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Background: The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. Methods: Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. Results: The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. Conclusion: GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up. [ABSTRACT FROM AUTHOR]

Ghana has made significant stride towards universal health coverage (UHC) by implementing the National Health Insurance Scheme (NHIS) in 2003. This paper investigates the progress of UHC indicators in Ghana from 1995 to 2015 and makes future predictions up to 2030 to assess the probability of achieving UHC targets. National representative surveys of Ghana were used to assess health service coverage and financial risk protection. The analyses estimated the coverage of 13 prevention and four treatment service indicators at the national level and across wealth quintiles. In addition, we calculated catastrophic health payments and impoverishment to assess financial hardship and used a Bayesian regression model to estimate trends and future projections as well as the probabilities of achieving UHC targets by 2030. Wealth-based inequalities and regional disparities were also assessed. At the national level, 14 out of the 17 health service indicators are projected to reach the target of 80% coverage by 2030. Across wealth quintiles, inequalities were observed amongst most indicators with richer groups obtaining more coverage than their poorer counterparts. Subnational analysis revealed while all regions will achieve the 80% coverage target with high probabilities for the prevention services, the same cannot be applied to the treatment services. In 2015, the proportion of households that suffered catastrophic health payments and impoverishment at a threshold of 25% non-food expenditure were 1.9% (95%CrI: 0.9–3.5) and 0.4% (95%CrI: 0.2–0.8), respectively. These are projected to reduce to 0.4% (95% CrI: 0.1–1.3) and 0.2% (0.0–0.5) respectively by 2030. Inequality measures and subnational assessment revealed that catastrophic expenditure experienced by wealth quintiles and regions are not equal. Significant improvements were seen in both health service coverage and financial risk protection over the years. However, inequalities across wealth quintiles and regions continue to be cause of concerns. Further efforts are needed to narrow these gaps. [ABSTRACT FROM AUTHOR]

In the past four decades, there has been an increase in the occurrence of zoonotic diseases. Some outbreaks have been devastating because of the inability of individuals and health workers to identify the diseases early. Generally, most zoonotic diseases are heralded by a fever. While fevers are common, they are often the symptoms of different diseases. This paper explores how a population at potential risk of zoonotic diseases identify fevers, and what treatments they seek when they develop fevers. The data are from focus group discussions and a survey of three communities in the Brong Ahafo, Volta and Greater Accra regions in Ghana. The quantitative data were analysed using descriptive statistics while the qualitative data were analysed using thematic analysis. The findings indicate that the perceived causes of fever differ from the traditional biomedical view. While orthodox treatment was the preferred choice for most participants, rural dwellers utilised traditional medicine more than their urban counterparts. Though there is no record of bat-borne zoonotic disease in Ghana, our findings could be used as a proxy to indicate how populations at risk of exposure might respond in the event of a spillover event from a zoonosis. We recommend that educational campaigns on zoonotic diseases should target rural dwellers, especially farmers, who may be most at risk of zoonoses. [ABSTRACT FROM AUTHOR]

Despite the double burden of infectious and chronic non-communicable diseases in Africa, health care expenditure disproportionately favours infectious diseases. In this paper, we examine quantitatively the extent of this disproportionate access to diagnoses and treatment of diabetes, hypertension and malaria in Ghana. A total of 220 health facilities was surveyed across the country in 2011. Findings indicate that diagnoses and treatment of infectious diseases were more accessible than NCDs. In terms of treatment, 78% and 87% of health facilities had two of the recommended malaria drugs while less than 35% had essential diabetes and hypertension drugs. There is a significant unmet need for diagnoses and treatment of NCDs in Ghana. These inequities have implications for high morbidity and mortality from NCDs. We recommend the use of task shifting as a model to increase the delivery of NCD services. [ABSTRACT FROM AUTHOR]

Even though cervical cancer is quite a prevalent disease in Ghana, there is hardly any study on this disease. This paper sought to explore the experiences of cervical cancer patients living with the disease with emphasis on their knowledge about the disease before and after the diagnosis. Qualitative data were collected through in-depth interviews with cervical cancer patients undergoing treatment in a specialised cancer treatment health facility in rural Ghana. Cervical cancer patients had inadequate knowledge about the disease, its symptoms, risk factors, treatment and prevention prior to being diagnosed of the disease. These patients were diagnosed late because they usually sought treatment elsewhere before reporting to health facilities. They experienced physical, psychological, economic and social disruptions in their daily lives, which affected their quality of life. It is evident that lack of knowledge about cervical cancer constitutes a threat to its prevention and treatment. Intensive health education through the mass media and community health promotion outreaches can be a sure way of creating adequate knowledge about cervical cancer in Ghana. Treatment and care for cervical cancer patients should incorporate counselling sessions, which should take into consideration the different levels of disruption the women experience and the implications for their wellbeing and management of the condition. [ABSTRACT FROM AUTHOR]

The Global Program to Eliminate Lymphatic Filariasis (GPELF) advocates for the treatment of entire endemic communities, in order to achieve its elimination targets. LF is predominantly a rural disease, and achieving the required treatment coverage in these areas is much easier compared to urban areas that are more complex. In Ghana, parts of the Greater Accra Region with Accra as the capital city are also endemic for LF. Mass Drug Administration (MDA) in Accra started in 2006. However, after four years of treatment, the coverage has always been far below the 65% epidemiologic coverage for interrupting transmission. As such, there was a need to identify the reasons for poor treatment coverage and design specific strategies to improve the delivery of MDA. This study therefore set out to identify the opportunities and barriers for implementing MDA in urban settings, and to develop appropriate strategies for MDA in these settings. An experimental, exploratory study was undertaken in three districts in the Greater Accra region. The study identified various types of non-rural settings, the social structures, stakeholders and resources that could be employed for MDA. Qualitative assessment such as in-depth interviews (IDIs) and focus group discussions (FGDs) with community leaders, community members, health providers, NGOs and other stakeholders in the community was undertaken. The study was carried out in three phases: pre-intervention, intervention and post-intervention phases, to assess the profile of the urban areas and identify reasons for poor treatment coverage using both qualitative and quantitative research methods. The outcomes from the study revealed that, knowledge, attitudes and practices of community members to MDA improved slightly from the pre-intervention phase to the post-intervention phase, in the districts where the interventions were readily implemented by health workers. Many factors such as adequate leadership, funding, planning and community involvement, were identified as being important in improving implementation and coverage of MDA in the study districts. Implementing MDA in urban areas therefore needs to be given significant consideration and planning, if the required coverage rates are to be achieved. This paper, presents the recommendations and strategies for undertaking MDA in urban areas. [ABSTRACT FROM AUTHOR]

Background: Health worker density per 1000 population in Ghana is one of the lowest in the world estimated to be 2.3, below the global average of 9.3. Low health worker motivation induced by poor working conditions partly explain this challenge. Albeit the wage bill for public sector health workers is about 90% of domestic government expenditure on health in countries such as Ghana, staff motivation and performance output remain a challenge, suggesting the need to complement financial incentives with non-financial incentives through a community-based approach. In this study, a systematic community engagement (SCE) intervention was implemented to engage community groups in healthcare quality assessment to promote mutual collaboration between clients and healthcare providers, and enhance health worker motivation levels. SCE involves structured use of existing community groups and associations to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements made and rewards given to best performing facilities for closing quality care gaps. Purpose: To evaluate the effect of SCE interventions on health worker motivation and experiences with clients. Methods: The study is a cluster randomized trial involving health workers in private (n = 38) and public (n = 26) primary healthcare facilities in two administrative regions in Ghana. Out of 324 clinical and non-clinical staff randomly interviewed at baseline, 234 (72%) were successfully followed at end-line and interviewed on workplace motivation factors and personal experiences with clients. Propensity score matching and difference-in-difference estimations were used to estimate treatment effect of the interventions on staff motivation. Results: Intrinsic (non-financial) work incentives including cordiality with clients and perceived career prospects appeared to be prime sources of motivation for health staff interviewed in intervention health facilities while financial incentives were ranked lowest. Intervention health facilities that were assessed by female community groups (Coef. = 0.2720, p = 0.0118) and informal groups with organized leadership structures like Artisans (Coef. = 0.2268, p = 0.0368) associated positively with higher intrinsic motivation levels of staff. Conclusion: Community-based approach to health worker motivation is a potential complementary strategy that needs policy deliberation to explore its prospects. Albeit financial incentives remain critical sources of staff motivation, innovative non-financial approaches like SCE should complement the latter. [ABSTRACT FROM AUTHOR]

Introduction: Women's reproductive health decision-making is indispensable for improving their reproductive health and achieving Sustainable Development Goal three. This study explored the association between reproductive health decision-making capacity and unintended pregnancy among women in Ghana. Materials and methods: We used data from the 2014 version of the Ghana Demographic and Health Survey. The unit of analysis for this study was pregnant women at the time of the survey (679). Bivariate and multivariable analyses were conducted using Pearson chi-square tests and binary logistic regression respectively. Results: We found that women who had the capacity to make reproductive health decision [AOR = 0.61; CI = 0.51–0.89] were less likely to experience unintended pregnancies, compared to those who did not have the capacity. Age was found to have a statistically significant influence on unintended pregnancy, with women aged 25–29 years [AOR = 0.29; CI = 0.13–0.63], 30–34 years [AOR = 0.18; CI = 0.08–0.45], and 35–39 years [AOR = 0.26; CI = 0.10–0.68] being less likely to experience unintended pregnancy compared to those aged 15–19 years. Women with primary level of education were more likely to have unintended pregnancies, compared to those with no education [AOR = 2.07; CI = 1.12–3.84]. Conclusion: This study has filled the gap in the already existing literature on the association between reproductive health decision making capacity and unintended pregnancy in Ghana and has created a room for specific interventions geared towards reducing unintended pregnancies, especially among women who are not capable of making reproductive health decisions, women aged 15–19 years, those with primary education, Traditionalists and unmarried women. [ABSTRACT FROM AUTHOR]

Neisseria gonorrhoeae antimicrobial resistance (AMR) surveillance is essential for tracking the emergence and spread of AMR strains in local, national and international populations. This is crucial for developing or refining treatment guidelines. N. gonorrhoeae multiantigen sequence typing (NG-MAST) is beneficial for describing the molecular epidemiology of gonococci at national and international levels. Elucidation of AMR determinants to β-lactam drugs, is a means of monitoring the development of resistance. In Ghana, little is known about the current gonococcal AMR prevalence and no characterization of gonococcal isolates has been previously performed. In this study, gonococcal isolates (n = 44) collected from five health facilities in Ghana from 2012 to 2015, were examined using AMR testing, NG-MAST and sequencing of penA. High rates of resistance were identified to tetracycline (100%), benzylpenicillin (90.9%), and ciprofloxacin (81.8%). One isolate had a high cefixime MIC (0.75 μg/ml). Twenty-eight NG-MAST sequence types (STs) were identified, seventeen of which were novel. The isolate with the high cefixime MIC contained a mosaic penA-34 allele and belonged to NG-MAST ST1407, an internationally spreading multidrug-resistant clone that has accounted for most cefixime resistance in many countries. In conclusion, AMR testing, NG-MAST, and sequencing of the AMR determinant penA, revealed high rates of resistance to tetracycline, benzylpenicillin, and ciprofloxacin; as well as a highly diverse population of N. gonorrhoeae in Ghana. It is imperative to continue with enhanced AMR surveillance and to understand the molecular epidemiology of gonococcal strains circulating in Ghana and other African countries. [ABSTRACT FROM AUTHOR]

Background: Ghana started its national programme to eliminate lymphatic filariasis (LF) in 2000, with mass drug administration (MDA) with ivermectin and albendazole as main strategy. We review the progress towards elimination that was made by 2016 for all endemic districts of Ghana and analyze microfilaria (mf) prevalence from sentinel and spot-check sites in endemic districts. Methods: We reviewed district level data on the history of MDA and outcomes of transmission assessment surveys (TAS). We further collated and analyzed mf prevalence data from sentinel and spot-check sites. Results: MDA was initiated in 2001–2006 in all 98 endemic districts; by the end of 2016, 81 had stopped MDA after passing TAS and after an average of 11 rounds of treatment (range 8–14 rounds). The median reported coverage for the communities was 77–80%. Mf prevalence survey data were available for 430 communities from 78/98 endemic districts. Baseline mf prevalence data were available for 53 communities, with an average mf prevalence of 8.7% (0–45.7%). Repeated measurements were available for 78 communities, showing a steep decrease in mean mf prevalence in the first few years of MDA, followed by a gradual further decline. In the 2013 and 2014 surveys, 7 and 10 communities respectively were identified with mf prevalence still above 1% (maximum 5.6%). Fifteen of the communities above threshold are all within districts where MDA was still ongoing by 2016. Conclusions: The MDA programme of the Ghana Health Services has reduced mf prevalence in sentinel sites below the 1% threshold in 81/98 endemic districts in Ghana, yet 15 communities within 13 districts (MDA ongoing by 2016) had higher prevalence than this threshold during the surveys in 2013 and 2014. These districts may need to intensify interventions to achieve the WHO 2020 target. [ABSTRACT FROM AUTHOR]

Background: Worldwide, snakebite envenomations total ~2.7 million reported cases annually with ~100,000 fatalities. Since 2009, snakebite envenomation has intermittently been classified as a very important ‘neglected tropical disease’ by the World Health Organisation. Despite this emerging awareness, limited efforts have been geared towards addressing the serious public health implications of snakebites, particularly in sub-Saharan Africa, where baseline epidemiological and ecological data remain incomplete. Due to poverty as well as limited infrastructure and public health facilities, people in rural Africa, including Ghana, often have no other choice than to seek treatment from traditional medical practitioners (TMPs). The African ‘snakebite crisis’ is highlighted here using regionally representative complementary data from a community-based epidemiological and ecological study in the savanna zone of northern Ghana. Methodology and findings: Our baseline study involved two data collection methods in the Savelugu-Nanton District (in 2019 the district was separated into Savelugu and Nanton districts) in northern Ghana, comprising a cross-sectional study of 1,000 residents and 24 TMPs between December 2008 and May 2009. Semi-structured interviews, as well as collection of retrospective snakebite and concurrent rainfall records from the Savelugu-Nanton District Hospital and Ghana Meteorological Authority respectively over 10-years (1999–2008) were used in the study. Variables tested included demography, human activity patterns, seasonality, snake ecology and clinical reports. Complementary data showed higher snakebite prevalence during the rainy season, and a hump-shaped correlation between rainfall intensity and snakebite incidences. Almost 6% of respondents had experienced a personal snakebite, whereas ~60% of respondents had witnessed a total of 799 snakebite cases. Out of a total of 857 reported snakebite cases, 24 (~2.8%) died. The highest snakebite prevalence was recorded for males in the age group 15–44 years during farming activities, with most bites occurring in the leg/foot region. The highest snakebite rate was within farmlands, most severe bites frequently caused by the Carpet viper (Echis ocellatus). Conclusion: The relatively high community-based prevalence of ~6%, and case fatality ratio of ~3%, indicate that snakebites represent an important public health risk in northern Ghana. Based on the high number of respondents and long recording period, we believe these data truly reflect the general situation in the rural northern savanna zone of Ghana and West Africa at large. We recommend increased efforts from both local and international health authorities to address the current snakebite health crisis generally compromising livelihoods and productivity of rural farming communities in West Africa. [ABSTRACT FROM AUTHOR]

A primary challenge in developing effective vaccines against obligate, intracellular, bacterial tick-borne pathogens that establish persistent infection is the identification of antigens that cross protect against multiple strains. In the case of Anaplasma marginale, the most prevalent tick-borne pathogen of cattle found worldwide, OmpA is an adhesin and thus a promising vaccine candidate. We sequenced ompA from cattle throughout Ghana naturally infected with A. marginale in order to determine the degree of variation in this gene in an area of suspected high genetic diversity. We compared the Ghanaian sequences with those available from N. America, Mexico, Australia and Puerto Rico. When considering only amino acid changes, three unique Ghanaian OmpA variants were identified. In comparison, strains from all other geographic regions, except one, shared a single OmpA variant, Variant 1, which differed from the Ghanaian variants. Next, using recombinant OmpA based on Variant 1, we determined that amino acid differences in OmpA in Ghanaian cattle as compared to OmpA Variant 1 did not alter the binding capacity of antibody directed against OmpA Variant 1, supporting the value of OmpA as a highly conserved vaccine candidate. [ABSTRACT FROM AUTHOR]

Background: Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited. Methods: We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities. Using multi-level models, we examined associations of facility management with five process outcomes and eight experiential outcomes. Findings: On a scale of 0 to 1, the average overall management score in Ghana was 0·76 (IQR = 0·68–0·85). Facility management was significantly associated with one process outcome and three experiential outcomes. Controlling for facility characteristics, facilities with management scores at the 90th percentile (management score = 0·90) had 22% more essential drugs compared to facilities with management scores at the 10th percentile (0·60) (p = 0·002). Positive statistically non-significant associations were also seen with three additional process outcomes—integration of family planning services (p = 0·054), family planning types provided (p = 0·067), and essential equipment availability (p = 0·104). Compared to women who sought care at facilities with management scores at the 10th percentile, women who sought care at facilities at the 90th percentile reported 8% higher ratings of trust in providers (p = 0·028), 15% higher ratings of ease of following provider’s advice (p = 0·030), and 16% higher quality rating (p = 0·020). However, women who sought care in the 90th percentile facilities rated their waiting times as worse (22% lower, p = 0·039). Interpretation: Higher management scores were associated with higher scores for some process and experiential outcomes. Large variations in management performance indicate the need to strengthen management practices to help realize the full potential of PHC in improving health outcomes. [ABSTRACT FROM AUTHOR]

Background: Method-specific contraceptive prevalence varies widely globally, as huge variations exist in the use of different types of contraception, with short-term methods being the most common methods in sub-Saharan Africa (SSA). Evidence is scanty on the trends, patterns and determinants of long-acting reversible contraceptive (LARC) methods in SSA. This study aimed to address this knowledge gap. Methods: Using a pseudo longitudinal research design and descriptive and inferential statistics, we analysed Demographic and Health Survey data of eight countries selected on the basis of contraceptive prevalence rates across SSA. Multinomial logistic regression modelling was used to tease out the predictors of the uptake of LARC methods in the selected countries. Results: Findings exhibit a steady but slow upward trend in LARC methods across selected countries, as a marginal increase was recorded in LARC uptake over a 10-year period in many of the selected countries. Results established significant predictors of LARC methods uptake, including fertility-related characteristics, age, level of education, work status, wealth index and exposure to mass media. This study underscored the need to address various barriers to the uptake of LARC methods in SSA. It is recommended that governments at different levels undertake to cover the costs of LARC methods in order to increase access and uptake. [ABSTRACT FROM AUTHOR]

Iodine deficiency (ID) during pregnancy results in pregnancy losses, intrauterine growth retardation, and lower IQ in the offspring. Even after two decades of universal salt iodization (USI) implementation, the efficacy of USI has not been reported in high risk groups in vulnerable regions in Ghana. We aimed to assess and improve ID status in childbearing age women (all lactating women) and their toddlers in northern Ghana, a geographically and socioeconomically vulnerable region. We provided weekly supply of household iodized salt and community-based feeding of native Hibiscus Sabdariffaa leaves meal (HSM) prepared with iodized salt to women and their toddlers in intervention (n = 60) vs. control group (n = 60). At baseline, ID was prevalent in women (36%) and their toddlers (29%). For women, both median UIC values for intervention (57.4 ug/l) and control group (65.1 ug/l) were below the recommended UIC value of 100 ug/l with no significant differences between the two groups (p = 0.2778). At the endpoint, median UIC for the intervention group (123.6 ug/l) was significantly higher (p = 0.008) than the control group (59.7 ug/l). Our results suggest that weekly supply of iodized salt along with the feeding HSM is an effective channel for improving iodine status of economically disadvantaged groups in communities remote from coastal lands. Furthermore, our results suggest that decreased median UIC among lactating mothers does not necessarily imply lower iodine status for their breastfed toddlers. And finally, the observed median UIC<100 ug/l may point to a non-improvement in iodine status for the past decade for Ghana. There is a need to revisit, assess, and ascertain the challenges in preventing populations from attaining the intended benefits of the USI policy in Ghana. [ABSTRACT FROM AUTHOR]

Health disparities research in low- and middle-income countries (LMICs) is hampered by the difficulty of measuring economic status in low-resource settings. We previously developed the EconomicClusters k-medoids clustering-based algorithm for defining population-specific economic models based on few Demographic and Health Surveys (DHS) assets. The algorithm previously defined a twenty-group economic model for Cameroon. The aims of this study are to optimize the functionality of our EconomicClusters algorithm and app based on collaborator feedback from early use of this twenty-group economic model, to test the validity of the model as a metric of economic status, and to assess the utility of the model in another LMIC context. We condense the twenty Cameroonian economic groups into fewer, ordinally-ranked, groups using agglomerative hierarchical clustering based on mean cluster child height-for-age Z-score (HAZ), women’s literacy score, and proportion of children who are deceased. We develop an EconomicClusters model for Ghana consisting of five economic groups and rank these groups based on the same three variables. The proportion of variance in women’s literacy score accounted for by the EconomicClusters model was 5–12% less than the proportion of variance accounted for by the DHS Wealth Index model. The proportion of the variance in child HAZ and proportion of children who are deceased accounted for by the EconomicClusters model was similar to (0.4–2.5% less than) the proportion of variance accounted for by the DHS Wealth Index model. The EconomicClusters model requires asking only five questions, as opposed to greater than twenty Wealth Index questions. The EconomicClusters algorithm and app could facilitate health disparities research in any country with DHS data by generating ordinally-ranked, population-specific economic models that perform nearly as well as the Wealth Index in evaluating variability in health and social outcomes based on wealth status but that are more feasible to assess in time-constrained settings. [ABSTRACT FROM AUTHOR]

African migrants in Europe and continental Africans are disproportionately affected by type 2 diabetes (T2D). Both groups develop T2D at a younger age, and have higher morbidity and mortality from T2D and complications, compared to European populations. To reduce risk, and avoidable disability and premature deaths, culturally congruent and context specific interventions are required. This study aimed to: (a) assess perceptions and knowledge of T2D among Ghanaian migrants in Europe and their compatriots in Ghana and (b) identify specific perceptions and knowledge gaps that might predispose migrants to higher risk of diabetes. Data was gathered through 26 focus groups with 180 individuals, aged 21 to 70, from Amsterdam, Berlin and London and rural and urban Ashanti Region, Ghana. Thematic analysis of the data was informed by Social Representations Theory, which focuses on the sources, content and functions of social knowledge. Three key insights emerged from analysis. First, there was general awareness, across migrant and non-migrant groups, of T2D as a serious chronic condition with life threatening complications, and some knowledge of biomedical strategies to prevent diabetes (e.g healthy eating) and diabetes complications (e.g medication adherence). However, knowledge of T2D prevention and reduction of diabetes complications was not comprehensive. Secondly, knowledge of biomedical diabetes theories and interventions co-existed with theories about psychosocial and supernatural causes of diabetes and the efficacy of herbal and faith-based treatment of diabetes. Finally, migrants’ knowledge was informed by both Ghanaian and European systems of T2D knowledge suggesting enculturation dynamics. We discuss the development of culturally congruent and context-specific T2D interventions for the research communities. [ABSTRACT FROM AUTHOR]

Background: Urogenital schistosomiasis is endemic throughout Ghana with elevated infection levels in certain areas e.g. Lake Volta Region. While the primary focus of the national control program is on mass drug administration of praziquantel to school-aged children, Female Genital Schistosomiasis (FGS), a disease-specific affliction of girls and women, has been largely overlooked. To better focus future actions, our study investigated the perceptions, knowledge and understanding of FGS amongst community members and health providers. Method/Principal findings: We used qualitative methods including 12 focus group discussions and 34 in-depth interviews. We purposively selected 16 communities along the Lake Volta in the Shai-Osudoku District. Participant selection was based on gender, age and occupation; providing an opportunity to explore community understanding of FGS through participants own words and perceptions. Awareness of schistosomiasis was reported and is commonly experienced among children (12–17 years) and younger adults (18–25 years) in the study communities but is typically considered a boy's disease. Knowledge of FGS was lacking in women, girls and front-line health workers. There was a general misconception that FGS may be the result of sexual promiscuity. Adolescent girls reporting vaginal discharge and itching were often stigmatized by health workers and treated for sexually transmitted infections. Limited alternatives to the river as key source of water meant that all members of the community faced the regular risk of schistosomiasis. Conclusion/Significance: There is a clear imperative for the national control program to better engage on FGS and implement interventions to meet girls and women's needs. The key consideration is to integrate more adequately preventive services with sexual and reproductive primary health care with future training of health workers for improved management of FGS cases. More broadly, harmonizing the portfolio of all actions on FGS is needed, especially with a call for improved access to safe water and sanitation for all those at current or future risk. [ABSTRACT FROM AUTHOR]

Background: Validation of elimination of trachoma as a public health problem is based on clinical indicators, using the WHO simplified grading system. Chlamydia trachomatis (Ct) infection and anti-Ct antibody responses (anti-Pgp3) have both been evaluated as alternative indicators in settings with varying levels of trachoma. There is a need to evaluate the feasibility of using tests for Ct infection and anti-Pgp3 antibodies at scale in a trachoma-endemic country and to establish the added value of the data generated for understanding transmission dynamics in the peri-elimination setting. Methodology/Principal findings: Dried blood spots for serological testing and ocular swabs for Ct infection testing (taken from children aged 1–9 years) were integrated into the pre-validation trachoma surveys conducted in the Northern and Upper West regions of Ghana in 2015 and 2016. Ct infection was detected using the GeneXpert PCR platform and the presence of anti-Pgp3 antibodies was detected using both the ELISA assay and multiplex bead array (MBA). The overall mean cluster-summarised TF prevalence (the clinical indicator) was 0.8% (95% CI: 0.6–1.0) and Ct infection prevalence was 0.04% (95%CI: 0.00–0.12). Anti-Pgp3 seroprevalence using the ELISA was 5.5% (95% CI: 4.8–6.3) compared to 4.3% (95%CI: 3.7–4.9) using the MBA. There was strong evidence from both assays that seropositivity increased with age (p<0.001), although the seroconversion rate was estimated to be very low (between 1.2 to 1.3 yearly events per 100 children). Conclusions/Significance: Infection and serological data provide useful information to aid in understanding Ct transmission dynamics. Elimination of trachoma as a public health problem does not equate to the absence of ocular Ct infection nor cessation in acquisition of anti-Ct antibodies. [ABSTRACT FROM AUTHOR]

Background: Pneumococcal carriage is the precursor for development of pneumococcal disease, and is also responsible for transmission of the organism from person-to-person. Individuals with Sickle Cell Disease (SCD) are more likely to develop invasive disease with S. pneumoniae compared to their healthy counterparts and the presentation of disease in the former is usually abrupt and severe. In Africa, little is known about the pneumococcus in relation to people with SCD Sickle Cell Disease (SCD). The aim of the study was to investigate the epidemiology of pneumococcal carriage among SCD patients including the carriage prevalence, risk factors, serotypes and antibiotic resistance. Method: This was a cross sectional study involving 402 SCD patients recruited from Korle Bu Teaching Hospital and Princess Marie Louis Hospital in Accra from October 2016 to March 2017. The study subjects included 202 children of the age groups: ≤5 years (94), >5–9 years (75), ≥10–13 years (33) and 200 adults of the age groups: 14–20 years (46), 21–40 years (112), 41–60 years (25), ≤ 61 years (17). Nasopharyngeal (NP) swabs were collected from the study participants as well as epidemiological data on demographic, household and clinical features. The NP specimens were cultured for S. pneumoniae and the isolates were serotyped by latex agglutination. Antimicrobial susceptibility tests of the isolates were done by the disc diffusion test and E-test. Results: Prevalence of S. pneumoniae carriage among children and adult SCD patients enrolled in the study were 79/202 (39.1%; 95% CI: 32.3 to 46.2) and 20/200 (10.0%; 95% CI: 6.2 to 15.0) respectively. Risk factors associated with pneumococcal carriage were age (OR = 1.137; 95% CI: 1.036–1.248; p = 0.007) and runny nose (OR = 5.371; 95% CI: 1.760–16.390; p = 0.003). Overall, twenty-six pneumococcal serotypes were isolated from the study participants and the predominant serotype was 6B (10.6%), followed by 23B (8.2%). Among the children, serotype coverage of the 13-valent Pneumococcal Conjugate Vaccine, which is currently used in Ghana was 32.4%. Prevalence of penicillin resistance among the pneumococcal isolates was 37.4% (37/99) and all the penicillin-resistant isolates exhibited intermediate penicillin resistance with the exception of one isolate that showed full resistance and was susceptible to ceftriaxone. Prevalence of resistance to the other antibiotics ranged from 2.5% (levofloxacin) to 85% (cotrimoxazole). Multidrug resistance occurred among 34.3% (34/99) of the pneumococcal isolates. Conclusion: Pneumococcal carriage was four-fold higher in SCD children than adults and was characterized by predominance of non-vaccine serotypes and considerable level of multidrug resistance, though penicillin, cefotaxime and levofloxacin resistance appeared to be very low. [ABSTRACT FROM AUTHOR]

Sulfadoxine-pyrimethamine (SP) is used as malaria chemoprophylaxis for pregnant women and children in Ghana. Plasmodium falciparum resistance to SP is linked to mutations in the dihydropteroate synthase gene (pfdhps), dihydrofolate reductase gene (pfdhfr) and amplification of GTP cyclohydrolase 1 (pfgch1) gene. The pfgch1 duplication is associated with pfdhfr L164, a crucial mutant for high level pyrimethamine resistance which is rare in Ghana. The presence of amplified pfgch1 in Ghanaian isolates could be an indicator of the evolution of the L164 mutant. This study therefore determined the pfgch1 copy number variations and SP resistance mutations in clinical isolates from Ghana. One hundred and ninety-two (192) blood samples collected from children aged ≤14 years with uncomplicated malaria in 2013–14 and 2015–16 were used. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to detect the pfgch1 copy number and nested PCR-Sanger sequencing used to detect mutations in pfdhps and pfdhfr genes. Twelve parasites (6.3%) harbored double copies of the pfgch1 gene out of the 192 samples. Of the 12, 75% had the pfdhfr I51-R59-N108, 92% had the pfdhps G437 mutant, 8% had the pfdhps E540 and 67% had the SP resistance haplotype IRNG. No L164 was detected in samples with amplified pfgch1. The rare T108 mutant associated with cycloguanil resistance showed predominance (60%) over N108 in the 2015–16 isolates. The observation of parasites with increased copy number of pfgch1 gene is indicative of the future evolution of the rare quadruple pfdhfr mutant, I51-R59-N108-L164, in Ghanaian parasites. Mutant pfdhps isolates also had increased gch1 copy number suggestive that it may also facilitate sulphadoxine resistance. The selection of parasites with pfgch1 gene amplification will enhance the sustenance and persistence of parasites with SP resistance in the country. Policy makers need to begin the search for a replacement chemoprophylaxis drug for malaria vulnerable groups in Ghana. [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) is a significant global public health problem. Understanding risk factors is crucial for developing prevention programmes. Yet, little evidence exists on population-based prevalence and risk factors for IPV in West Africa. Our objective was to measure both lifetime and past year prevalence of IPV and to determine factors associated with past year physical or sexual IPV experience. This population-based survey involved 2000 randomly selected women aged 18 to 49 years living in 40 localities within four districts of the Central Region of Ghana. Questionnaires were interviewer-administered from February to May 2016. Respondents were currently or ever-partnered, and resident in study area ≥12months preceding the survey. Data collected included: socio-demographics; sexual behavior; mental health and substance use; employment status; 12-month and lifetime experience of violence; household food insecurity; gender norms/attitudes; partner characteristics and childhood trauma. Logistic regression modelling was used to determine factors associated with sexual or physical IPV, adjusting for age and survey design. About 34% of respondents had experienced IPV in the past year, with 21.4% reporting sexual and or physical forms. Past year experience of emotional and economic IPV were 24.6% and 7.4% respectively. Senior high school education or higher was protective of IPV (AOR = 0.51[0.30–0.86]). Depression (AOR = 1.06[1.04–1.08], disability (AOR = 2.30[1.57–3.35]), witnessing abuse of mother (AOR = 2.1.98[1.44–2.72]), experience of childhood sexual abuse (AOR = 1.46[1.07–1.99]), having had multiple sexual partners in past year (AOR = 2.60[1.49–4.53]), control by male partner (AOR = 1.03[1.00–1.06]), male partner alcohol use in past year (AOR = 2.65[2.12–3.31]) and male partner infidelity (AOR = 2.31[1.72–3.09]) were significantly associated with increased odds of past year physical or sexual IPV experience. Male perpetrated IPV remains a significant public health issue in Ghana. Evidence-based interventions targeting women’s mental health, disabilities, exposure to violence in childhood, risky sexual behavior and unequal power in relationships will be critical in reducing IPV in this setting. [ABSTRACT FROM AUTHOR]

Introduction: The current surge of mobile phone use in many African countries creates the opportunity to provide caregivers with limited access to the health care system with vital health recommendations. At the same time such communication system can be utilised to collect tempero-spatial data on disease symptoms. Objective: We assessed the feasibility of an mHealth system among caregivers with children under-five years, designed as a health information and surveillance tool in a rural district of Ghana. Methods: A mobile phone-based electronic health information and surveillance system was piloted from February to December 2015. Toll-free numbers were provided to 1446 caregivers, which they could call to receive health advice in case their children showed disease symptoms. The system was setup to evaluate the illness of a sick child. Symptoms reported via the system were evaluated and compared to clinician’s report after follow-up. Cogency of the reported symptoms was assessed using Cohen’s kappa coefficient. Results: A total of 169 children with disease symptoms were identified based on phone calls from caregivers. The predominant reported symptoms were fever (64%; n = 108), cough (55%; n = 93) and diarrhoea (33%; n = 55). Temporal pattern of symptomatic cases revealed a peak saturation in the month of September, with fever registering the highest number of symptoms observed. Reported symptoms and clinician’s report revealed a very good agreement for fever (95%, kappa = 0.89); good for diarrhoea (87%, kappa = 0.73) and moderate for cough (76%, kappa = 0.49). Conclusion: This pilot concept, has demonstrated the practicality of using mobile phones for assessing childhood disease symptoms and encouraging caregivers to seek early treatment for their children if needed. The strategy to use mobile phones in disease surveillance and treatment support is a promising strategy especially for areas with limited access to the health care system. [ABSTRACT FROM AUTHOR]

Reduced climatic suitability due to climate change in cocoa growing regions of Ghana is expected in the coming decades. This threatens farmers’ livelihood and the cocoa sector. Climate change adaptation requires an improved understanding of existing cocoa production systems and farmers’ coping strategies. This study characterized current cocoa production, income diversification and shade tree management along a climate gradient within the cocoa belt of Ghana. The objectives were to 1) compare existing production and income diversification between dry, mid and wet climatic regions, and 2) identify shade trees in cocoa agroforestry systems and their distribution along the climatic gradient. Our results showed that current mean cocoa yield level of 288kg ha-1yr-1 in the dry region was significantly lower than in the mid and wet regions with mean yields of 712 and 849 kg ha-1 yr-1, respectively. In the dry region, farmers diversified their income sources with non-cocoa crops and off-farm activities while farmers at the mid and wet regions mainly depended on cocoa (over 80% of annual income). Two shade systems classified as medium and low shade cocoa agroforestry systems were identified across the studied regions. The medium shade system was more abundant in the dry region and associated to adaptation to marginal climatic conditions. The low shade system showed significantly higher yield in the wet region but no difference was observed between the mid and dry regions. This study highlights the need for optimum shade level recommendation to be climatic region specific. [ABSTRACT FROM AUTHOR]

Objective: Using our previously developed and tested Adolescent Sexual and Reproductive Health (SRH) Stigma Scale, we investigated factors associated with perceived SRH stigma among adolescent girls in Ghana. Methods: We drew upon data from our survey study of 1,063 females 15-24yrs recruited from community- and clinic-based sites in two Ghanaian cities. Our Adolescent SRH Stigma Scale comprised 20 items and 3 sub-scales (Internalized, Enacted, Lay Attitudes) to measure stigma occurring with sexual activity, contraceptive use, pregnancy, abortion and family planning service use. We assessed relationships between a comprehensive set of demographic, health and social factors and SRH Stigma with multi-level multivariable linear regression models. Results: In unadjusted bivariate analyses, compared to their counterparts, SRH stigma scores were higher among girls who were younger, Accra residents, Muslim, still in/dropped out of secondary school, unemployed, reporting excellent/very good health, not in a relationship, not sexually experienced, never received family planning services, never used contraception, but had been pregnant (all p-values <0.05). In multivariable models, higher SRH stigma scores were associated with history of pregnancy (β = 1.53, CI = 0.51,2.56) and excellent/very good self-rated health (β = 0.89, CI = 0.20,1.58), while lower stigma scores were associated with older age (β = -0.17, 95%CI = -0.24,-0.09), higher educational attainment (β = -1.22, CI = -1.82,-0.63), and sexual intercourse experience (β = -1.32, CI = -2.10,-0.55). Conclusions: Findings provide insight into factors contributing to SRH stigma among this young Ghanaian female sample. Further research disentangling the complex interrelationships between SRH stigma, health, and social context is needed to guide multi-level interventions to address SRH stigma and its causes and consequences for adolescents worldwide. [ABSTRACT FROM AUTHOR]

Background: The need to evaluate the human health safety of fishery resources remain urgent in the mist of the ever-increasing fear of heavy metal toxicity from the consumption of Ghana’s fisheries resource, as a consequence of pollution from several anthropogenic activities including artisanal gold mining. Nevertheless, the bigeye grunt (Brachydeuterus auritus) and Bagrid catfish (Chrysichthys nigrodigitatus) remain commercially valuable fish species in West Africa and continue to attract high patronage. Method: Forty-five specimens each of C. nigrodigitatus and B. auritus collected from the Weija Dam and the Tema Fishing Habour in Ghana, between June and September 2016, were analysed for seven heavy metals using Atomic Absorption Spectrometry. Result: Lead and Cadmium were below detection in all samples while Cu was not detected in B. auritus. Levels of the remaining metals (mg kg-1) were below FAO/WHO maximum permissible limits in fish and occurred in the rank order Se (3.5) > Zn (2.34) > Cu (0.59) > As (0.37) > Hg (0.19) in C. nigrodigitatus and Se (2.97) > Zn (2.28) > Hg (0.31) > As (0.21) in B. auritus. Only As in C. nigrodigitatus recorded Estimated Weekly Intake (EWI) greater than FAO/WHO Provisional Tolerable Weekly Intake (PTWI). Also, As in C. nigrodigitatus and Hg in B. auritus had Targeted Hazard Quotient (THQ) greater than 1 for individuals consuming the fishes on daily basis and therefore, raising concerns. However, for both species of fish, cancer risk of As was 1 in 10,000,000,000 and modified Health Benefits values of Se (HBVSe) were positive indicating the health risks that might accompany Hg exposure would be negated. Since toxicity depends on the concentration and quantity of a pollutant consumed, safe maximum consumption rate of C. nigrodigitatus based on As concentrations was 0.21 mg per day and that of B. auritus was 0.058 mg per day for Hg. With an average of 0.227 kg fish per meal of an adult human, these translated into not more than 24 C. nigrodigitatus and nine (9) B. auritus meals in a month but because fish is consumed at 0.0685 kg per person per day in Ghana, these values respectively translates to 93 and 30 safe days of consumption per month. Conclusion: At the rate of 0.0685 kg fish per person per day that fish is consumed in Ghana, the consumption of the two species of fish in Ghana would essentially be of little or no consequence to consumers. [ABSTRACT FROM AUTHOR]

Introduction: The WHO yaws eradication strategy consists of one round of total community treatment (TCT) of single-dose azithromycin with coverage of > 90%.The efficacy of the strategy to reduce the levels on infection has been demonstrated previously in isolated island communities in the Pacific region. We aimed to determine the efficacy of a single round of TCT with azithromycin to achieve a decrease in yaws prevalence in communities that are endemic for yaws and surrounded by other yaws-endemic areas. Methods: Surveys for yaws seroprevalence and prevalence of skin lesions were conducted among schoolchildren aged 5–15 years before and one year after the TCT intervention in the Abamkrom sub-district of Ghana. We used a cluster design with the schools as the primary sampling unit. Among 20 eligible primary schools in the sub district, 10 were assigned to the baseline survey and 10 to the post-TCT survey. The field teams conducted a physical examination for skin lesions and a dual point-of-care immunoassay for non-treponemal and treponemal antibodies of all children present at the time of the visit. We also undertook surveys with non-probabilistic sampling to collect lesion swabs for etiology and macrolide resistance assessment. Results: At baseline 14,548 (89%) of 16,287 population in the sub-district received treatment during TCT. Following one round of TCT, the prevalence of dual seropositivity among all children decreased from 10.9% (103/943) pre-TCT to 2.2% (27/1211) post-TCT (OR 0.19; 95%CI 0.09–0.37). The prevalence of serologically confirmed skin lesions consistent with active yaws was reduced from 5.7% (54/943) pre-TCT to 0.6% (7/1211) post-TCT (OR 0.10; 95% CI 0.25–0.35). No evidence of resistance to macrolides against Treponema pallidum subsp. pertenue was seen. Discussion: A single round of high coverage TCT with azithromycin in a yaws affected sub-district adjoining other endemic areas is effective in reducing the prevalence of seropositive children and the prevalence of early skin lesions consistent with yaws one year following the intervention. These results suggest that national yaws eradication programmes may plan the gradual expansion of mass treatment interventions without high short-term risk of reintroduction of infection from contiguous untreated endemic areas. [ABSTRACT FROM AUTHOR]

Background: Reducing neonatal and child mortality is a key component of the health-related sustainable development goal (SDG), but most low and middle income countries lack data to monitor child mortality on an annual basis. We tested a mortality monitoring system based on the continuous recording of pregnancies, births and deaths by trained community-based volunteers (CBV). Methods and findings: This project was implemented in 96 clusters located in three districts of the Northern Region of Ghana. Community-based volunteers (CBVs) were selected from these clusters and were trained in recording all pregnancies, births, and deaths among children under 5 in their catchment areas. Data collection lasted from January 2012 through September 2013. All CBVs transmitted tallies of recorded births and deaths to the Ghana Birth and deaths registry each month, except in one of the study districts (approximately 80% reporting). Some events were reported only several months after they had occurred. We assessed the completeness and accuracy of CBV data by comparing them to retrospective full pregnancy histories (FPH) collected during a census of the same clusters conducted in October-December 2013. We conducted all analyses separately by district, as well as for the combined sample of all districts. During the 21-month implementation period, the CBVs reported a total of 2,819 births and 137 under-five deaths. Among the latter, there were 84 infant deaths (55 neonatal deaths and 29 post-neonatal deaths). Comparison of the CBV data with FPH data suggested that CBVs significantly under-estimated child mortality: the estimated under-5 mortality rate according to CBV data was only 2/3 of the rate estimated from FPH data (95% Confidence Interval for the ratio of the two rates = 51.7 to 81.4). The discrepancies between the CBV and FPH estimates of infant and neonatal mortality were more limited, but varied significantly across districts. Conclusions: In northern Ghana, a community-based data collection systems relying on volunteers did not yield accurate estimates of child mortality rates. Additional implementation research is needed to improve the timeliness, completeness and accuracy of such systems. Enhancing pregnancy monitoring, in particular, may be an essential step to improve the measurement of neonatal mortality. [ABSTRACT FROM AUTHOR]

Introduction: Generating a nationally representative sample in low and middle income countries typically requires resource-intensive household level sampling with door-to-door data collection. High mobile phone penetration rates in developing countries provide new opportunities for alternative sampling and data collection methods, but there is limited information about response rates and sample biases in coverage and nonresponse using these methods. We utilized data from an interactive voice response, random-digit dial, national mobile phone survey in Ghana to calculate standardized response rates and assess representativeness of the obtained sample. Materials and methods: The survey methodology was piloted in two rounds of data collection. The final survey included 18 demographic, media exposure, and health behavior questions. Call outcomes and response rates were calculated according to the American Association of Public Opinion Research guidelines. Sample characteristics, productivity, and costs per interview were calculated. Representativeness was assessed by comparing data to the Ghana Demographic and Health Survey and the National Population and Housing Census. Results: The survey was fielded during a 27-day period in February-March 2017. There were 9,469 completed interviews and 3,547 partial interviews. Response, cooperation, refusal, and contact rates were 31%, 81%, 7%, and 39% respectively. Twenty-three calls were dialed to produce an eligible contact: nonresponse was substantial due to the automated calling system and dialing of many unassigned or non-working numbers. Younger, urban, better educated, and male respondents were overrepresented in the sample. Conclusions: The innovative mobile phone data collection methodology yielded a large sample in a relatively short period. Response rates were comparable to other surveys, although substantial coverage bias resulted from fewer women, rural, and older residents completing the mobile phone survey in comparison to household surveys. Random digit dialing of mobile phones offers promise for future data collection in Ghana and may be suitable for other developing countries. [ABSTRACT FROM AUTHOR]

The author discusses the implementation of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) by the World Health Organization (WHO) that aim to eradicate the lymphatic filariasis (LF) in Ghana. Topics discussed include the effect of mass drug administration (MDA) in the immunoparasitological indicators, the use of albendazole (ALB) and ivermectin (IVM) as a treatment for lymphatic filariasis, and the challenges encountered while implementing the national program.

Background: Yaws is a treponemal infection that was almost eradicated fifty years ago; however, the disease has re-emerged in a number of countries including Ghana. A single-dose of intramuscular benzathine penicillin has been the mainstay of treatment for yaws. However, intramuscular injections are painful and pose safety and logistical constraints in the poor areas where yaws occurs. A single center randomized control trial (RCT) carried out in Papua New Guinea in 2012 demonstrated the efficacy of a single-dose of oral azithromycin for the treatment of yaws. In this study, we also compared the efficacy of a single oral dose of azithromycin as an alternative to intramuscular benzathine penicillin for the treatment of the disease in another geographic setting. Methodology: We conducted an open-label, randomized non-inferiority trial in three neighboring yaws-endemic districts in Southern Ghana. Children aged 1–15 years with yaws lesions were assigned to receive either 30mg/kg of oral azithromycin or 50,000 units/kg of intramuscular benzathine penicillin. The primary end point was clinical cure rate, defined as a complete or partial resolution of lesions 3 weeks after treatment. The secondary endpoint was serological cure, defined as at least a 4-fold decline in baseline RPR titre 6 months after treatment. Non- inferiority of azithromycin treatment was determined if the upper bound limit of a 2 sided 95% CI was less than 10%. Findings: The mean age of participants was 9.5 years (S.D.3.1, range: 1–15 years), 247(70%) were males. The clinical cure rates were 98.2% (95% CI: 96.2–100) in the azithromycin group and 96.9% (95% CI: 94.1–99.6) in the benzathine penicillin group. The serological cure rates at 6 months were 57.4% (95% CI: 49.9–64.9) in the azithromycin group and 49.1% (95% CI: 41.2–56.9) in the benzathine penicillin group, thus achieving the specified criteria for non-inferiority. Conclusions: A single oral dose of azithromycin, at a dosage of 30mg/kg, was non-inferior to a single dose of intramuscular benzathine penicillin for the treatment of early yaws among Ghanaian patients, and provides additional support for the WHO policy for use of oral azithromycin for the eradication of yaws in resource-poor settings. Trial Registration: Pan African Clinical Trials Registry [ABSTRACT FROM AUTHOR]

Increasing equitable access to health care is a main challenge African policy makers are facing. The Ghanaian government implemented the National Health Insurance Scheme in 2004 and the aim of this study is to evaluate its early effects on maternal and infant healthcare use. We exploit data on births before and after the intervention and apply propensity score matching to limit the bias arising from self-selection into the health insurance. About forty percent of children had a mother who is enrolled in this insurance. The scheme significantly increased the proportion of pregnancies with at least four antenatal care visits with 7 percentage points and had a significant effect on attended deliveries (10 percentage points). Caesarean sections increased (6 percentage points) and the number of children born from an unwanted pregnancy decreased (7 percentage points). Insurance enrollment had almost no effect on child vaccinations. Among the poorest forty percent of the sample, the effects of the scheme on antenatal care and attended deliveries were similar. However, the effects of the scheme on caesarean sections were about half the size (3 percentage points) and the reduction in unwanted pregnancies was larger (10 percentage points) compared to the effects in the full sample. We conclude that in the first years of operation, the National Health Insurance Scheme had a modest impact on the use of antenatal and delivery care. This is important for other African countries currently introducing or considering a national health insurance as a means towards universal health coverage. [ABSTRACT FROM AUTHOR]

Populations in sub-Saharan Africa are shifting from rural to increasingly urban. Although the burden of cardiovascular disease is expected to increase with this changing landscape, few large studies have assessed a wide range of risk factors in urban and rural populations, particularly in West Africa. We conducted a cross-sectional, population-based survey of 3317 participants from Ghana (≥18 years old), of whom 2265 (57% female) were from a mid-sized city (Sunyani, population ~250,000) and 1052 (55% female) were from surrounding villages (populations <5000). We measured canonical cardiovascular disease risk factors (BMI, blood pressure, fasting glucose, lipids) and fibrinolytic markers (PAI-1 and t-PA), and assessed how their distributions and related clinical outcomes (including obesity, hypertension and diabetes) varied with urban residence and sex. Urban residence was strongly associated with obesity (OR: 7.8, 95% CI: 5.3–11.3), diabetes (OR 3.6, 95% CI: 2.3–5.7), and hypertension (OR 3.2, 95% CI: 2.6–4.0). Among the quantitative measures, most affected were total cholesterol (+0.81 standard deviations, 95% CI 0.73–0.88), LDL cholesterol (+0.89, 95% CI: 0.79–0.99), and t-PA (+0.56, 95% CI: 0.48–0.63). Triglycerides and HDL cholesterol profiles were similarly poor in both urban and rural environments, but significantly worse among rural participants after BMI-adjustment. For most of the risk factors, the strength of the association with urban residence did not vary with sex. Obesity was a major exception, with urban women at particularly high risk (26% age-standardized prevalence) compared to urban men (7%). Overall, urban residents had substantially worse cardiovascular risk profiles, with some risk factors at levels typically seen in the developed world. [ABSTRACT FROM AUTHOR]

Background: There is a perception that genomic differences in the species/lineages of the nine species making the Mycobacterium tuberculosis complex (MTBC) may affect the efficacy of distinct control tools in certain geographical areas. We therefore analyzed the prevalence and spatial distribution of MTBC species and lineages among isolates from pulmonary TB cases over an 8-year period, 2007–2014. Methodology: Mycobacterial species isolated by culture from consecutively recruited pulmonary tuberculosis patients presenting at selected district/sub-district health facilities were confirmed as MTBC by IS6110 and rpoß PCR and further assigned lineages and sub lineages by spoligotyping and large sequence polymorphism PCR (RDs 4, 9, 12, 702, 711) assays. Patient characteristics, residency, and risks were obtained with a structured questionnaire. We used SaTScan and ArcMap analyses to identify significantly clustered MTBC lineages within selected districts and spatial display, respectively. Results: Among 2,551 isolates, 2,019 (79.1%), 516 (20.2%) and 16 (0.6%) were identified as M. tuberculosis sensu stricto (MTBss), M. africanum (Maf), 15 M. bovis and 1 M. caprae, respectively. The proportions of MTBss and Maf were fairly constant within the study period. Maf spoligotypes were dominated by Spoligotype International Type (SIT) 331 (25.42%), SIT 326 (15.25%) and SIT 181 (14.12%). We found M. bovis to be significantly higher in Northern Ghana (1.9% of 212) than Southern Ghana (0.5% of 2339) (p = 0.020). Using the purely spatial and space-time analysis, seven significant MTBC lineage clusters (p< 0.05) were identified. Notable among the clusters were Ghana and Cameroon sub-lineages found to be associated with north and south, respectively. Conclusion: This study demonstrated that overall, 79.1% of TB in Ghana is caused by MTBss and 20% by M. africanum. Unlike some West African Countries, we did not observe a decline of Maf prevalence in Ghana. [ABSTRACT FROM AUTHOR]

Background: This study was conducted with the aim to understand some of the cultural belief systems in the management of wounds and patients practices that could contaminate wounds at the Obom sub-district of the Ga South Municipality of Ghana. Methods: This was an ethnographic study using in-depth interviews, Focus Group Discussions and participant observation techniques for data collection. Observations were done on Buruli ulcer patients to document how they integrate local and modern wound management practices in the day-to-day handling of their wounds. Content analysis was done after the data were subjected to thematic coding and representative narratives selected for presentation. Results: It was usually believed that wounds were caused by charms or spirits and, therefore, required the attention of a native healer. In instances where some patients’ wounds were dressed in the hospital by clinicians whose condition/age/sex contradict the belief of the patient, the affected often redress the wounds later at home. Some of the materials often used for such wound dressing include urine and concoctions made of charcoal and gunpowder with the belief of driving out evil spirits from the wounds. Conclusion: Clinicians must therefore be aware of these cultural beliefs and take them into consideration when managing Buruli ulcer wounds to prevent redressing at home after clinical treatment. This may go a long way to reduce secondary infections that have been observed in Buruli ulcer wounds. [ABSTRACT FROM AUTHOR]

Background: Under-five mortality is declining in Ghana and many other countries. Very few studies have measured under-five mortality-and its social and environmental risk factors-at fine spatial resolutions, which is relevant for policy purposes. Our aim was to estimate under-five mortality and its social and environmental risk factors at the district level in Ghana.Methods and Findings: We used 10% random samples of Ghana's 2000 and 2010 National Population and Housing Censuses. We applied indirect demographic methods and a Bayesian spatial model to the information on total number of children ever born and children surviving to estimate under-five mortality (probability of dying by 5 y of age, 5q0) for each of Ghana's 110 districts. We also used the census data to estimate the distributions of households or persons in each district in terms of fuel used for cooking, sanitation facility, drinking water source, and parental education. Median district 5q0 declined from 99 deaths per 1,000 live births in 2000 to 70 in 2010. The decline ranged from <5% in some northern districts, where 5q0 had been higher in 2000, to >40% in southern districts, where it had been lower in 2000, exacerbating existing inequalities. Primary education increased in men and women, and more households had access to improved water and sanitation and cleaner cooking fuels. Higher use of liquefied petroleum gas for cooking was associated with lower 5q0 in multivariate analysis.Conclusions: Under-five mortality has declined in all of Ghana's districts, but the cross-district inequality in mortality has increased. There is a need for additional data, including on healthcare, and additional environmental and socioeconomic measurements, to understand the reasons for the variations in mortality levels and trends. [ABSTRACT FROM AUTHOR]

Hepatitis B virus (HBV) infections account for approximately 780,000 deaths per year, most of which occur in the developing world. Co-infection with HBV and hepatitis delta virus (HDV) may lead to the most severe form of viral hepatitis. In Ghana, knowledge on the prevalence of HBV and HDV in the general population is scanty and the few genetic analyses of the prevailing HBV genotypes are dating back more than a decade. In the present study, 1,323 serum samples from individuals living in a rural area (Offin river valley) of Ghana were analyzed for the presence of the hepatitis B surface antigen (HBsAg). Positive sera were subsequently tested for the presence of anti-HDV antibodies. A total of 107 (8%) sera were HBsAg positive with an 8.4% prevalence of anti-HDV antibodies among the HBsAg positives. Phylogenetic analysis based on HBV pre-S/S sequences, attributed all 52 typable samples to genotype E. All belonged to serotype ayw4. While 19 sequences clustered with those from a number of African countries, the other 33 formed a separate cluster distinguished by an intergroup mean distance of 1.5% from the pan-African HBV/E cluster. Successful implementation of HBV vaccination in the region was reflected by the low HBsAg carrier rate of 1.8% among children ≤11 years. [ABSTRACT FROM AUTHOR]

Background: Ghana is affected by regular cholera epidemics and an annual average of 3,066 cases since 2000. In 2014, Ghana experienced one of its largest cholera outbreaks within a decade with more than 20,000 notified infections. In order to attribute this rise in cases to a newly emerging strain or to multiple simultaneous outbreaks involving multi-clonal strains, outbreak isolates were characterized, subtyped and compared to previous epidemics in 2011 and 2012. Methodology/Principal Findings: Serotypes, biotypes, antibiotic susceptibilities were determined for 92 Vibrio cholerae isolates collected in 2011, 2012 and 2014 from Southern Ghana. For a subgroup of 45 isolates pulsed-field gel electrophoresis, multilocus sequence typing and multilocus-variable tandem repeat analysis (MLVA) were performed. Eighty-nine isolates (97%) were identified as ctxB (classical type) positive V. cholerae O1 biotype El Tor and three (3%) isolates were cholera toxin negative non-O1/non-O139 V. cholerae. Among the selected isolates only sulfamethoxazole/trimethoprim resistance was detectable in 2011, while 95% of all 2014 isolates showed resistance towards sulfamethoxazole/trimethoprim, ampicillin and reduced susceptibility to ciprofloxacin. MLVA achieved the highest subtype discrimination, revealing 22 genotypes with one major outbreak cluster in each of the three outbreak years. Apart from those clusters genetically distant genotypes circulate during each annual epidemic. Conclusions/Significance: This analysis suggests different endemic reservoirs of V. cholerae in Ghana with distinct annual outbreak clusters accompanied by the occurrence of genetically distant genotypes. Preventive measures for cholera transmission should focus on aquatic reservoirs. Rapidly emerging multidrug resistance must be monitored closely. [ABSTRACT FROM AUTHOR]

Background: Malaria-endemic countries in sub-Saharan Africa are shifting from the presumptive approach that is based on clinical judgement (CJ) to the test-based approach that is based on confirmation through test with rapid diagnostic tests (RDT). It has been suggested that the loss of the prophylactic effect of presumptive-administered ACT in children who do not have malaria will result in increase in their risk of malaria and anaemia. Methods and Findings: We undertook a cluster-randomized controlled trial to compare the effects of the presumptive approach using clinical judgment (CJ-arm) and the test-based approach using RDTs (RDT-arm in a high-transmission setting in Ghana. A total of 3046 eligible children (1527 in the RDT arm and 1519 in the CJ- arm) living around 32 health centres were enrolled. Nearly half were female (48.7%) and 47.8% were below the age of 12 months as at enrolment. Over 24-months, the incidence of all episodes of malaria following the first febrile illness was 0.64 (95% CI 0.49–0.82) and 0.76 (0.63–0.93) per child per year in the RDT and CJ arms respectively (adjusted rate ratio 1.13 (0.82–1.55). After the first episode of febrile illness, the incidence of severe anaemia was the same in both arms (0.11 per child per year) and that of moderate anaemia was 0.16 (0.13–0.21) vs. 0.17 (0.14–0.21) per child year respectively. The incidence of severe febrile illness was 0.15 (0.09, 0.24) in the RDT arm compared to 0.17 (0.11, 0.28) per child per year respectively. The proportion of fever cases receiving ACT was lower in the RDT arm (72% vs 81%; p = 0.02). Conclusion: The test-based approach to the management of malaria did not increase the incidence of malaria or anaemia among under-five children in this setting. Trial Registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

Poor food hygiene is a significant risk to public health globally, but especially in low and middle-income countries where access to sanitation, and general hygiene remain poor. Food hygiene becomes even more pertinent when untreated, or poorly treated wastewater is used in agriculture. In such circumstances the WHO recommends the adoption of a multiple-barrier approach that prescribes health protective measures at different entry points along the food chain. This study sought to assess the knowledge and awareness of wastewater use for crop production, its related health risks, and adoption of health protective measures by farmers, market salespersons and consumers using questionnaires and focus group discussions. In the period from September 2012 to August 2013, 490 respondents were interviewed during two cropping seasons. The study found that awareness of the source of irrigation water was low among consumers and street food vendors, though higher among market vendors. In contrast, health risk awareness was generally high among salespersons and consumers, but low among farmers. The study found that consumers did not prioritize health indicators when buying produce from vendors but were motivated to buy produce, or prepared food based on taste, friendship, cost, convenience and freshness of produce. Similarly, farmers’ awareness of health risk did not influence their adoption of safer farm practices. The study recommends the promotion of interventions that would result in more direct benefits to both producers and vendors, together with hygiene education and enforcement of food safety byelaws in order to influence behaviour change, and increase the uptake of the multiple-barrier approach. [ABSTRACT FROM AUTHOR]

Background: Ebola Virus Disease (EVD) is not new to the world. However, the West African EVD epidemic which started in 2014 evolved into the largest, most severe and most complex outbreak in the history of the disease. The three most-affected countries faced enormous challenges in stopping the transmission and providing care for all patients. Although Ghana had not recorded any confirmed Ebola case, social factors have been reported to hinder efforts to control the outbreak in the three most affected countries. This qualitative study was designed to explore community knowledge and attitudes about Ebola and its transmission. Methods: This study was carried out in five of the ten regions in Ghana. Twenty-five focus group discussions (N = 235) and 40 in-depth interviews were conducted across the five regions with community members, stakeholders and opinion leaders. The interviews were recorded digitally and transcribed verbatim. Framework analysis was adopted in the analysis of the data using Nvivo 10. Results: The results showed a high level of awareness and knowledge about Ebola. The study further showed that knowledge on how to identify suspected cases of Ebola was also high among respondents. However, there was a firm belief that Ebola was a spiritual condition and could also be transmitted through air, mosquito bites and houseflies. These misconceptions resulted in perceptions of stigma and discrimination towards people who may get Ebola or work with Ebola patients. Conclusion: We conclude that although knowledge and awareness about Ebola is high among Ghanaians who participated in the study, there are still misconceptions about the disease. The study recommends that health education on Ebola disease should move beyond creating awareness to targeting the identified misconceptions to improve future containment efforts. [ABSTRACT FROM AUTHOR]

Mycobacterium africanum is a member of the Mycobacterium tuberculosis complex (MTBC) and an important cause of human tuberculosis in West Africa that is rarely observed elsewhere. Here we genotyped 613 MTBC clinical isolates from Ghana, and searched for associations between the different phylogenetic lineages of MTBC and patient variables. We found that 17.1% (105/613) of the MTBC isolates belonged to M. africanum, with the remaining belonging to M. tuberculosis sensu stricto. No M. bovis was identified in this sample. M. africanum was significantly more common in tuberculosis patients belonging to the Ewe ethnic group (adjusted odds ratio: 3.02; 95% confidence interval: 1.67–5.47, p<0.001). Stratifying our analysis by the two phylogenetic lineages of M. africanum (i.e. MTBC Lineages 5 and 6) revealed that this association was mainly driven by Lineage 5 (also known as M. africanum West Africa 1). Our findings suggest interactions between the genetic diversity of MTBC and human diversity, and offer a possible explanation for the geographical restriction of M. africanum to parts of West Africa. [ABSTRACT FROM AUTHOR]

Malaria is a leading cause of morbidity and mortality among children in Ghana. As part of the effort to inform local and national decision-making in preparation for possible malaria vaccine introduction, this qualitative study explored community-level factors that could affect vaccine acceptance in Ghana and provides recommendations for a health communications strategy. The study was conducted in two purposively selected districts: the Ashanti and Upper East Regions. A total of 25 focus group discussions, 107 in-depth interviews, and 21 semi-structured observations at Child Welfare Clinics were conducted. Malaria was acknowledged to be one of the most common health problems among children. While mosquitoes were linked to the cause and bed nets were considered to be the main preventive method, participants acknowledged that no single measure prevented malaria. The communities highly valued vaccines and cited vaccination as the main motivation for taking children to Child Welfare Clinics. Nevertheless, knowledge of specific vaccines and what they do was limited. While communities accepted the idea of minor vaccine side effects, other side effects perceived to be more serious could deter families from taking children for vaccination, especially during vaccination campaigns. Attendance at Child Welfare Clinics after age nine months was limited. Observations at clinics revealed that while two different opportunities for counseling were offered, little attention was given to addressing mothers’ specific concerns and to answering questions related to child immunization. Positive community attitudes toward vaccines and the understanding that malaria prevention requires a comprehensive approach would support the introduction of a malaria vaccine. These attitudes are bolstered by a well-established child welfare program and the availability in Ghana of active, flexible structures for conveying health information to communities. At the same time, it would be important to improve the quality of Child Welfare Clinic services, particularly in relation to communication around vaccination. [ABSTRACT FROM AUTHOR]