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Abstract Background Exclusive breastfeeding is a public health priority in sub-Saharan Africa. However, systematic reviews on its determinants in Ghana remain scarce. Therefore, we systematically reviewed the prevalence and determinants of exclusive breastfeeding in children 0–6 months in Ghana. Methods We conducted systematic searches in Embase, Medline, and Africa-Wide Information from the databases’ inception until February 2021 for studies that assessed the prevalence and determinants of exclusive breastfeeding in children 0–6 months in Ghana. Random-effects meta-analysis was used to estimate the pooled prevalence of exclusive breastfeeding and narrative synthesis to summarise the determinants. We calculated the proportion of total variability that was due to between study heterogeneity using I² statistics, and Egger’s test assessed publication bias. The review is registered with PROSPERO, CRD42021278019. Results Out of the 258 articles identified, 24 met the inclusion criteria. Most of the included studies were cross-sectional and were published between 2005 and 2021. The pooled prevalence of exclusive breastfeeding (EBF) among children 0–6 months in Ghana was 50% (95%CI 41.0–60.0%). The prevalence was higher in rural areas (54%) than in urban areas (44%). Several factors were identified as facilitators of EBF, including older maternal age, self-employment, unemployment, living in a large house, being a house owner, giving birth in a health facility, non-caesarean delivery, adequate antenatal attendance, counselling services, participation in support groups, adequate knowledge about EBF, positive attitude towards EBF, and higher maternal education among rural dwellers. Additionally, having an average birthweight facilitated EBF. Barriers to EBF were also identified, including higher maternal education among urban dwellers, less than three months of maternity leave, maternal HIV-positive status, the experience of partner violence, lack of access to radio, inadequate breastmilk production, lack of family support, having a partner who wants more children, counselling on complementary feeding, healthcare worker recommendation of complementary feed, single marital status, and infant admission to neonatal intensive care units. Conclusion In Ghana, EBF rates are low, with only about half of all children aged 0–6 months breastfed exclusively. A multi-dimensional approach is required to tackle the diverse sociodemographic, obstetric, and infant-related issues that hinder EBF practice in Ghana.

Abstract Introduction The increasing population of older adults and rapid increases in co‐morbidities globally has necessitated the need for a healthcare delivery system that meets the multifaceted needs of the growing population of older adults. Concurrent with these rising complex health needs is the importance of positive, non‐judgmental attitudes of health services providers towards older adults. Moreover, this is particularly important in the nursing profession, given nurses' significant and crucial roles in healthcare settings. Aim The study aimed to evaluate nurses’ attitudes towards older adults in a tertiary hospital in Ghana. Design It employed a descriptive cross‐sectional quantitative design. Method Data were collected from 160 registered adult medical and surgical ward nurses using the Ageism Attitude Scale (AAS). Results Findings indicated that more than half of the participants had a diploma in general nursing. None of the nurses surveyed specialized in the care of older adults, and the mean age of participants was 30.14 (3.75) (minimum 24 and maximum 42 years). Female nurses had more positive attitudes than their male counterparts. Although the surveyed nurses reported a somewhat positive attitude towards older adults, there was no correlation between nurses' education levels and positive attitudes.

Abstract Study aim Considering the alarming rate at which young people abuse tramadol, as evidenced by the numerous media reports on the subject, this qualitative study was conducted to explore the facilitators to the abuse of tramadol by young people. Design and methods A qualitative exploratory descriptive design was employed in conducting the study. A total of 18 participants were purposively sampled. Data for the study were collected through two focused group discussions and three in‐depth‐interviews. Thematic analysis was used to analyse the data. Results The findings of the study revealed four main themes. These themes were initiating factors of abuse; desirable physical effects; desirable psychological effects; and undesirable effects. It was revealed that many young people initially get into tramadol abuse because of peer pressure, curiosity or post‐traumatic addiction. However, they often continue the practice for various physical and psychological gratifications including euphoria, attentiveness, high energy levels, pain relief and improved sexual performance. The study also revealed some unpleasant side effects of tramadol abuse such as severe vomiting, loss of appetite, seizures, emotional aloofness and irritability. Many of the participants in this study also expressed willingness to quit tramadol abuse because of social discrimination and the enormous side effects that come with the abuse of the drug.

Ionizing radiation, emanating from decaying nuclides, poses potential biological harm to human organs. Wadi B, a village within the Jere local government area of Borno State, Nigeria, is currently undergoing oil exploration activities. This study was conducted to evaluate the outdoor gamma radiation levels at the Wadi B oil exploration site. Utilizing a portable hand dosimeter (Radiation Alert Inspector), gamma exposure levels (GEL) were measured across sixteen (16) spots within the exploration site. Results revealed that the gamma exposure levels measured in the boreholes FYM (1 to 8), range from 0.17- 0.27 Mr/hr, with an average of 0.21 Mr/hr while, the levels around the wells FYM (9 to 16) vary from 0.14- 0.25 Mr/hr, with an average of 0.18 Mr/hr. The estimated annual effective dose (AED) varied from 0.24528 to 0.47304 μSv/yr, averaging at 0.3460 μSv/yr. Notably, the average values of Total Dissolved Solids (TDS), Conductivity, and Gamma radiation exceeded the recommended limits established by the World Health Organization (WHO, 2006), which are 400 μS/cm for conductivity, (50-150) ppm for TDS, and 0.002 mR/hr for radiation doses, respectively. However, the calculated Excess Lifetime Cancer Risk (ELCR) values were lower than the proposed world average level of 70 μSv/yr by the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR). This study suggests a heightened risk of exposure to outdoor ionizing radiation among inhabitants residing near the study locations

This study assesses the activity concentration of Radon in underground water around Bagwai and Shanono artisan gold mining Sites in Kano State, Northwestern Nigeria. A total of (39) underground water samples, including sixteen (16) from boreholes and twenty-three (23) from hand-dug wells, were randomly collected. The activity concentration of Radon was analyzed using a portable radon detector, Rad7, from DURRIDGE Company. The results show that the radon concentration in all the water samples ranges from 4.13 to 45.24 Bq/l, with an average value of 20.13 Bq/l. The calculated total annual effective dose due to both ingestion and inhalation for different age groups ranges from 42.40, 57.60 and 65.30 (µSv/y) to 457.10, 622.06 and 704.60 (µSv/y), with an average value of 203.32, 276.70 and 313.51 (µSv/y) for adults, children, and infants respectively. The total excess lifetime cancer risk for different age groups varies from 0.00149, 0.00202 and 0.0247 to 0.0160, 0.0220 and 0.0247 with mean values of 0.00703, 0.00956 and 0.0109 for adults, children, and infants. The obtained results are higher than the internationally recommended limits set by USEPA of 4 to 40Bq/l and the International Commission on Radiological Protection (ICRP) value of 0.1mS/y; thus, the water in the study area is not suitable for drinking and other domestic purposes. Hence, remedial action needs to be taken by the authorities to ensure the continuous utilization of water within the study area.

An experiment was conducted to ascertain the histopathology of the liver, kidney, and spleen of rams fed Tiger nut chaff and cowpea husk in a mixed ration. The dietary treatments compared were T1 (Cowpea husk 40% + Tiger nuts chaff 0%), T2 (Cowpea husk 30% + Tiger nuts chaff 10%), T3 (Cowpea husk 20% + Tiger nuts chaff 20%), T4 (Cowpea husk 10% + Tiger nuts chaff 30%), and T5 (Cowpea husk 0% + Tiger nuts chaff 40%). The results show a significant difference (p<0.05) in crude protein content of the diet, with T1 having the highest value (155.1 g kg-1 DM), and the lowest value observed in T5 (145.1 g kg-1 DM). Dry matter content of the experimental diets ranged from 895.7 g kg-1 DM in T4 (10% Cowpea husk and 30% Tiger nuts chaff ration mix) to 920.1 g kg-1 DM in T3 (20% Cowpea husk and 20% Tiger nuts chaff ration mix). T1 was observed to have the lowest ash content compared to other treatments. The pattern of significant differences (p<0.05) for Lignin and NDF were similar with the highest values (122 g kg-1 DM and 453.7 g kg-1 DM respectively) recorded in T1 and the lowest values (113 g kg-1 DM and 420.6 g kg-1 DM respectively) in T5. ADF was significantly different with T1 recording the highest value of 265.1 g kg-1 DM and the lowest in T5 at 232.0 g kg-1 DM. Histopathology indicated that the liver had some form of sinusoidal dilation at higher levels of inclusion of tiger nuts chaff, kidneys showed different levels of degeneration and vaculation with a few inflammatory cells around the glomerulus while the spleen indicated normal lymphoid cells with clear demarcation of the marginal zone and follicle. It can be concluded that feeding a mixed ration of 30% cowpea husk and 10% tiger nut chaff does not have any clinically harmful effect on the liver, and no histopathological impact on the kidney and spleen was observed at all levels of the feed ration mix. [ABSTRACT FROM AUTHOR]

Diabetes mellitus (DM) is a diverse group of metabolic disorder which is often associated with a high disease burden in developing countries such as Nigeria. It is one of the dreaded complications leading to repeated hospitalizations and even amputation, drastically reducing the quality of life. Hence proper management of infections among diabetic patients and choosing appropriate antibiotic is crucial. The study aimed to determine the prevalence of Extended Spectrum Betalactamase (ESBL) and Ampicillinases (AmpC) producing Enterobacteriaceae from diabetic patients attending some hospitals in Bauchi state. A total of 196 samples were collected from diabetic patients attending Abubakar Tafawa Balewa University Teaching Hospital Bauchi, Bauchi state. The samples were processed according to standard microbiological techniques, Gram negative; oxidase negative isolates were suspected as Enterobacteriaceae and were confirmed using API20E kit. Antimicrobial susceptibility testing was done using disc diffusion method, ESBL and AmpC production were detected using double disc synergy test and disc approximation assay respectively. A total of 74 (37.8%) Enterobacteriaceae were isolated from study participants, age group 11 to 85 years comprising of 103 male and 93 female, the most frequently isolated enterobacteriaceae was Escherichia coli which has 41(20.9 %) while the least occurring was Enterobacter spp with 3 (1.5%). Antibiotic screening shows 58 (78.4%) of the isolates were resistant to third generation cephalosporin antibiotics, 54.0% were resistant to cephamycin (cefoxitin). Extendedspectrum Beta lactamase (ESBL) production was noted among 38 (51.3%) of the total isolates, followed by 25 AmpC producing enterobacteriaceae (33.8%), statistically there is significant association between inpatient (hospitalizes diabetes patients) and ESBL producing enterobacteriaceae in the study area (P-value = 0.04). [ABSTRACT FROM AUTHOR]

The aetiology of lower respiratory tract infection (LRTI) is diverse and complicated, hence in most developing countries, treatment of LRTI is made usually empirically in which the etiologic agent is rarely identified. Therefore this study was designed to isolate and identify bacterial pathogens of lower respiratory tract among patients attending some hospitals in Kebbi State, Nigeria. Three hundred and fifty sputum samples were collected from six different hospitals in Kebbi State after obtaining an ethical approval from the ministry of health and informed consent from all the participants. Sputum samples were inoculated into blood agar, chocolate agar and MacConkey agar plates. The chocolate agar plates were incubated in an incubator (5% CO2) at 37 °C for 24 hours while blood agar and MacConkey agars were incubated in an aerobic atmosphere at 37°C for 24 hours. The bacterial isolates were identified using conventional biochemical tests and then confirmed using commercial biochemical test kit (MICROBACT) according to manufacturer's instruction. Antimicrobial susceptibility test were determined using disc diffusion method according to CLSI guidelines. Staphylococcus aureus was the most predominant bacteria isolated in this location followed by Klebsiella pneumoniae with an estimated percentage occurrence of 31.1% and 22.2% respectively. Other bacteria isolated include Klebsiella oxytoca (13.9%), Escherichia coli (11.1%), Pseudomonas aeruginosa (5.6%), Aeromonas hydrophila (5.6%), Acinetobacter baumannii (4.6%), Burkholderia pseudomallei (2.8%) and Proteus spp (2.8%). It was found out that, the young adults and the elderly were most at risk of a severe respiratory condition. The result also shows that LRTI were more common in males than in females. Most of the isolates were susceptible to piperacilin ((51%), trimethoprim sulphamethoxazole (61%), Azithromycin (70%), Ciprofloxacin (71%) and Gentamycin (74%), in order of ranking. High resistance were recorded in almost all the βeta-lactam antibiotics, erythromycin and vancomycin tested. In conclusion, Staphylococcus aureus was the most predominant bacteria isolated followed by Klebsiella pneumoniae while the least bacteria isolated were Burkholderia. pseudomallei and Proteus vulgaris. Lower respiratory tract infection was also more common in male and occurred mostly in young adults and elderly. Azithromycin, Ciprofloxacin, Gentamycin and piperacillin remain the useful antibiotics in the treatment of LRTIs in this location. [ABSTRACT FROM AUTHOR]

The consumption of fresh vegetables serves as source of important nutrients in the body; however, parasitic infection from the consumption of raw fruits and vegetables is on the increase. This study aimed at identifying the parasitic contamination of Vegetables sold at Masaka market New Karu, Nasarawa State. A total of 240 samples of vegetables were examined by sedimentation concentration after washing using normal saline. The overall prevalence of parasitic contamination was 52.5%. Fluted pumpkin (93.3%) was the most contaminated vegetable while cucumber and apple (16.7%) were the least contaminated vegetables (P>0.05). Strongyloides stercoralis (28.9%) was the most frequently detected parasite followed by Taenia spp (18.8%), Entamoeba coli (17.2%), Hookworm (13.3%), Entamoeba histolytica (8.6%), Ascaris lumbricoides (7.8%) and Toxocara spp (5.5%) was the least detected parasite. The parasitic contamination of different vegetables shows that Tomatoes and Lettuce had the highest poly-parasitic contamination of four species of parasites, whereas Apple and Cucumber had the least poly-parasitic contamination of one parasite. Strongyloides stercoralis had the highest infestation (37.5%) of the water samples used to refresh the vegetables. Vegetables that were washed before display for selling was significantly associated with reduced parasitic contamination (P>0.05). Vegetables are potential sources of transmission for intestinal parasites in the study area, hence, proper washing of fruits and cooking of vegetables is required to reduce parasitic infections. [ABSTRACT FROM AUTHOR]

Blood parasites of animals reduce livestock productivity and could lead to high mortality. This study aims at determining the haematological status and prevalence of blood parasites in cattle slaughtered in abattoirs in Minna. Blood samples were obtained from 300 apparently healthy cattle from both male and female cattle from three abattoirs (Taye, Chanchaga and Maikunkele), using standard field and laboratory techniques. The blood samples were examined for blood parasites by making thin blood smear and staining with Giemsa stain. . Three genera of blood parasites Trypanosoma species Babesia species and Anaplasma species were observed. An overall parasitaemia of 47.67% accounting for 143 positive cattle out of 300 cattle examined. Abattoir-specific prevalence indicated 16.33%, 16.00% and 15.33% for Taye, Maikunkele and Chanchaga abattoirs respectively. The three species of parasites identified showed prevalence of 26.67%, 13.67% and 3.67% for Trypanosoma brucei, Babesia bovis and Anaplasma marginale respectively. Sex-related parasitaemia revealed that females had higher prevalence 91(33.55%) than males 51(23.11%) which was not statistically significant (p>0.05). The haematological parameters showed anaemia with significant decreases in the female RBC (3.00 ± 0.69), PCV (14.20 ± 3.85) and Hb (7.38 ± 2.44) compared to male RBC (4.69 ± 1.23), PCV (25.80 ± 4.15) and Hb (12.13 ± 5.23) respectively which is statistically significant (p<0.05)), While there was a record of significant increase in the WBC (18.04 ± 1.78) of the female cattle compared with their male WBC (11.19 ± 3.42) counterpart. There was no significant difference (p>0.05) between MCV, MCH and MCHC of the two sexes. This study provides information on the blood parasites status of cattle which calls for more control and preventive measures against the diseases in Minna metropolis. [ABSTRACT FROM AUTHOR]

Environmental cleaning is essential to patient and health worker safety, yet it is a substantially neglected area in terms of knowledge, practice, and capacity-building, especially in resource-limited settings. Public health advocacy, research and investment are urgently needed to develop and implement cost-effective interventions to improve environmental cleanliness and, thus, overall healthcare quality and safety. We outline here the CLEAN Group Consensus exercise yielding twelve urgent research questions, grouped into four thematic areas: standards, system strengthening, behaviour change, and innovation., (© 2024. The Author(s).)

Background: Hand hygiene is known to reduce healthcare-associated infections. However, it remains suboptimal among healthcare providers. In this study, we used the Behaviour-centered Design approach to explore the facilitators and deterrents to hand hygiene among healthcare providers in the Kampala Metropolitan area, Uganda., Methods: We conducted a formative qualitative study as part of a cluster randomised trial in 19 healthcare facilities (HCFs). The study used 19 semi-structured and 18 key informant interviews to collect data on hand hygiene status and facilitators and deterrents of hand hygiene. Research assistants transcribed verbatim and used a thematic framework aided by Nvivo 14.0. to undertake analysis. We used thick descriptions and illustrative quotes to enhance the credibility and trustworthiness of our findings., Results: About 47.4% of the HCFs had sufficient hand hygiene infrastructure, and 57.9% did not report total compliance with hand hygiene during patient care. The physical facilitator for hand hygiene was the presence of constant reminders such as nudges, while the biological included the frequency of patient contact and the nature of clinical work. The only biological deterrent was the heavy workload in HCFs. The executive brain facilitators included knowledge of workplace health risks, infection prevention and control (IPC) guidelines, and a positive attitude. A negative attitude was the executive brain deterrent to hand hygiene. Recognition, rewards, and fear of infections were the only motivated brain facilitators. Behavioural setting facilitators included proximity to functional hand hygiene infrastructure, the existence of active IPC committees, good leadership, and the availability of a budget for hand hygiene supplies. Behavioural setting deterrents included the non-functionality and non-proximity to hand hygiene infrastructure and inadequate supplies., Conclusions: The study revealed low compliance with hand hygiene during the critical moments of patient care and inadequacy of hand hygiene infrastructure. The deterrents to hand hygiene included a heavy workload, negative attitude, inadequate supplies, non-functionality, and long distance to hand washing stations. Facilitators included constant reminders, fear of infections, frequency of patient contact and nature of clinical work, positive attitude, knowledge of IPC guidelines, recognition and reward, good leadership, availability of budgets for hand hygiene supplies, availability and proximity to hand hygiene supplies and infrastructure and active IPC committees., Trial Registration: ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020., (© 2024. The Author(s).)

Cholera is a diarrhoeal disease caused by Vibrio cholerae (V. cholerae) bacterium, with strains belonging to serogroups 01 and 0139 causing a huge proportion of the disease. V. cholerae can contaminate drinking water sources and food through poor sanitation and hygiene. This study aimed to identify environmental routes of exposure to V. cholerae within Mukuru informal settlement in Nairobi. We collected nine types of environmental samples (drinking water, flood water, open drains, surface water, shaved ice, raw produce, street food, soil, and public latrine swabs) over 12 months. All samples were analysed for V. cholerae by culture and qPCR, then qPCR-positive samples were quantified using a V. cholerae DNA standard. Data about the frequency of contact with the environment was collected using behavioural surveys. Of the 803 samples collected, 28.5% were positive for V. cholerae by qPCR. However, none were positive for V. cholerae by culture. V. cholerae genes were detected in majority of the environmental water samples (79.3%), including open drains, flood water, and surface water, but were only detected in small proportions of other sample types. Vibrio-positive environmental water samples had higher mean V. cholerae concentrations [2490-3469 genome copies (gc) per millilitre (mL)] compared to drinking water samples (25.6 gc/mL). Combined with the behavioural data, exposure assessment showed that contact with surface water had the highest contribution to the total V. cholerae exposure among children while ingestion of municipal drinking water and street food and contact with surface water made substantial contributions to the total V. cholerae exposure for adults. Detection of V. cholerae in street food and drinking water indicates possible risk of exposure to toxigenic V. cholerae in this community. Exposure to V. cholerae through multiple pathways highlights the need to improve water and sanitation infrastructure, strengthen food hygiene practices, and roll out cholera vaccination., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Kering 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: During 2014 to 2019, the SaniPath Exposure Assessment Tool, a standardized set of methods to evaluate risk of exposure to fecal contamination in the urban environment through multiple exposure pathways, was deployed in 45 neighborhoods in ten cities, including Accra and Kumasi, Ghana; Vellore, India; Maputo, Mozambique; Siem Reap, Cambodia; Atlanta, United States; Dhaka, Bangladesh; Lusaka, Zambia; Kampala, Uganda; Dakar, Senegal., Objective: Assess and compare risk of exposure to fecal contamination via multiple pathways in ten cities., Methods: In total, 4053 environmental samples, 4586 household surveys, 128 community surveys, and 124 school surveys were collected. E. coli concentrations were measured in environmental samples as an indicator of fecal contamination magnitude. Bayesian methods were used to estimate the distributions of fecal contamination concentration and contact frequency. Exposure to fecal contamination was estimated by the Monte Carlo method. The contamination levels of ten environmental compartments, frequency of contact with those compartments for adults and children, and estimated exposure to fecal contamination through any of the surveyed environmental pathways were compared across cities and neighborhoods., Results: Distribution of fecal contamination in the environment and human contact behavior varied by city. Universally, food pathways were the most common dominant route of exposure to fecal contamination across cities in low-income and lower-middle-income countries. Risks of fecal exposure via water pathways, such as open drains, flood water, and municipal drinking water, were site-specific and often limited to smaller geographic areas (i.e., neighborhoods) instead of larger areas (i.e., cities)., Conclusions: Knowledge of the relative contribution to fecal exposure from multiple pathways, and the environmental contamination level and frequency of contact for those "dominant pathways" could provide guidance for Water, Sanitation, and Hygiene (WASH) programming and investments and enable local governments and municipalities to improve intervention strategies to reduce the risk of exposure to fecal contamination., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Our study aimed at assessing the determinants of hand hygiene and utilisation of bathing facilities in healthcare facilities (HCFs) in the greater Kampala metropolitan area, Uganda. Results indicate that 19.9% of the respondents wished to wash hands and failed while 39.3% faced challenges related to bathing. Failure to wash hands was associated with received information on hand washing (APR = 1.14, 95% CI: 1.06-1.24), using piped water (APR = 0.88, 95%CI: 0.78-0.98) or a well as the main water source at the HCF (APR = 1.21,95% CI: 1.03-1.42). Experiencing challenges of bathing was associated with accessing healthcare services at a hospital (APR = 0.89, 95% CI 0.81-0.97) and using public HCF (APR = 1.10, 95% CI: 1.01-1.120). There is urgent need to improve hand hygiene and bathing facilities though providing reliable water and soap.

Background: Health facility deliveries are generally associated with improved maternal and child health outcomes. However, in Uganda, little is known about factors that influence use of health facilities for delivery especially in rural areas. In this study, we assessed the factors associated with health facility deliveries among mothers living within the catchment areas of major health facilities in Rukungiri and Kanungu districts, Uganda., Methods: Cross-sectional data were collected from 894 randomly-sampled mothers within the catchment of two private hospitals in Rukungiri and Kanungu districts. Data were collected on the place of delivery for the most recent child, mothers' sociodemographic and economic characteristics, and health facility water, sanitation and hygiene (WASH) status. Modified Poisson regression was used to estimate prevalence ratios (PRs) for the determinants of health facility deliveries as well as factors associated with private versus public utilization of health facilities for childbirth., Results: The majority of mothers (90.2%, 806/894) delivered in health facilities. Non-facility deliveries were attributed to faster progression of labour (77.3%, 68/88), lack of transport (31.8%, 28/88), and high cost of hospital delivery (12.5%, 11/88). Being a business-woman [APR = 1.06, 95% CI (1.01-1.11)] and belonging to the highest wealth quintile [APR = 1.09, 95% CI (1.02-1.17)] favoured facility delivery while a higher parity of 3-4 [APR = 0.93, 95% CI (0.88-0.99)] was inversely associated with health facility delivery as compared to parity of 1-2. Factors associated with delivery in a private facility compared to a public facility included availability of highly skilled health workers [APR = 1.15, 95% CI (1.05-1.26)], perceived higher quality of WASH services [APR = 1.11, 95% CI (1.04-1.17)], cost of the delivery [APR = 0.85, 95% CI (0.78-0.92)], and availability of caesarean services [APR = 1.13, 95% CI (1.08-1.19)]., Conclusion: Health facility delivery service utilization was high, and associated with engaging in business, belonging to wealthiest quintile and having higher parity. Factors associated with delivery in private facilities included health facility WASH status, cost of services, and availability of skilled workforce and caesarean services.

Background: Hand hygiene (HH) among healthcare workers (HCWs) is critical for infection prevention and control (IPC) in healthcare facilities (HCFs). Nonetheless, it remains a challenge in HCFs, largely due to lack of high-impact and efficacious interventions. Environmental cues and mobile phone health messaging (mhealth) have the potential to improve HH compliance among HCWs, however, these remain under-studied. Our study will determine the impact of mhealth hygiene messages and environmental cues on HH practice among HCWs in the Greater Kampala Metropolitan Area (GKMA)., Methods: The study is a cluster-randomized trial, which will be guided by the behaviour centred design model and theory for behaviour change. During the formative phase, we shall conduct 30 key informants' interviews and 30 semi-structured interviews to explore the barriers and facilitators to HCWs' HH practice. Besides, observations of HH facilities in 100 HCFs will be conducted. Findings from the formative phase will guide the intervention design during a stakeholders' insight workshop. The intervention will be implemented for a period of 4 months in 30 HCFs, with a sample of 450 HCWs who work in maternity and children's wards. HCFs in the control arm will receive innovatively designed HH facilities and supplies. HCWs in the intervention arm, in addition to the HH facilities and supplies, will receive environmental cues and mhealth messages. The main outcome will be the proportion of utilized HH opportunities out of the 9000 HH opportunities to be observed. The secondary outcome will be E. coli concentration levels in 100mls of hand rinsates from HCWs, an indicator of recent fecal contamination and HH failure. We shall run multivariable logistic regression under the generalized estimating equations (GEE) framework to account for the dependence of HH on the intervention., Discussion: The study will provide critical findings on barriers and facilitators to HH practice among HCWs, and the impact of environmental cues and mhealth messages on HCWs' HH practice., Trial Registration: ISRCTN Registry with number ISRCTN98148144 . The trial was registered on 23/11/2020.

Background: Improved Water, Sanitation and Hygiene (WASH) in Healthcare facilities (HCFs) is of significant public health importance. It is associated with a reduction in the transmission of healthcare acquired infections (HAIs), increased trust and uptake of healthcare services, cost saving from infections averted, increased efficiency and improved staff morale. Despite these benefits, there is limited evidence on availability of WASH services in HCFs in the Greater Kampala Metropolitan Area (GKMA). This study assessed the availability and status of WASH services within HCFs in the GKMA in order to inform policy and WASH programming., Methods: A cross-sectional study was conducted in 60 HCFs. Availability of WASH services in the study HCFs was assessed using a validated WASH Conditions (WASHCon) tool comprising of structured interviews, HCF observations and microbial water quality analysis. Data were analysed using Stata 14 software and R software., Results: Overall, 84.5% (49/58) and 12.1% (7/58) of HCFs had limited and basic WASH service respectively. About 48.3% (28/58) had limited water service, 84.5% (49/58) had limited sanitation service, 50.0% (29/58) had limited environmental cleanliness service, 56.9% (33/58) had limited hand hygiene service, and 51.7% (30/58) had limited waste management service. About 94.4% of public HCFs had limited WASH service compared to only 68.2% of private not for profit facilities. More health centre IIIs, 92.5% and health centre IVs (85.7%) had limited WASH service compared to hospitals (54.5%)., Conclusions: Our findings indicate that provision of water, sanitation, hand hygiene, environmental cleanliness, and health care waste management services within HCFs is largely hindered by structural and performance limitations. In spite of these limitations, it is evident that environmental cleanliness and treatment of infectious waste can be attained with better oversight and dedicated personnel. Attaining universal WASH coverage in HCFs will require deliberate and strategic investments across the different domains.

Inadequate sanitation can lead to exposure to fecal contamination through multiple environmental pathways and can result in adverse health outcomes. By understanding the relative importance of multiple exposure pathways, sanitation interventions can be tailored to those pathways with greatest potential public health impact. The SaniPath Exposure Assessment Tool allows users to identify and quantify human exposure to fecal contamination in low-resource urban settings through a systematic yet customizable process. The Tool includes: a project management platform; mobile data collection and a data repository; protocols for primary data collection; and automated exposure assessment analysis. The data collection protocols detail the process of conducting behavioral surveys with households, school children, and community groups to quantify contact with fecal exposure pathways and of collecting and analyzing environmental samples for E. coli as an indicator of fecal contamination. Bayesian analyses are used to estimate the percentage of the population exposed and the mean dose of fecal exposure from microbiological and behavioral data. Fecal exposure from nine pathways (drinking water, bathing water, surface water, ocean water, open drains, floodwater, raw produce, street food, and public or shared toilets) can be compared through a common metric-estimated ingestion of E. coli units (MPN or CFU) per month. The Tool generates data visualizations and recommendations for interventions designed for both scientific and lay audiences. When piloted in Accra, Ghana, the results of the Tool were comparable with that of an in-depth study conducted in the same neighborhoods and highlighted consumption of raw produce as a dominant exposure pathway. The Tool has been deployed in nine cities to date, and the results are being used by local authorities to design and prioritize programming and policy. The SaniPath Tool is a novel approach to support public-health evidence-based decision-making for urban sanitation policies and investments., Competing Interests: The authors have declared that no competing interests exist.

Alongside efforts to improve safe management of feces along the entire sanitation chain, including after the toilet, global sanitation efforts are focusing on universal access 'basic' services: onsite facilities that safely contain excreta away from human contact. Although fecal sludge management is improving in urban areas, open drains remain a common fate for feces in these often densely-populated neighborhoods in low-income countries. To-date, it is unclear to what extent complete coverage of onsite sanitation reduces fecal contamination in the urban environment and how fecal contamination varies within urban drains across neighborhoods by sanitation status within a city. We assessed how neighborhood levels of environmental fecal contamination (via spatially-representative sampling of open drains for E. coli) varied across four neighborhoods with varying income, type and coverage of household sanitation facilities, and population density in Accra, Ghana. Neighborhoods with very high sanitation coverage (≥89%) still had high (>4 log 10  CFU/100 mL) E. coli concentrations in drains. Between-neighborhood variation in E. coli levels among the high coverage neighborhoods was significant: drain concentrations in neighborhoods with 93% and 89% coverage (4.7 (95% CI: 4.5, 4.9) & 4.9 (95% CI: 4.5, 5.3) log 10  CFU/100 mL, respectively) were higher than in the neighborhood with 97% coverage (4.1 log 10  CFU/100 mL, 95% CI: 3.8, 4.4 log 10  CFU/100 mL). Compared with the highest coverage neighborhood, the neighborhood with lowest coverage (48%) also had higher E. coli concentrations (5.6 log 10  CFU/100 mL, 95% CI: 5.3, 5.9 log 10  CFU/100 mL). Although fecal contamination in open drains appeared lower in neighborhoods with higher onsite sanitation coverage (and vice versa), other factors (e.g. fecal sludge management, animals, population density) may affect drain concentrations. These results underscore that neighborhood-level onsite sanitation improvements alone may not sufficiently reduce fecal hazards to public health from open drains. These findings supporting the need for integrated, city-level fecal sludge management alongside multifaceted interventions to reduce fecal contamination levels and human exposure., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results., (Published by Elsevier GmbH.)

Introduction: The purpose of the study was to determine the preventable trauma-related death rate (PDR) at Komfo Anokye Teaching Hospital in Kumasi, Ghana three years after initiation of an Emergency Medicine (EM) residency., Method: This was a retrospective, cross-sectional study. A multidisciplinary panel of physicians completed a structured implicit review of clinical data for trauma patients who died during the period 2011 to 2012. The panel judged the preventability of each death and the nature of inappropriate care. Categories were definitely preventable (DP), possibly preventable (PP), and not preventable (NP)., Results: 1) The total number of cases was forty-five; 36 cases had adequate data for review. Subjects were predominately male; road traffic injury (RTI) was the leading mechanism of injury. Four cases (11.1%) were DP, 14 cases (38.9%) were PP and 18 (50%) were NP. Hemorrhage was the leading cause of death (39%). Among DP/PP deaths there were 37 instances of inappropriate care. Delay in surgical intervention was the predominate event (50%). 2) The PDR for this study was 50% (0.95 CI, 33.7%-66.3%)., Conclusion: Fifty percent of trauma deaths were DP/PP. Multiple episodes of varying types of inappropriate care occurred. More efficient surgical evaluation and appropriate treatment of hemorrhage could reduce trauma morality. Large amounts of missing and incomplete clinical data suggest considerable selection bias. A major implication of this study is the importance of having a robust, prospective trauma registry to collect clinical information to increase the number of cases for review., (2019 African Federation for Emergency Medicine. Publishing services provided by Elsevier.)

Background: Open drains are common methods of transporting solid waste and excreta in low-income urban neighborhoods. Open drains can overflow due to blockages with solid waste and during rainfall, posing exposure risks. The goal of this study was to evaluate whether pediatric enteric infection was associated with open drains and flooding in a dense, low-income, urban neighborhood., Methods: As part of the MAL-ED study in Vellore, India, a cohort of 230 children provided stool specimens at 14-17 scheduled home visits and during diarrheal episodes in the first two years of life. All specimens were analyzed for enteric pathogens. Caregivers in 100 households reported on flooding of drains and households and monthly frequency of contact with open drains and flood water. Household GPS points were collected. Monthly rainfall totals for the Vellore district were collected from the Indian Meteorological Department. Clustering of reported drain and house flooding were identified by Kulldorff's Bernoulli Spatial Scan. Differences in enteric infection were assessed for household responses and spatial clusters, with interactions between reported flooding and rainfall to approximate monthly drain flooding retrospectively, using multivariable, mixed-effects logistic regression models., Results: Coverage of household toilets was low (33%), and most toilets (82%) discharged directly into open drains, suggesting poor neighborhood fecal sludge management. Odds of enteric infection increased significantly with total monthly rainfall for children who lived in households that reported that the nearby drain flooded (4% increase per cm of rain: OR: 1.04, 95% CI: 1.00-1.08) and for children in households in a downstream spatial cluster of reported drain flooding (5% increase per cm of rain: OR: 1.05, 95% CI: 1.01-1.09). There was no association between odds of enteric infection and frequency of reported contact with drain or floodwater., Conclusions: Children in areas susceptible to open drain flooding had increased odds of enteric infection as rainfall increased. Results suggested that infection increased with rainfall due to neighborhood infrastructure (including poor fecal sludge management) and not frequency of contact. Thus, these exposures may not be mitigated by changes in personal behaviors alone. These results underscore the importance of improving the neighborhood environment to improve children's health in low-income, urban settings.

Exposure to fecal contamination in public areas, especially in dense, urban environments, may significantly contribute to enteric infection risk. This study examined associations between sanitation and fecal contamination in public environments in four low-income neighborhoods in Accra, Ghana. Soil (n = 72) and open drain (n = 90) samples were tested for E. coli, adenovirus, and norovirus. Sanitation facilities in surveyed households (n = 793) were categorized by onsite fecal sludge containment ("contained" vs. "uncontained") using previous Joint Monitoring Program infrastructure guidelines. Most sanitation facilities were shared by multiple households. Associations between spatial clustering of household sanitation coverage and fecal contamination were examined, controlling for neighborhood and population density (measured as enumeration areas in the 2010 census and spatially matched to sample locations). E. coli concentrations in drains within 50m of clusters of contained household sanitation were more than 3 log-units lower than those outside of clusters. Further, although results were not always statistically significant, E. coli concentrations in drains showed consistent trends with household sanitation coverage clusters: concentrations were lower in or near clusters of high coverage of household sanitation facilities-especially contained facilities-and vice versa. Virus detection in drains and E. coli concentrations in soil were not significantly associated with clustering of any type of household sanitation and did not exhibit consistent trends. Population density alone was not significantly associated with any of the fecal contamination outcomes by itself and was a significant, yet inconsistent, effect modifier of the association between sanitation clusters and E. coli concentrations. These findings suggest clustering of contained household sanitation, even when shared, may be associated with lower levels of fecal contamination within drains in the immediate public domain. Further research is needed to better quantify these relationships and examine impacts on health., Competing Interests: The authors have declared that no competing interests exist.

In crowded urban settlements in low-income countries, many households rely on shared sanitation facilities. Shared facilities are not currently considered "improved sanitation" because of concerns about whether hygiene conditions sufficiently protect users from the feces of others. Prevention of fecal exposure at a latrine is only one aspect of sanitary safety. Ensuring consistent use of latrines for feces disposal, especially child feces, is required to reduce fecal contamination in households and communities. Household crowding and shared latrine access are correlated in these settings, rendering latrine use by neighbors sharing communal living areas as critically important for protecting one's own household. This study in Accra, Ghana, found that household access to a within-compound basic latrine was associated with higher latrine use by children of ages 5-12 years and for disposal of feces of children < 5 years, compared with households using public latrines. However, within-compound access was not associated with improved child feces disposal by other caregivers in the compound. Feces was rarely observed in household compounds but was observed more often in compounds with latrines versus compounds relying on public latrines. Escherichia coli and human adenovirus were detected frequently on household surfaces, but concentrations did not differ when compared by latrine access or usage practices. The differences in latrine use for households sharing within-compound versus public latrines in Accra suggest that disaggregated shared sanitation categories may be useful in monitoring global progress in sanitation coverage. However, compound access did not completely ensure that households were protected from feces and microbial contamination.

Lack of adequate sanitation results in fecal contamination of the environment and poses a risk of disease transmission via multiple exposure pathways. To better understand how eight different sources contribute to overall exposure to fecal contamination, we quantified exposure through multiple pathways for children under 5 years old in four high-density, low-income, urban neighborhoods in Accra, Ghana. We collected more than 500 hours of structured observation of behaviors of 156 children, 800 household surveys, and 1,855 environmental samples. Data were analyzed using Bayesian models, estimating the environmental and behavioral factors associated with exposure to fecal contamination. These estimates were applied in exposure models simulating sequences of behaviors and transfers of fecal indicators. This approach allows us to identify the contribution of any sources of fecal contamination in the environment to child exposure and use dynamic fecal microbe transfer networks to track fecal indicators from the environment to oral ingestion. The contributions of different sources to exposure were categorized into four types (high/low by dose and frequency), as a basis for ranking pathways by the potential to reduce exposure. Although we observed variation in estimated exposure (10 8 -10 16 CFU/day for Escherichia coli ) between different age groups and neighborhoods, the greatest contribution was consistently from food (contributing > 99.9% to total exposure). Hands played a pivotal role in fecal microbe transfer, linking environmental sources to oral ingestion. The fecal microbe transfer network constructed here provides a systematic approach to study the complex interaction between contaminated environment and human behavior on exposure to fecal contamination.

Rapid urbanization has contributed to an urban sanitation crisis in low-income countries. Residents in low-income, urban neighborhoods often have poor sanitation infrastructure and services and may experience frequent exposure to fecal contamination through a range of pathways. There are little data to prioritize strategies to decrease exposure to fecal contamination in these complex and highly contaminated environments, and public health priorities are rarely considered when planning urban sanitation investments. The SaniPath Study addresses this need by characterizing pathways of exposure to fecal contamination. Over a 16 month period, an in-depth, interdisciplinary exposure assessment was conducted in both public and private domains of four neighborhoods in Accra, Ghana. Microbiological analyses of environmental samples and behavioral data collection techniques were used to quantify fecal contamination in the environment and characterize the behaviors of adults and children associated with exposure to fecal contamination. Environmental samples (n = 1,855) were collected and analyzed for fecal indicators and enteric pathogens. A household survey with 800 respondents and over 500 hours of structured observation of young children were conducted. Approximately 25% of environmental samples were collected in conjunction with structured observations (n = 441 samples). The results of the study highlight widespread and often high levels of fecal contamination in both public and private domains and the food supply. The dominant fecal exposure pathway for young children in the household was through consumption of uncooked produce. The SaniPath Study provides critical information on exposure to fecal contamination in low-income, urban environments and ultimately can inform investments and policies to reduce these public health risks.

Objective: This study examined associations between household sanitation and enteric infection - including diarrhoeal-specific outcomes - in children 0-2 years of age in a low-income, dense urban neighbourhood., Methods: As part of the MAL-ED study, 230 children in a low-income, urban, Indian neighbourhood provided stool specimens at 14-17 scheduled time points and during diarrhoeal episodes in the first 2 years of life that were analysed for bacterial, parasitic (protozoa and helminths) and viral pathogens. From interviews with caregivers in 100 households, the relationship between the presence (and discharge) of household sanitation facilities and any, pathogen-specific, and diarrhoea-specific enteric infection was tested through mixed-effects Poisson regression models., Results: Few study households (33%) reported having toilets, most of which (82%) discharged into open drains. Controlling for season and household socio-economic status, the presence of a household toilet was associated with lower risks of enteric infection (RR: 0.91, 95% CI: 0.79-1.06), bacterial infection (RR: 0.87, 95% CI: 0.75-1.02) and protozoal infection (RR: 0.64, 95% CI: 0.39-1.04), although not statistically significant, but had no association with diarrhoea (RR: 1.00, 95% CI: 0.68-1.45) or viral infections (RR: 1.12, 95% CI: 0.79-1.60). Models also suggested that the relationship between household toilets discharging to drains and enteric infection risk may vary by season., Conclusions: The presence of a household toilet was associated with lower risk of bacterial and protozoal enteric infections, but not diarrhoea or viral infections, suggesting the health effects of sanitation may be more accurately estimated using outcome measures that account for aetiologic agents., (© 2017 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

AbstractUrban sanitation necessitates management of fecal sludge inside and outside the household. This study examined associations between household sanitation, fecal contamination, and enteric infection in two low-income neighborhoods in Vellore, India. Surveys and spatial analysis assessed the presence and clustering of toilets and fecal sludge management (FSM) practices in 200 households. Fecal contamination was measured in environmental samples from 50 households and household drains. Enteric infection was assessed from stool specimens from children under 5 years of age in these households. The two neighborhoods differed significantly in toilet coverage (78% versus 33%) and spatial clustering. Overall, 49% of toilets discharged directly into open drains ("poor FSM"). Children in households with poor FSM had 3.78 times higher prevalence of enteric infection when compared with children in other households, even those without toilets. In the neighborhood with high coverage of household toilets, children in households with poor FSM had 10 times higher prevalence of enteric infection than other children in the neighborhood and drains in poor FSM clusters who had significantly higher concentrations of genogroup II norovirus. Conversely, children in households with a toilet that contained excreta in a tank onsite had 55% lower prevalence of enteric infection compared with the rest of the study area. Notably, households with a toilet in the neighborhood with low toilet coverage had more fecal contamination on floors where children played compared with those without a toilet. Overall, both toilet coverage levels and FSM were associated with environmental fecal contamination and, subsequently, enteric infection prevalence in this urban setting.

In low-income countries, rapid urbanization adds pressure to already stressed water and sanitation systems that are critical to the health of communities. Drainage networks, designed for stormwater but commonly used for disposing of waste, are rarely covered completely, allowing residents to easily come into contact with their contents. This study used spatial mapping, documentation of physical drain characteristics, microbiological analysis of drain samples, and behavioral observation to comprehensively examine drains as a route of exposure to fecal contamination in four low-income neighborhoods in Accra, Ghana. A stochastic model of six likely exposure scenarios was constructed to estimate children's exposure to drain water. Regardless of the age of the child, any exposure scenario considered resulted in exposure to a high level of fecal contamination. Fecal contamination levels in drains were high (Escherichia coli: geometric mean (GM), 8.60 cfu log(10)/100 mL; coliphage: GM, 5.56 pfu log(10)/100 mL), and did not differ by neighborhood or physical drain characteristics, indicating that frequency of contact with drains, and not drain type or location, drives exposure risk. To mitigate health risks associated with this exposure, drains should be covered, with priority given to large concrete and small to medium dirt-lined drains that children were most commonly observed entering.

To better understand the risks of exposure for young children to fecal contamination in their environment, we systematically characterized and quantified behaviors of 154 children, 0-5 years old, in four high-density, low-income neighborhoods in Accra, Ghana. A repertoire of six different activities and five different compartments (categories of locations within the household) was developed, and about 500 hours of ordered structured observations of activities and locations of individual children were collected. These records were analyzed using a competing hazards model, estimating (Weibull) hazard rates for each state (activity/compartment combination), dependent on the present state and the preceding state. The estimated rates were used to simulate sequences of behavior and describe days in the life of a child in low-income, urban Africa. Children younger than 1 year spent most time playing or sleeping off the ground, older children frequently played on floors. Relatively little time was spent in drains or wet trash areas. Critical combinations of activities, like handwashing after defecation or before eating were estimated to occur rarely. These quantitative behavior estimates can inform future risk assessments that examine the relative roles of various fecal-oral exposure pathways in low-income urban settings., (© The American Society of Tropical Medicine and Hygiene.)