenatal services and supervised delivery. However, only 114(44.5%) of men ever accompanied their wives/partners to seek skilled delivery services. Men's involvement was hindered by barriers such as attitude of health workers, long waiting time and socio-cultural beliefs., Conclusion: The study revealed a gap between men's awareness of the importance of maternal and safe motherhood services and their actual involvement in accessing these services with their female partners. There is a need to create a supportive environment that encourages men to be involved in maternal health services to help reduce maternal/neonatal morbidity and mortality.

Background: Globally, overweight and obesity are becoming a mounting concern, impacting negatively on the health of populations especially in low-income settings. However, there is paucity of epidemiological information available in Ghana to support intervention activities. We conducted a study among public servants to estimate overweight/obesity, hypertension and diabetes prevalence and associated risk factors., Methods: A descriptive cross sectional survey involving 271 purposively sampled public servants aged 20 to 59 years was conducted. We used a structured questionnaire to collect data on eating patterns, risk factors for overweight and obesity, as well as data on socio-demographics and physical activity. Anthropometric measurements were carried out and body mass index (BMI) calculated. Information on blood pressure and diabetes was also gathered. We used descriptive statistical and logistic regression analyses to, respectively, estimate overweight/obesity prevalence, and examine associations between behavioral factors and overweight/obesity and hypertension/diabetes., Results: The overall hypertension/diabetes, overweight and obesity prevalence were 20, 29.9 and 4.8% respectively. The study found that marital status ( p  < 0.001), leisure time with physical activity and level of physical activity during work ( p  < 0.035) as well as morbidities such as diabetes and hypertension ( p  < 0.012) were significantly associated with BMI. Findings showed no significant relationship between mealtime, eating habits, education, age and body mass index. Even though prevalence of overweight/obesity was higher among respondents who travelled to work by car compared to respondents who used motor bikes or walked, the association between weight status and means of transport was not statistically significant. Both smoking ( p  = 0.730) and alcohol consumption ( p  = 0.109) were not linked to weight status., Conclusion: Population-based interventions are needed to promote nutritious food selection and consumption, physical activity and healthy life styles. We also recommend that age and gender-specific interventions should be designed and implemented by relevant authorities to promote and support healthy living and healthy-lifestyles at home and in workplaces.

Background: Uncommon and rare adverse events (AEs), with delayed onset may not be detected before new drugs are licensed and deployed. The present study examined the post licensure safety of dihydroartemisinin-piperaquine (DHP) as an additional treatment for malaria in Ghana. The relationship between the incidence of AEs, treatment completion rate, participant characteristics and concomitant medications are reported., Methods: A study conducted from September 2013 to June 2014 in Navrongo, Kintampo and Dodowa health research centres in Ghana is presented. Participants had confirmed malaria and no known allergy to study drug. Patients provided informed consent and had their symptoms and results of their clinical examinations documented. Treatment with Eurartesim® (20/160mg dihydroartemisinin and 40/320mg piperaquine by Sigma-Tau Incorporated) was given, according to the body weight of patients. First treatment doses were under observation but the second and third doses were taken at home except in a sub-study involving a nested cohort. Patients were contacted at Day 5 (± 2 days) either on telephone or by a home visit to document any AEs experienced. Patients were asked to report to the study team any other AEs that occurred within 28 days post-treatment. All patients in the nested cohort had electrocardiogram (ECG)., Findings: A total of 4563 patients, 52.1% females and 48.2% <6 years completed the study. A total of 444 patients were enrolled into the nested cohort. About 33% had temperature ≥ 37.5°C at enrolment. Approximately 3.4% reported taking prior antimalarials, 19.4% other medications and 86% took at least one concomitant medication. Incidence of AEs was 7.6% including infections (4.6%), gastrointestinal disorders (1.0%) and local reactions at the site of venesection (0.5%). Others were respiratory disorders (0.4%) and nervous system disorders (0.3%). There were nine adverse events of special interest (AESI); itching/pruritus (7), dizziness (1), and skin lesions (1). Patients who took medications prior to enrolment had higher incidence of AEs compared with those without (9.3% vs. 6.1%; P<0.001). Statistically significant associations were found between the reported AEs and age of patients (P<0.001), their body mass index (BMI) (P< 0.001) and parasite densities (P< 0.001)., Conclusion: Dihydroartemisinin-Piperaquine was well tolerated with no serious safety concerns identified. Obesity and prior enrolment medication were among significant factors associated with increased AEs reporting.

The antimalarial drug piperaquine is associated with delayed ventricular depolarization, causing prolonged QT interval (time taken for ventricular de-polarisation and re-polarisation). There is a lack of safety data regarding dihydroartemisinin/piperaquine (DHA/PPQ) for the treatment of uncomplicated malaria, which has limited its use. We created a platform where electrocardiograms (ECG) were performed in public hospitals for the safety assessment of DHA/PPQ, at baseline before the use of dihydroartemisinin/piperaquine (Eurartesim®), and on day 3 (before and after administration of the final dose) and day 7 post-administration. Laboratory analyses included haematology and clinical chemistry. The main objective of the ECG assessment in this study was to evaluate the effect of administration of DHA/PPQ on QTc intervals and the association of QTc intervals with changes in blood biochemistry, full and differential blood count over time after the DHA/PPQ administration. A total of 1315 patients gave consent and were enrolled of which 1147 (87%) had complete information for analyses. Of the enrolled patients 488 (42%), 323 (28%), 213 (19%) and 123 (11%) were from Ghana, Burkina Faso, Tanzania and Mozambique, respectively. Median (lower-upper quartile) age was 8 (5-14) years and a quarter of the patients were children under five years of age (n = 287). Changes in blood biochemistry, full and differential blood count were temporal which remained within clinical thresholds and did not require any intervention. The mean QTcF values were significantly higher than on day 1 when measured on day 3 before and after administration of the treatment as well as on day 7, four days after completion of treatment (12, 22 and 4 higher, p < 0.001). In all age groups the values of QT, QTcF and QTcB were highest on day 3 after drug intake. The mean extreme QTcF prolongation from baseline was lowest on day 3 before drug intake (33 ms, SD = 19) and highest on day 3 after the last dose (60 ms, SD = 31). There were 79 (7%) events of extreme mean QTcF prolongation which were not clinically significant. Nearly a half of them (n = 37) were grade 3 and mainly among males (33/37). Patients in Burkina Faso, Mozambique and Tanzania had significantly lower mean QTcF than patients in Ghana by an average of 3, 4 and 11 ms, respectively. We found no evidence that Eurartesim® administered in therapeutic doses in patients with uncomplicated malaria and no predisposing cardiac conditions in Africa was associated with adverse clinically significant QTc prolongation., Competing Interests: The authors have declared that no competing interests exist.

Background: Family planning services help save lives by reducing women's exposure to risks of child birth and abortion. While family planning services provide measures to prevent unintended pregnancies and time the formation of families, the acceptability and coverage is still very low worldwide. Some of the reasons for this include poor quality of service, unavailability of range of methods, fear of opposition from partners, side effects and health concerns among others.About 40 % of the world's 215,000 annual deaths in childbirth occur in the Sub-Saharan region. In Ghana, urban-rural fertility differences range from two to three children. The acceptability and coverage of family planning are still low and in the study area in particular., Methods: We sought to examine factors that contribute to low acceptability and coverage of family planning services in a sub-urban community with a design of quantitative cross-sectional. Ethical approval was given by the Ghana Health Service. Midwives and community health nurses who provide family planning services were interviewed. Exit-interview was also conducted with women receiving a variety of outpatient services., Results: Most of the women in this study (48.7 %) were in the 25-34 age range and were either married (42.8 %) or cohabiting (40.5 %). Majority of these women (67.7 %) have middle/Junior high level of formal education with a modal parity of two. Sixty eight (68) clients were identified as current family planning users. About 6.0 % and 4.5 % were dissatisfied about auditory and visual privacy during counselling respectively. This was confirmed by providers who attributed it to inappropriate facility layout. Most of the clients (79.1 %) were not given educational materials although 88.8 % were talked to about family planning and this could be due to unavailability of these hand-outs.Though clients show satisfaction of services received, providers did not follow standard protocols with as much as 73.7 % faced with challenges in provision of services which were attributed to improper facility layout and lack of furniture. About 77.2 % were willing to provide short term methods, while 91.2 % wanted to provide long term methods. As much as 93.3 % of the women said they would have liked providers give more detailed information on family planning. While most of the women (88.3 %) used injectables, only 6.1 % and 0.9 % used Implants and IUD respectively., Conclusions: Finding ways to improve client privacy through good facility layout will ensure visual and auditory privacy to enhance family planning service provision and uptake. Continuous competency training will assist providers design innovative action plans and meet client satisfaction needs.

Background: Dihydroartemisinin-piperaquine (DHA-PQ) is one of five WHO recommended artemisinin combination therapy (ACT) for the treatment of uncomplicated malaria. However, little was known on its post-registration safety and effectiveness in sub-Saharan Africa. DHA-PQ provides a long post-treatment prophylactic effect against re-infection; however, new infections have been reported within a few weeks of treatment, especially in children. This paper reports the clinical outcomes following administration of DHQ-PQ in real-life conditions in public health facilities in Burkina Faso, Ghana, Mozambique, and Tanzania for the treatment of confirmed uncomplicated malaria., Methods: An observational, non-comparative, longitudinal study was conducted on 10,591 patients with confirmed uncomplicated malaria visiting public health facilities within seven health and demographic surveillance system sites in four African countries (Ghana, Tanzania, Burkina Faso, Mozambique) between September 2013 and April 2014. Patients were treated with DHA-PQ based on body weight and followed up for 28 days to assess the clinical outcome. A nested cohort of 1002 was intensely followed up. Clinical outcome was assessed using the proportion of patients who reported signs and symptoms of malaria after completing 3 days of treatment., Results: A total of 11,097 patients were screened with 11,017 enrolled, 94 were lost to follow-up, 332 withdrew and 10,591 (96.1%) patients aged 6 months-85 years met protocol requirements for analysis. Females were 52.8 and 48.5% were <5 years of age. Malaria was diagnosed by microscopy and rapid diagnostic test in 69.8% and 29.9%, respectively. At day 28, the unadjusted risk of recurrent symptomatic parasitaemia was 0.5% (51/10,591). Most of the recurrent symptomatic malaria patients (76%) were children <5 years. The mean haemoglobin level decreased from 10.6 g/dl on day 1 to 10.2 g/dl on day 7. There was no significant renal impairment in the nested cohort during the first 7 days of follow-up with minimal non-clinically significant changes noted in the liver enzymes., Conclusion: DHA-PQ was effective and well tolerated in the treatment of uncomplicated malaria and provides an excellent alternative first-line ACT in sub-Saharan Africa.

Background: The growing need to capture data on health and health events using faster and efficient means to enable prompt evidence-based decision-making is making the use of mobile phones for health an alternative means to capture anti-malarial drug safety data. This paper examined the feasibility and cost of using mobile phones vis-à-vis home visit to monitor adverse events (AEs) related to artemisinin-based combination therapy (ACT) for treatment of uncomplicated malaria in peri-urban Ghana., Methods: A prospective, observational, cohort study conducted on 4270 patients prescribed ACT in 21 health facilities. The patients were actively followed by telephone or home visit to document AEs associated with anti-malarial drugs. Call duration and travel distances of each visit were recorded. Pre-paid call cards and fuel for motorbike travels were used to determine cost of conducting both follow-ups. Ms-Excel 2010 and STATA 11.2 were used for analysis., Results: Of the 4270 patients recruited, 4124 (96.6 %) were successfully followed up and analyzed. Of these, 1126/4124 (27.3 %) were children under 5 years. Most 3790/4124 (91.9 %) follow-ups were done within 7 days of ACT intake. Overall, follow up by phone (2671/4124-64.8 %) was almost two times the number done by home visits (1453/4124-35.2 %). Duration of telephone calls ranged from 38 s to 53 min, costing between GH¢0.26 (0.20USD) and GH¢41.70 (27.USD). On the average, the calls lasted 3 min 51 s (SD = 3 min, 21 s) costing GH¢2.70 (0.77USD). Distance travelled for home visit ranged from 0.65 to 62 km costing GH¢0.29 (0.20USD) and GH¢279.00 (79.70USD). Thirty-two per cent (1128/4124) of patients reported AEs. In total, 1831 AE were reported, 1016/1831(55.5 %) by telephone and 815/1831 (44.5 %) by home visits. Events such as nausea, dizziness, diarrhoea, and vomiting were commonly reported., Conclusion: Majority of patients was successfully followed up by telephone and reported the most AEs. The cost of telephone interviewing was almost two times less than the cost of home visit. Telephone follow up should be considered for monitoring drug adverse events in low resource settings.

Background: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 through an Act of Parliament (Act 650) as a strategy to improve financial access to quality basic health care services. Although attendance at health facilities has increased since the introduction of the NHIS, there have been media reports of widespread abuse of the NHIS by scheme operators, service providers and insured persons. The aim of the study was to document behaviors and practices of service providers and clients of the NHIS in the Kassena-Nankana District (KND) of Ghana that constitute moral hazards (abuse of the scheme) and identify strategies to minimize such behaviors., Methods: Qualitative methods through 14 Focused Group Discussions (FGDs) and 5 individual in-depth interviews were conducted between December 2009 and January 2010. Thematic analysis was performed with the aid of QSR NVivo 8 software., Results: Analysis of FGDs and in-depth interviews showed that community members, health providers and NHIS officers are aware of various behaviors and practices that constitute abuse of the scheme. Behaviors such as frequent and 'frivolous' visits to health facilities, impersonation, feigning sickness to collect drugs for non-insured persons, over charging for services provided to clients, charging clients for services not provided and over prescription were identified. Suggestions on how to minimize abuse of the NHIS offered by respondents included: reduction of premiums and registration fees, premium payments by installment, improvement in the picture quality of the membership cards, critical examination and verification of membership cards at health facilities, some ceiling on the number of times one can seek health care within a specified time period, and general education to change behaviors that abuse the scheme., Conclusion: Attention should be focused on addressing the identified moral hazard behaviors and pursue cost containment strategies to ensure the smooth operation of the scheme and enhance its sustainability.

Background: Birth weight is a major determinant of infant morbidity and mortality. Fetal undernourishment means an increased risk of dying during a baby's early months and years. Birth weight has emerged as the leading indicator of infant health and welfare and the central focus of infant health policy. The issues have not been comprehensively evaluated in part due to lack of or limited empirical data. To this end, this study is aimed to evaluate the effects of maternal determinants on the birth weights of neonates in two major hospitals., Results: Low birth weight neonates were significantly (p < 0.001) associated with low gestation at birth (34.8 ± 3.8) while mothers of low birth weight neonates had significantly (p = 0.034) lower body mass index (27.3 ± 5.4) than their normal birth weight counterparts (29.0 ± 6.3). Gestation at birth (p < 0.001), diastolic blood pressure (p = 0.008) was the only significant determinant of birth weight., Conclusion: An increase in gestation at birth by 1 week results in over twice more likelihood of a normal birth weight while a rise in diastolic blood pressure is less likely to give rise to a normal birth weight neonate.

Background: The World Health Organization recommends artemisinin-based combination (ACT) for the treatment of uncomplicated malaria. Post-licensure safety data on newly registered ACT is critical for evaluating their risk/benefit profile in malaria endemic countries. The clinical safety of the newly registered combination, Eurartesim®, following its introduction into the public health system in four African countries was assessed., Methods: This was a prospective, observational, open-label, non-comparative, longitudinal, multi-centre study using cohort event monitoring. Patients with confirmed malaria had their first dose observed and instructed on how to take the second and the third doses at home. Patients were contacted on day 5 ± 2 to assess adherence and adverse events (AEs). Spontaneous reporting of AEs was continued till day 28. A nested cohort who completed full treatment course had repeated electrocardiogram (ECG) measurements to assess effect on QTc interval., Results: A total of 10,925 uncomplicated malaria patients were treated with Eurartesim®. Most patients,95% (10,359/10,925), did not report any adverse event following at least one dose of Eurartesim®. A total of 797 adverse events were reported. The most frequently reported, by system organ classification, were infections and infestations (3. 24%) and gastrointestinal disorders (1. 37%). In the nested cohort, no patient had QTcF > 500 ms prior to day 3 pre-dose 3. Three patients had QTcF > 500 ms (509 ms, 501 ms, 538 ms) three to four hours after intake of the last dose. All the QTcF values in the three patients had returned to <500 ms at the next scheduled ECG on day 7 (470 ms, 442 ms, 411 ms). On day 3 pre- and post-dose 3, 70 and 89 patients, respectively, had a QTcF increase of ≥ 60 ms compared to their baseline, but returned to nearly baseline values on day 7., Conclusion: Eurartesim® single course treatment for uncomplicated falciparum malaria is well-tolerated. QT interval prolongation above 500 ms may occur at a rate of three per 1,002 patients after the third dose with no association of any clinical symptoms. QT interval prolongation above 60 ms was detected in less than 10% of the patients without any clinical abnormalities.

Background: To investigate IOP control following twelve months of continuous medical therapy in Ghana., Methods: This retrospective case series included 163 glaucoma patients diagnosed at a referral eye center between 1996 and 2006. Information collected included age, gender, IOP at presentation, six months and one year post treatment and types of anti-glaucoma medications prescribed. Optimal IOP control was defined according to results from the Advanced Glaucoma Intervention Study (AGIS), which demonstrated arrest of visual field progression in patients with IOP < 18 mmHg at all visitations: Level 1 (post-treatment IOP ≤ 21 mmHg); Level 2 (≤ 18 mmHg) and level 3 (≤ 16 mmHg). The principal outcome measure was the achievement of IOP <18 mmHg at six months and twelve month visitations., Results: One hundred sixty three patients were analyzed. These included 68 males (41.7%) and 95 females (58.3%). The mean age was 57±16 (median 59 years; range 7 - 95 years). There was no significant difference in age (p=0.35) or mean IOP (p=0.08) between genders. The mean pre-treated IOP of 31.9±8.9 mmHg significantly decreased to 21.3±6.6 mmHg at 6 months (p=0.001), with 57.4% of eyes at Level 1 IOP control, 25.3% at Level 2 and 15.4% at Level 3 and decreased further at 12 months to 20.7±6.9 mmHg (p=0.48) with 69.7% of eyes at Level 1, 34.4% at Level 2, and 12.4% at Level 3., Conclusions: Current medical regimen is insufficient to reduce IOP to target levels as defined in the Advanced Glaucoma Intervention Study.

Purpose: To compare the clinical features of glaucoma patients who present at a rural hospital in North Eastern Ghana and an urban hospital in the capital city of Accra., Methods: This is a multi-center retrospective case series involving records of newly diagnosed glaucoma patients with emphasis on primary open angle glaucoma (POAG). Information collected included basic demographic data, intraocular pressures and optic disc measurements., Results: A total of 949 patients (437 rural; 512 urban; 1868 eyes) were included. Rural vs. urban comparisons, respectively: mean age, 53.2 ± 16.3 vs. 54.5 ± 16.4 years; male: female ratio, 3:2 vs. 1:1; POAG, 78.1% vs. 50.6%; POAG suspect, 10.3% vs. 41.9%; IOP, 39.2 ± 7.1 vs. 31.8 ± 7.3 mmHg; bilateral blindness, 34.1% vs. 17.5%; uniocular blindness, 52.2% vs. 32.9%. Females at the rural hospital were twice as likely to present blind in at least one eye (OR 2.04, CI 1.36 - 3.07, p < 0.001)., Conclusions: Patients with POAG at the rural hospital present with more advanced disease characteristics.

Background: In order to measure and analyse the technical efficiency of district hospitals in Ghana, the specific objectives of this study were to (a) estimate the relative technical and scale efficiency of government, mission, private and quasi-government district hospitals in Ghana in 2005; (b) estimate the magnitudes of output increases and/or input reductions that would have been required to make relatively inefficient hospitals more efficient; and (c) use Tobit regression analysis to estimate the impact of ownership on hospital efficiency., Methods: In the first stage, we used data envelopment analysis (DEA) to estimate the efficiency of 128 hospitals comprising of 73 government hospitals, 42 mission hospitals, 7 quasi-government hospitals and 6 private hospitals. In the second stage, the estimated DEA efficiency scores are regressed against hospital ownership variable using a Tobit model. This was a retrospective study., Results: In our DEA analysis, using the variable returns to scale model, out of 128 district hospitals, 31 (24.0%) were 100% efficient, 25 (19.5%) were very close to being efficient with efficiency scores ranging from 70% to 99.9% and 71 (56.2%) had efficiency scores below 50%. The lowest-performing hospitals had efficiency scores ranging from 21% to 30%.Quasi-government hospitals had the highest mean efficiency score (83.9%) followed by public hospitals (70.4%), mission hospitals (68.6%) and private hospitals (55.8%). However, public hospitals also got the lowest mean technical efficiency scores (27.4%), implying they have some of the most inefficient hospitals.Regarding regional performance, Northern region hospitals had the highest mean efficiency score (83.0%) and Volta Region hospitals had the lowest mean score (43.0%).From our Tobit regression, we found out that while quasi-government ownership is positively associated with hospital technical efficiency, private ownership negatively affects hospital efficiency., Conclusions: It would be prudent for policy-makers to examine the least efficient hospitals to correct widespread inefficiency. This would include reconsidering the number of hospitals and their distribution, improving efficiency and reducing duplication by closing or scaling down hospitals with efficiency scores below a certain threshold. For private hospitals with inefficiency related to large size, there is a need to break down such hospitals into manageable sizes.

Background: Community health workers in Dangme-West district, Ghana, treated children aged 2-59 months with fever with either artesunate-amodiaquine (AAQ) or AAQ plus amoxicillin (AAQ + AMX) within a cluster-randomized controlled trial (registration no. TDR/UNDP Trial registration A: 20189). The intervention was introduced in a stepped-wedge manner. The aim of the study was reduction of mortality. This paper reports on the reduction of morbidity, notably anaemia, severe anaemia and severe illness. Clusters of 100 children were randomized in to AAQ, AAQ + AMX and pre-intervention arms. Six months later the pre-intervention clusters were randomized in to the AAQ and AAQ + AMX arms., Methods: Data were collected in eight cross-sectional surveys. Using stratified sampling, 10 clusters were randomly selected per survey. Blood samples were taken to assess haemoglobin. Caregivers were interviewed about diseases (signs and symptoms) among their children in the preceding 14 days. Multivariate logistic regression analysis was used to determine the impact on anaemia, severe anaemia and severe illness., Results: Compared with the pre-intervention clusters, anaemia was reduced in the AAQ (OR = 0.20, 95% CI 0.12-0.33) and AAQ + AMX (OR = 0.23, 95% CI 0.15-0.36) clusters, severe anaemia was reduced in the AAQ (OR = 0.20, 95% CI 0.09-0.45) and AAQ + AMX (OR = 0.12, 95% CI 0.04-0.31) clusters and severe illness was reduced in the AAQ (OR = 0.46, 95% CI 0.26-0.80) and AAQ + AMX (OR = 0.38, 95% CI 0.22-0.63) clusters. No significant differences were found in outcome variables between the AAQ and AAQ + AMX clusters., Conclusions: Treating fever with antimalarials significantly reduced the prevalence of anaemia, severe anaemia and severe illness. We found no significant reduction in outcomes when the AAQ and AAQ+AMX clusters were compared.

Background: The use of non-prescribed anti-malarial drugs can lead to treatment failure and development of drug-resistant parasites. This study investigated the use of non-prescribed anti-malarial drugs for the treatment of malaria in the Bolgatanga Municipality of northern Ghana., Methods: This was a cross-sectional survey of a random sample of 392 adults and children with episodes of malaria in the last four weeks prior to the study., Results: Majority of survey respondents 96.9% (380) knew the symptoms of malaria, 75% (294) knew the causes of malaria and 93.1% (365) were aware of mode of transmission of malaria. The use of non-prescribed anti-malarial drugs was 16.8% (95% CI: 13.3-21.0) among the respondents. About 56% (95% CI: 43.3-68.3) of the respondents who took non-prescribed anti-malaria drugs took non-artemisinin-based combination therapy (chloroquine, artemether, amodiaquine and sulphadoxine-pyrimethamine). Respondents above five years of age were more likely to use non-prescribed anti-malarial drugs than those below five years of age [P < 0.001]; respondents who knew the right source of malaria treatment were less likely to use non-prescribed anti-malarial drugs than those who did not [P = 0.002]. Respondents using non-prescribed anti-malarials were influenced by people around them who used non-prescribed anti-malarials. Thus, these respondents were more likely to use non-prescribed anti-malarials than those who were not influenced [P = 0.004]., Conclusions: Respondents' knowledge of malaria treatment and the influence of people using non-prescribed anti-malarials are factors affecting use of non-prescribed anti-malarials. The study concludes that there is high use of non-prescribed anti-malarial drugs in the municipality and most of the non-prescribed anti-malarias were non-artemisinin-based combination therapy. The study recommends education of the general public and chemical sellers to reduce the use of non-prescribe anti-malaria drugs.

Background: The relationship between entomological measures of malaria transmission intensity and mortality remains uncertain. This is partly because transmission is heterogeneous even within small geographical areas. Studying this relationship requires high resolution, spatially structured, longitudinal entomological data. Geostatistical models that have been used to analyse the spatio-temporal heterogeneity have not considered the uncertainty in both sporozoite rate (SR) and mosquito density data. This study analysed data from Kassena-Nankana districts in northern Ghana to obtain small area estimates of malaria transmission rates allowing for this uncertainty., Methods: Independent Bayesian geostatistical models for sporozoite rate and mosquito density were fitted to produce explicit entomological inoculation rate (EIR) estimates for small areas and short time periods, controlling for environmental factors., Results: Mosquitoes were trapped from 2,803 unique locations for three years using mainly CDC light traps. Anopheles gambiae constituted 52%, the rest were Anopheles funestus. Mean biting rates for An. funestus and An. gambiae were 32 and 33 respectively. Most bites occurred in September, the wettest month. The sporozoite rates were higher in the dry periods of the last two years compared with the wet period. The annual EIR varied from 1,132 to 157 infective bites. Monthly EIR varied between zero and 388 infective bites. Spatial correlation for SR was lower than that of mosquito densities., Conclusion: This study confirms the presence of spatio-temporal heterogeneity in malaria transmission within a small geographical area. Spatial variance was stronger than temporal especially in the SR. The estimated EIR will be used in mortality analysis for the area.

Objectives: Studies from low-income countries have suggested that routine vaccinations may have non-specific effects on child mortality; measles vaccine (MV) is associated with lower mortality and diphtheria-tetanus-pertussis (DTP) with relatively higher mortality. We used data from Navrongo, Ghana, to examine the impact of vaccinations on child mortality., Methods: Vaccination status was assessed at the initiation of a trial of vitamin A supplementation and after 12 and 24 months of follow-up. Within the placebo group, we compared the mortality over the first 4 months and the full 2 years of follow-up for different vaccination status groups with different likelihoods of additional vaccinations during follow-up. The frequency of additional vaccinations was assessed among children whose vaccination card was seen at 12 and 24 months of follow-up., Results: Among children with a vaccination card, more than 75% received missing DTP or MV during the first 12 months of follow-up, whereas only 25% received these vaccines among children with no vaccination card at enrollment. Children without a card at enrollment had a significant threefold higher mortality over the 2-year follow-up period than those fully vaccinated. The small group of children with DTP3-4 but no MV at enrollment had lower mortality than children without a card and had the same mortality as fully vaccinated children. In contrast, children with 1-2 DTP doses but no MV had a higher mortality during the first 4 months than children without a card [MRR = 1.65 (0.95, 2.87)]; compared with the fully vaccinated children, they had significantly higher mortality after 4 months [MRR = 2.38 (1.07, 5.30)] and after 2 years [MRR = 2.41 (1.41, 4.15)]. Children with 0-2 DTP doses at enrollment had higher mortality after 4 months (MRR = 1.67 (0.82, 3.43) and after 2 years [MRR = 1.85 (1.16, 2.95)] than children who had all three doses of DTP at enrollment., Conclusions: As hypothesised, DTP vaccination was associated with higher child mortality than measles vaccination. To optimise vaccination policies, routine vaccinations need to be evaluated in randomised trials measuring the impact on survival., (© 2012 Blackwell Publishing Ltd.)

Malaria and pneumonia are leading causes of childhood mortality. Home Management of fever as Malaria (HMM) enables presumptive treatment with antimalarial drugs but excludes pneumonia. We aimed to evaluate the impact of adding an antibiotic, amoxicillin (AMX) to an antimalarial, artesunate amodiaquine (AAQ + AMX) for treating fever among children 2-59 months of age within the HMM strategy on all-cause mortality. In a stepped-wedge cluster-randomized, open trial, children 2-59 months of age with fever treated with AAQ or AAQ + AMX within HMM were compared with standard care. Mortality reduced significantly by 30% (rate ratio [RR] = 0.70, 95% confidence interval [CI] = 0.53-0.92, P = 0.011) in AAQ clusters and by 44% (RR = 0.56, 95% CI = 0.41-0.76, P = 0.011) in AAQ + AMX clusters compared with control clusters. The 21% mortality reduction between AAQ and AAQ + AMX (RR = 0.79, 95% CI = 0.56-1.12, P = 0.195) was however not statistically significant. Community fever management with antimalarials significantly reduces under-five mortality. Given the lower mortality trend, adding an antibiotic is more beneficial.

Objectives: To compare (i) side effects associated with the simultaneous adminstration of praziquantel, albendazole and ivermectin with side affects associated with albendazole and ivermectin only and (ii) coverage by volunteers distributing three or two drugs., Methods: Two-arm comparative study in northern Ghana integrated praziquantel distribution into an existing lymphatic filariasis and onchocerciasis control programme using Community Directed Distributors. The control arm continued to distribute only ivermectin and albendazole. Dosages of ivermectin and praziquantel were based on height. Treatment was directly observed, and all two/three drugs were co-administered. Adverse effects were recorded based on passive surveillance. Parasitological, anthropometric and haematological data were collected at baseline., Results: Prevalence of Schistosoma haematobium infection among 1001 (boys: 47.9% girls: 52.1%) school-age children (6-15 years) [intervention: 30.0% (CI: 23.1-34.2); control: 23.0% (CI: 18.9-27.0)], mean haemoglobin, weight and age were similar among the intervention and control groups. While 1676 (99.1%) compounds in the control area were visited and 15,020 (96.58%) people were treated, only 1375 (88.5%) compounds in the intervention area were visited and 8454 (80.97%) people treated (P < 0.001). The numbers of adverse effects were similar (intervention: 50/6896; control: 130/15,020). The most reported adverse effects was headache (intervention: 14/50; control: 13/130), followed by body weakness, which was reported more from the intervention group (intervention: 13/50, 95% CI: 14.6-40.3; control: 6/130, 95% CI: 1.7-9.8]. Sixty-six per cent (6896/10,441) of the eligible population received praziquantel., Conclusions: Reported adverse events were mild and managed at the subdistrict level with no cases of hospitalization; intensive health education will, however, be required to improve coverage., (© 2011 Blackwell Publishing Ltd.)

The current study was designed to determine the age at which menarche occurs among school girls in Madina, Accra. A survey was conducted among 529 girls selected using multi-stage sampling from basic schools in Madina, Accra. Respondents completed a questionnaire that recorded age-at-first menstruation by recall, household characteristics, and anthropometry. Mean age at menarche was 12.74 +/- 1.15 years; probit analysis yielded a median age of 12.09 years. Menarcheal age was significantly correlated with current age (r = 0.48; p < 0.01). Most girls (90%) had first menstruation before age 13. Their mothers' mean age at menarche was 13.6 +/- 1.08 years. In a multivariate linear regression model, household wealth (p < 0.01) and body mass index (p < 0.01) were the main modifiable independent predictors of age at onset of menarche. School girls in Madina attained menarche earlier than previously estimated. Our study suggests an influence of household level improvement in socio-economic status on menarcheal age.

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

Background: Under-five mortality is a major public health problem and one of the health indicators of health care in sub-Saharan Africa. In order to address inefficient health systems, there is a need to identify the spatial distribution of under-five mortality, especially areas of high mortality clustering. This study aimed to explore spatial and temporal clustering in under-five mortality in the Kassena-Nankana() District of the Upper East region., Methods: We used data from the Navrongo Health and Demographic Surveillance System in the Kassena- Nankana District of northern Ghana, which had an average population of 140,000 of which about 18,400 were under five years of age. We analysed under-five mortality in 49 villages during the period 1997-2006. We calculated total under-five mortality rates and investigated their geographical distributions. A spatial scan statistic was used to test for clustering of the mortality in both space and time., Results: Under-five mortality has been declining during the period. However, the data show a persistently higher than average clustering of mortality over the period among villages mainly in the north-eastern parts of the district., Conclusion: There is a higher than average under-five mortality clustering in the villages in the north-east of the district and this may suggest a relatively poor health care system despite the many health interventions that took place over time in the district, including the Community Health and Family Planning Project, whose impact may not have been felt in these parts of the district between 1995 and 2004.

Demographics and health practices of 2,232 pregnant women in rural northeastern Ghana and characteristics of their 2,279 newborns were analyzed to determine benefits associated with intermittent preventive treatment (IPTp), antenatal care, and/or bed net use during pregnancy. More than half reported bed net use, 90% reported at least two antenatal care visits, and > 82% took at least one IPTp dose of sulfadoxine-pyrimethamine. Most used a bed net and IPTp (45%) or IPTp alone (38%). Low birth weight (< 2,500 grams) characterized 18.3% of the newborns and was significantly associated with female sex, Nankam ethnicity, first-born status, and multiple births. Among newborns of primigravidae, IPTp was associated with a significantly greater birth weight, significantly fewer low birth weight newborns, improved hemoglobin levels, and less anemia. Babies of multigravidae derived no benefit to birth weight or hemoglobin level from single or multiple doses of sulfadoxine-pyrimethamine during pregnancy. No differences or benefits were seen when a bed net was the only protective factor.

Introduction: Previous reports have indicated that open angle glaucoma is a major problem in the Upper East region of Ghana. Such reports have shown high prevalence among young patients under the age of 40 years. None has given enough details on the burden, pattern of distribution and extent of changes in the optic nerve head and intraocular pressures. This study aims at addressing these issues in order to highlight the situation., Methods: Retrospective case series involving review of clinical records of all first-time attendants diagnosed with glaucoma at the Bawku Hospital between October 2003 and December 2005. Case definitions and diagnostic criteria were made to conform as much as possible to the ISGEO and EGS recommendations. Data analysis was done using the Epi-Info software., Results: Records of 891 eyes of 446 patients were reviewed. Median age was 56 years with 23.6% below 40 years. POAG was diagnosed in 98.4% with 8.3% manifesting the NTG variant. One third (34.1%) of all the patients reported bilaterally blind while half were uniocularly blind. Nearly a third (70.2%) had CDRs>0.8 while more than half (54.9%) had CDRs measured at unity. Males were twice as many as females (65.5% and 34.5% respectively) but blindness sequelae among the latter was twice as much and this was statistically significant (p=0.0008;chi2 test), Conclusion: late presentation of open angle glaucoma cases is a major problem in this part of Ghana. We recommend a more aggressive approach to tackle the disease and reduce its blindness sequelae.

Background: Research conducted in Africa has consistently demonstrated that parental poverty and low educational attainment adversely affect child survival. Research conducted elsewhere has demonstrated that low-cost vaccines against preventable diseases reduce childhood mortality. Therefore, the extension of vaccination to impoverished populations is widely assumed to diminish equity effects. Recent evidence that childhood mortality is increasing in many countries where vaccination programmes are active challenges this assumption., Data and Methods: This paper marshals data from accurate and complete immunization records and survival histories for 18,368 children younger than five years in a rural northern Ghanaian population that is generally impoverished, but where family wealth and parental educational differentials exist nonetheless. Time-conditional Weibull hazard models are estimated to test the hypothesis that childhood immunization offsets the detrimental effects of poverty and low educational attainment., Conclusions: Findings show that the adverse effects of poverty disappear and that the effects of educational attainment are reduced in survival models that control for immunization status. This finding lends empirical support to policies that promote immunization as a strategic component of poverty-reduction programmes.

Background: Intermittent preventive treatment for malaria in children (IPTc) is a promising new intervention for the prevention of malaria but its delivery is a challenge. We have evaluated the coverage of IPTc that can be achieved by two different delivery systems in Ghana., Methods: IPTc was delivered by volunteers in six villages (community-based arm) and by health workers at health centres or at Expanded Programme on Immunisation outreach clinics (facility based) in another six communities. The villages were selected randomly and drugs were administered in May, June, September and October 2006. The first dose of a three-dose regimen of amodiaquine plus sulphadoxine-pyrimethamine was administered under supervision to 3-59 month-old children (n = 964) in the 12 study villages; doses for days 2 and 3 were given to parents/guardians to administer at home., Results: The proportion of children who received at least the first dose of 3 or more courses of IPTc was slightly higher in the community based arm (90.5% vs 86.6%; p = 0.059). Completion of the three dose regimen was high and similar with both delivery systems (91.6% and 91.7% respectively)., Conclusion: Seasonal IPTc delivered through community-based or facility-based systems can achieve a high coverage rate with the support and supervision of the district health management team. However, in order to maximise the impact of IPTc, both delivery systems may be needed in some settings., Trial Registration: ClinicalTrials.gov NCT00119132.

Background: Information on the epidemiology of malaria is essential for designing and interpreting results of clinical trials of drugs, vaccines and other interventions. As a background to the establishment of a site for anti-malarial drugs and vaccine trials, the epidemiology of malaria in a rural site in central Ghana was investigated., Methods: Active surveillance of clinical malaria was carried out in a cohort of children below five years of age (n = 335) and the prevalence of malaria was estimated in a cohort of subjects of all ages (n = 1484) over a 12-month period. Participants were sampled from clusters drawn around sixteen index houses randomly selected from a total of about 22,000 houses within the study area. The child cohort was visited thrice weekly to screen for any illness and a blood slide was taken if a child had a history of fever or a temperature greater than or equal to 37.5 degree Celsius. The all-age cohort was screened for malaria once every eight weeks over a 12-month period. Estimation of Entomological Inoculation Rate (EIR) and characterization of Anopheline malaria vectors in the study area were also carried out., Results: The average parasite prevalence in the all age cohort was 58% (95% CI: 56.9, 59.4). In children below five years of age, the average prevalence was 64% (95% CI: 61.9, 66.0). Geometric mean parasite densities decreased significantly with increasing age. More than 50% of all children less than 10 years of age were anaemic. Children less than 5 years of age had as many as seven malaria attacks per child per year. The attack rates decreased significantly with increasing cut-offs of parasite density. The average Multiplicity of Infection (MOI) was of 6.1. All three pyrimethamine resistance mutant alleles of the Plasmodium falciparum dhfr gene were prevalent in this population and 25% of infections had a fourth mutant of pfdhps-A437G. The main vectors were Anopheles funestus and Anopheles gambiae and the EIR was 269 infective bites per person per year., Conclusion: The transmission of malaria in the forest-savanna region of central Ghana is high and perennial and this is an appropriate site for conducting clinical trials of anti-malarial drugs and vaccines.

Objective: To determine the causes and incidence of destructive ophthalmic procedures as seen at a major reference eye centre in northern Ghana, Methods: Retrospective case series involving a review of surgical records of all evisceration and enucleation procedures done between January 2002 and December 2006 at the Bawku Hospital Eye Department. Information collected included basic demographic data, diagnosis, visual acuity at diagnosis and the eye affected. The aetiology responsible was determined from history, clinical examination and investigations as contained in the existing records. The primary clinical indications for evisceration were categorized into degenerative lesions, infections, trauma, neoplasms, and others. Statistical analysis was done using the Epi Info software., Results: A total of 337 eyes of 336 patients made up of 217 (64.6%) males and 119 (35.4%) females were removed during the study period. Mean age was 36.4 with a range of 1-90 years. Children under 15 years constituted 25.1% of whom 9.3% were under 5 years. The elderly (>/=60 years) comprised 26.3%. The most common cause of destructive procedure was endophthalmitis /panophthalmitis (47.9%), ocular injuries (23.2%), degenerative lesions (8.9%) and neoplasms (5.1%). Regarding neoplasms, females were more likely to be enucleated while the reverse was so for traumas (p=0.04 and p=0.02, Chi(2) test, respectively). Compared to the total number of surgeries done each year the crude incidence was computed at 26.6% per 1000 cases per year., Conclusion: Most causes of destructive procedures in this part of Ghana are preventable and serious preventive strategies are needed to reverse this trend.

Background: Malaria is a major public health problem in Ghana. The current strategy of the National Malaria Control Programme is based on effective case management and the use of insecticide treated bed nets among vulnerable groups such as children under-five years of age and pregnant women. Resistance to pyrethroids by Anopheles gambiae s.l. and Anopheles funestus has been reported in several African countries including neighbouring Burkina Faso., Methods: Indoor resting Anopheles mosquitoes were collected. Blood-fed and gravid females were allowed to oviposit, eggs hatched and larvae reared to 1-3 days old adults and tested against permethrin 0.75%, deltamethrin 0.05%, cyfluthrin 0.15%, lambdacyhalothrin 0.1% and DDT 4%, based on WHO methodology. PCR analyses were carried out on a sub-sample of 192 of the An. gambiae for sibling species complex determination. Resistance to pyrethroids and DDT was determined by genotyping the knock-down resistance kdr gene mutations in the study area., Results: A total of 9,749 1-3 days-old F1 female Anopheles mosquitoes were exposed to the insecticides. Among the pyrethroids, permethrin, 0.75% had the least knockdown effect, whilst cyfluthrin 0.15%, had the highest knock-down effect. Overall, no difference in susceptibility between An. gambiae 93.3% (95% CI: 92.5-94.1) and An. funestus 94.5% (95% CI: 93.7-95.3) was observed when exposed to the pyrethroids. Similarly, there was no difference in susceptibility between the two vector species (An. gambiae = 79.1% (95% CI: 76.6-81.8) and An. funestus = 83.5% (95% CI: 80.2-86.4) when exposed to DDT. Overall susceptibility to the insecticides was between 80% and 98%, suggesting that there is some level of resistance, except for cyfluthrin 0.15%. The kdr PCR assay however, did not reveal any kdr mutations. The analysis also revealed only the molecular M (Mopti) form., Conclusion: The findings in this study show that An. gambiae and An. funestus, the main malaria vector mosquitoes in the Kassena-Nankana district are susceptible to the insecticides being used in the treatment of bed nets in the malaria control programme. There is however, the need for continuous monitoring of the pyrethroids as the efficacy is not very high.

Introduction: Health systems in developing countries including Ghana are faced with critical resource constraints in pursuing the goal of improving the health status of the population. The constrained ability to adequately meet health care needs is exacerbated by inefficiency in the health care systems, especially within public health centres., Methods: The study used Data Envelopment Analysis (DEA) method, to calculate the technical and allocative efficiency of 113 randomly sampled health centres. A logistic regression model was also applied on whether a health centre was technically efficient or not to determine the factors that significantly influence the efficiency of health centres., Findings: The findings showed that 78% of health centres were technically inefficient and so were using resources that they did not actually need. Eight-eight percent were also allocatively inefficient. The overall efficiency, (product of the technical and allocative efficiency), was also calculated and over 90% of the health centres were inefficient. The results of a logistic regression analysis show that newer health centres and those which receive incentives were more likely to be technically efficient compared to older health centres and those who did receive incentives., Conclusion: The results broadly point to grave inefficiency in the health care delivery system of the health centres and that lots of resources could be saved if measures were put in place to curb the waste. Incentives to health centres were found to be major motivating factors to the promotion of efficiency.