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Reporting child sexual abuse (CSA) to law enforcement institutions is the ideal child protection imperative. The role of parents in this process is unquestionably profound. Yet, there is limited evidence on parental perspectives on reporting CSA to law enforcement agencies in developing country contexts. We apply vignettes to describe the views of parents about reporting CSA perpetrated by “family members, schoolteachers, and strangers.” Data was collected from 89 parents from four culturally diverse regions of Ghana. A systematic inductive approach was used to determine patterns and similarities in participants’ attitudes toward reporting. We note that the attitudes of participants about reporting CSA varied considerably; these are influenced by the nature of social relationships between the victim and perpetrator. In a seeming order of severity, CSA perpetrated by a family member was viewed less seriously compared to victimization by a teacher or a stranger. The desire to preserve familial/kin ties and reputation and keeping to the cultural heritage of resolving “disputes and disagreements” amicably were primary norms against reporting CSA. However, attitudes toward reporting CSA by teachers were influenced by expectation of higher moral standards, which made reporting CSA by a teacher a reasonable cause of action. Positive attitudes toward reporting CSA by “strangers” were prevalent. Child protection programs must recognzse the segmented attitudes toward CSA and tackle the deep-seated cultural and social norms through social and behavioral change communication (SBCC).

Infrastructure investments can contribute substantially to alleviating burdens of morbidity and mortality while also providing a positive return on investment in the long term.

Background Utilization of adequate and quality prenatal healthcare services confers critical benefits to women and their unborn children. However, utilization rates remain low in many countries in Africa. Several studies have attempted to understand the primary drivers behind these low statistics. This article contributes to this discourse by examining the associations between birth interval and timing and number/frequency of antenatal care visits in Africa. Methods We pooled data from the publicly available Demographic and Health Surveys conducted in the last decade (2010–2020) for 32 African countries. Data were analysed using descriptive proportions and mixed effect binary logistic regression. Results The results illustrate moderate significant associations between spacing on the most recent birth by ≥36 months and early (first trimester) first antenatal care contact in both our bivariate (odds ratio [OR] 1.18, p Conclusions Optimal birth spacing is beneficial for ANC utilization in terms of timing and total number of contacts. Post-partum family planning/contraceptive use can be an effective pathway to prolonging birth intervals. We argue that maternal and child health programmes strengthen prioritizing contraceptive use between births.

Background Women in sub-Saharan Africa (SSA) have a higher risk of unintended pregnancies that are more likely to be terminated, most of which are unsafe with associated complications. Unmet need for contraception is highest in SSA and exceeds the global average. This study investigates the association between unmet/met need for contraception and pregnancy termination SSA. Methods We used pooled data from Demographic and Health Surveys conducted from January 2010 to December 2018 in 32 countries in SSA. Our study involved 265,505 women with diverse contraception needs and with complete data on all variables of interest. Multilevel logistic regression at 95% CI was used to investigate the association between individual and community level factors and pregnancy termination. Results We found an overall pregnancy termination rate of 16.27% ranging from 9.13% in Namibia to 38.68% in Gabon. Intriguingly, women with a met need for contraception were more likely to terminate a pregnancy [aOR = 1.11; 95% CI 1.07–1.96] than women with unmet needs. Women with secondary education were more likely to terminate a pregnancy as compared to those without education [aOR = 1.23; 95% CI 1.19–1.27]. With regards to age, we observed that every additional age increases the likelihood of terminating a pregnancy. At the contextual level, the women with female household heads were less likely to terminate a pregnancy [aOR = 0.95; 95% CI 0.92–0.97]. The least socio-economically disadvantaged women were less likely to terminate a pregnancy compared to the moderately and most socio-economically disadvantaged women. Conclusions Our study contributes towards the discussion on unmet/met need for contraception and pregnancy termination across SSA. Women with met need for contraception have higher odds of terminating a pregnancy. The underlying cause of this we argued could be poor adherence to the protocols of contraceptives or the reluctance of women to utilise contraceptives after experiencing a failure. Governments of SSA and non-governmental organisations need to take pragmatic steps to increase met needs for contraception and also utilise mass media to encourage women to adhere to the prescription of contraceptives in order to reduce the incidence of unplanned pregnancies and unsafe abortions., Plain language summary Women in sub-Saharan Africa (SSA) have a higher risk of unintended pregnancies that are more likely to be terminated, most of which are unsafe with associated complications. Unmet need for contraception is highest in SSA and exceeds the global average. This study investigates the association between unmet/met need for contraception and pregnancy termination SSA. We used pooled data from Demographic and Health Surveys conducted from January 2010 to December 2018 in 32 countries in SSA. Our study involved 265,505 women with diverse contraception needs and with complete data on all variables of interest. We found an overall pregnancy termination rate of 16.27% ranging from 9.13% in Namibia to 38.68% in Gabon. Met need of contraception, education, sex of household head, and socio-economic disadvantage of women had a significant association with pregnancy termination. Our study contributes towards the discussion on unmet/met need for contraception and pregnancy termination across SSA. Governments of SSA and non-governmental organisations need to take pragmatic steps to increase met needs for contraception and also utilise mass media to encourage women to adhere to the prescription of contraceptives in order to reduce the incidence of unplanned pregnancies and unsafe abortions.

Background In many parts of sub-Saharan Africa, access to abortion is legally restricted, which partly contributes to high incidence of unsafe abortion. This may result in unsafe abortion-related complications that demand long hospital stays, treatment and attendance by skilled health providers. There is however, limited knowledge on the capacity of public health facilities to deliver post-abortion care (PAC), and the spread of PAC services in these settings. We describe and discuss the preparedness and capacity of public health facilities to deliver complete and quality PAC services in Burkina Faso, Kenya and Nigeria. Methods A cross-sectional survey of primary, secondary and tertiary-level public health facilities was conducted between November 2018 and February 2019 in the three countries. Data on signal functions (including information on essential equipment and supplies, staffing and training among others) for measuring the ability of health facilities to provide post-abortion services were collected and analyzed. Results Across the three countries, fewer primary health facilities (ranging from 6.3–12.1% in Kenya and Burkina Faso) had the capacity to deliver on all components of basic PAC services. Approximately one-third (26–43%) of referral facilities across Burkina Faso, Kenya and Nigeria could provide comprehensive PAC services. Lack of trained staff, absence of necessary equipment and lack of PAC commodities and supplies were a main reason for inability to deliver specific PAC services (such as surgical procedures for abortion complications, blood transfusion and post-PAC contraceptive counselling). Further, the lack of capacity to refer acute PAC cases to higher-level facilities was identified as a key weakness in provision of post-abortion care services. Conclusions Our findings reveal considerable gaps and weaknesses in the delivery of basic and comprehensive PAC within the three countries, linked to both the legal and policy contexts for abortion as well as broad health system challenges in the countries. There is a need for increased investments by governments to strengthen the capacity of primary, secondary and tertiary public health facilities to deliver quality PAC services, in order to increase access to PAC and avert preventable maternal mortalities.

The content of comprehensive sexuality education (CSE) programmes is contested in many parts of the world, yet we know less about what primary beneficiaries (learners) consider as (in) appropriate school curriculum. I examined this phenomenon in Ghana. Data generated from focus group discussions suggests that, overall, participants used positive phrases to describe the need for sexuality education. The prevalent and recurrent needs of adolescents centred around personal reproductive health hygiene, pregnancy prevention, healthy relationships, reproductive infections and control, reproductive physiology and maturation, gender differences and sexual orientations, and sexual pleasure and pain. However, these needs varied in some ways between males and females and between early adolescents and older adolescents. The study shows that what adolescents seek to learn fall within international norms/standards on CSE. However, some of these concepts were not covered in the guidelines proposed for Ghana. The prevalent view among many opponents that CSE is not driven by local need may not be consistent with adolescents' own aspirations and realities. The voices of children and adolescents should constitute part of the discussions on the form and content of sexuality education.

Providing young people and children with age and developmentally appropriate comprehensive sexuality education (CSE) is important for young people in making informed decisions. There are presently ...

Very few studies examine sexual violence perpetrated on adolescents in Ghana or in sub-Saharan Africa more generally. Using data collected in 2015 as part of a multi-country initiative, we employed multinomial logit models to examine violence experienced by Ghanaian adolescents at sexual debut. Results of our gender-specific models showed violence at sexual debut is gendered. While adolescent girls reported higher levels of forced sex (rape) at sexual debut, boys reported higher levels of coercion. Compared to those who had sex at relatively older ages, girls who had sex at younger ages were significantly more likely to say they were raped, were coerced or that sex ‘just happened’ than to report sex was wanted. Both male and female adolescents were significantly more likely to report sex was forced than wanted if the sexual partner was older. Female respondents who lived with family members other than their parents were significantly more likely to report forced sex (rape). We recommend government and interested stakeholders to promote social norms that discourage violence against adolescents. School-based programs, such as Ghana’s comprehensive sexuality education, must focus on equipping adolescents with the confidence and skills required to handle cultural pressures and the power differences that characterize sexual relationships.

Although Ghana’s comprehensive sexuality education (CSE) program has been lauded, no study has examined its association with the sexual health outcomes of Ghanaian youth. Using data collected from 2,982 in-school youth (male = 1,820 and female = 1,162) aged 15 to 17 years in three administrative regions of the country, we applied discrete-time hazard models to examine associations between components of Ghana’s CSE on the timing of sexual debut among male and female youth. Results indicate significant relationships between components on HIV prevention and timing of sexual debut for male youth. Male youth who learned about HIV prevention delayed sexual debut; however, male youth who endorsed myths about HIV transmission started sex early. Females who learned about values and interpersonal skills delayed their sexual debut, but the influence of this variable was attenuated by respondents’ demographic characteristics. Female respondents residing in the Greater Accra and Northern regions delayed sex, compared with those in the Brong Ahafo region.

Background On the account of limited doses of COVID-19 available to the country, the Government of Ghana created a priority list of persons to target for its vaccination agenda. In this paper, we look at trust and how it informs willingness to take the COVID-19 vaccine among persons targeted for the first phase of COVID-19 vaccination program in Ghana. Methods A sequential mixed-method investigation was conducted among the priority population - persons 60 years and above, frontline government functionaries, health workers, persons with underlying health conditions and, religious leaders and teachers. We sampled 415 respondents from the target population for a survey and 15 religious and traditional leaders from three cities; Accra, Cape Coast and Tamale for follow-up in-depth interviews based on the results of the survey data. Quantitative data is presented with descriptive proportions and multinomial logistic regression and thematic approach is applied to the interview data. Results Trust and willingness to take the vaccine are high in this priority population. Trust in the effectiveness and safety of the vaccine, rather than socioeconomic characteristics of respondents better predicted acceptance. From interview narratives, mistrust in political actors - both local and foreign, believe in superior protection of God and seeming misunderstanding of vaccine development processes countermand acceptance. On the other hand, the professional influence of people in one’s social networks, and past triumphs of vaccination programmes against concerning childhood diseases embed trust and acceptance. Conclusions Attention ought to be given to trust enhancing triggers while strategic communication approaches are used to remove triggers of mistrust.

The multiple realities around the sexual and reproductive health of Ghanaian adolescents are explored in this paper. Female and male adolescents (aged 10–19 years, N=298) participated in 40 focus group discussions in 20 communities. A comparative inductive approach has been used to present, analyse and document the sexual and reproductive realities of adolescents in their communities. The findings reveal commonalities as well as differences in the realities among participants. Common realities, regardless of age and sex, were teenage pregnancy and abortion, sexual violence (defilement, rape and coercive sex) and parental neglect. These aside, there were divergent realities for older adolescent girls in particular, e.g. lack of access to contraceptives and understanding of the fertility cycle, and the influences and pressures of social media and varied notions about sexual harassment between female and male adolescents. The findings, overall, underscore the complexity and nuanced lives of adolescents in traversing the sexual and reproductive maturation processes. These events unfold in communities where adolescents are ‘required’ to be silent and ‘play’ innocent regardless of their daily struggles, compounded by limited opportunities to learn and unlearn embedded norms about sexual and reproductive functioning. Some implications for sexual health promotion programmes are outlined.

BackgroundQuality nutrition is an important basis of health and well-being, especially for children as their bodies need to grow, develop and reach their physical and mental potential. Women’s empowerment is not only important for women’s human rights, but also improves nutrition outcomes of both mothers and their children. This study sought to investigate the association between women’s empowerment and minimum meal frequency in Ghana.MethodsThe study used data from the 2014 Ghana Demographic and Health Survey (GDHS). A sample of 1,640 mother-child (6-23 months) dyad was used and univariate and multiple linear regression techniques were applied.ResultsDecisions on large household purchases (β=0.351, pConclusionMinimum meal frequency was largely influenced by economic and socio-familial empowerment of women as decisions on large household purchases and family visits showed association with minimum meal frequency. Interventional programs should target households and mothers with lower socio-demographics characteristics such as lower educational level.

To estimate the direct costs of treating women with maternal near misses and potentially life-threatening conditions in Kenya and the factors associated with catastrophic health expenditure for these women and their households.As part of a prospective, nationally representative study of all women with near misses during pregnancy and childbirth or within 42 days of delivery or termination of pregnancy, we compared the cost of treating maternal near-miss cases admitted to referral facilities with that of women with potentially life-threatening conditions. We used logistic regression analysis to assess clinical, demographic and household factors associated with catastrophic health expenditure.Of 3025 women, 1180 (39.0%) had maternal near misses and 1845 (61.0%) had potentially life-threatening conditions. The median cost of treating maternal near misses was 7135 Kenyan shillings (71 United States dollars, US$) compared with 2690 Kenyan shillings (US$ 27) for potentially life-threatening conditions. Of the women who made out-of-pocket payments, 26.4% (122/462) experienced catastrophic expenditure. The highest median costs for treatment of near misses were in Nairobi and Central region (22 220 Kenyan shillings; US$ 222). Women with ectopic pregnancy complications and pregnancy-related infections had the highest median costs of treatment, at 7800 Kenyan shillings (US$ 78) and 3000 Kenyan shillings (US$ 30), respectively. Pregnancy-related infections, abortion, ectopic pregnancy, and treatment in secondary and tertiary facilities were significantly associated with catastrophic expenditure.The cost of treating maternal near misses is high and leads to catastrophic spending through out-of-pocket payments. Universal health coverage needs to be expanded to guarantee financial protection for vulnerable women.Estimer les coûts directs engendrés par la prise en charge des mères ayant évité un décès de justesse et par les maladies potentiellement mortelles au Kenya, ainsi que les facteurs liés aux dépenses de santé catastrophiques pour ces femmes et leur foyer.Une étude prospective et représentative à l'échelle nationale a été menée auprès de l'ensemble des femmes ayant évité un décès de justesse durant la grossesse et l'accouchement, ou dans les 42 jours suivant l'accouchement ou l'interruption de grossesse. C'est dans ce contexte que nous avons comparé le coût du traitement des décès maternels évités de justesse avec celui des femmes souffrant de maladies potentiellement mortelles. Nous avons procédé à une analyse de régression logistique afin d'évaluer les facteurs cliniques, démographiques et domestiques liés aux dépenses de santé catastrophiques.Sur un total de 3025 femmes, 1180 (39,0%) avaient évité un décès de justesse et 1845 (61,0%) présentaient des maladies potentiellement mortelles. La prise en charge des décès maternels évités de justesse coûtait en moyenne 7135 shillings kényans (71 dollars américains), tandis que les maladies potentiellement mortelles revenaient à 2690 shillings kényans (27 dollars américains). Parmi les femmes contraintes de payer elles-mêmes ces frais, 26,4% (122/462) ont fait face à des dépenses catastrophiques. C'est à Nairobi et dans la Province centrale que la prise en charge des décès évités de justesse s'est avérée la plus onéreuse (22 220 shillings kényans; 222 dollars américains). Les coûts moyens les plus élevés étaient assumés par les femmes ayant subi des complications à cause d'une grossesse ectopique (7800 shillings kényans; 78 dollars américains) et des infections liées à la grossesse (3000 shillings kényans; 30 dollars américains). Les infections liées à la grossesse, l'avortement, les grossesses ectopiques et les traitements dans des établissements secondaires et tertiaires étaient fréquemment synonymes de dépenses catastrophiques.Le montant que représente la prise en charge des décès maternels évités de justesse est considérable et entraîne des dépenses catastrophiques lorsqu'il doit être déboursé par la patiente elle-même. Il est impératif d'étendre la couverture maladie universelle afin d'assurer la protection financière des femmes vulnérables.Estimar los costes directos del tratamiento de las mujeres con morbilidad materna extrema y con enfermedades potencialmente mortales en Kenia, así como los factores asociados a los gastos sanitarios catastróficos para estas mujeres y sus hogares.Como parte de un estudio de cohortes y representativo a nivel nacional de todas las mujeres con morbilidad extrema durante el embarazo y el parto o dentro de los 42 días posteriores al parto o a la interrupción del embarazo, se comparó el coste del tratamiento de los casos de morbilidad extrema ingresados en centros de referencia con el de las mujeres con enfermedades potencialmente mortales. Se utilizó un análisis de regresión logística para evaluar los factores clínicos, demográficos y domésticos asociados a los gastos sanitarios catastróficos.De 3025 mujeres, 1180 (39,0 %) tuvieron morbilidad materna extrema y 1845 (61,0 %) padecieron enfermedades potencialmente mortales. El coste medio del tratamiento de los casos de morbilidad materna extrema fue de 7135 chelines kenianos (71 dólares estadounidenses, USD), en comparación con los 2690 chelines kenianos (27 USD) de las enfermedades potencialmente mortales. De las mujeres que pagaron de su bolsillo, el 26,4 % (122/462) tuvo gastos catastróficos. La mediana de los costes más elevados para el tratamiento de la morbilidad materna extrema se registró en Nairobi y en la región central (22 220 chelines kenianos; 222 USD). Las mujeres con problemas de embarazo ectópico y con infecciones causadas por el embarazo tuvieron los costes medios de tratamiento más elevados, 7800 chelines kenianos (78 USD) y 3000 chelines kenianos (30 USD), respectivamente. Las infecciones causadas por el embarazo, el aborto, el embarazo ectópico y el tratamiento en centros de atención secundaria y terciaria se asociaron de manera significativa con los gastos catastróficos.El coste del tratamiento de la morbilidad materna extrema es alto y genera un gasto catastrófico mediante los pagos de bolsillo. Se debe ampliar la cobertura sanitaria universal para garantizar la protección financiera de las mujeres vulnerables.تقدير التكاليف المباشرة لمعالجة النساء اللاتي كن على وشك الوفاة أثناء الولادة، والظروف المحتمل تهديدها للحياة في كينيا، والعوامل المرتبطة بالإنفاق الصحي الكارثي لهؤلاء النساء وأسرهن.كجزء من دراسة مستقبلية تمثيلية على المستوى الوطني لجميع النساء اللاتي كن على وشك الوفاة أثناء الحمل والولادة، أو في غضون 42 يومًا من الولادة أو نهاية الحمل، قمنا بمقارنة تكلفة معالجة حالات الأمهات على وشك الوفاة، والتي تم قبولها في مرافق الإحالة مع تكلفة النساء اللاتي تعرضن لظروف قد تهدد الحياة. لقد استخدمنا تحليل الانحدار اللوجستي لتقييم العوامل السريرية والديموغرافية والأسرية المرتبطة بالإنفاق الصحي الكارثي.من بين 3025 امرأةً، كانت 1180 (39.0%) منهن على وشك الوفاة، وتعرضت 1845 (61.0%) منهم لظروف قد تهدد الحياة. كان متوسط تكلفة علاج الأمهات اللاتي كن على وشك الوفاة 7135 شلنًا كينيًا (71 دولارًا أمريكيًا)، مقارنة بـ 2690 شلنًا كينيًا (27 دولارًا أمريكيًا) للحالات التي قد تهدد الحياة. من بين النساء اللاتي سددن المدفوعات من أموالهن، تعرضت 26.4% (122/462) منهن لنفقات كارثية. وكان أعلى متوسط لتكاليف علاج الحالات التي كانت على وشك الوفاة في نيروبي والمنطقة الوسطى (2220 شلنًا كينيًا؛ 222 دولارًا أمريكيًا). كانت النساء المصابات بمضاعفات الحمل خارج الرحم وحالات العدوى المرتبطة بالحمل، هن أصحاب أعلى متوسط لتكاليف العلاج، 7800 شلن كيني (78 دولارًا أمريكيًا) و3000 شلن كيني (30 دولارًا أمريكيًا)، على التوالي. ارتبطت حالات العدوى المرتبطة بالحمل والإجهاض والحمل خارج الرحم والمعالجة في المرافق الثانوية والثالثية بشكل كبير بالنفقات الكارثية.تكلفة علاج حالات الأمهات الوشيكة على الوفاة مرتفعة، وتؤدي إلى إنفاق كارثي من خلال المدفوعات الشخصية. تحتاج التغطية الصحية الشاملة للتوسيع لضمان الحماية المالية للنساء المعرضات للخطر.估计治疗肯尼亚女性的孕产妇险兆事件和可能危及生命的情况的直接成本，以及导致这些女性及其家庭将这笔成本视为灾难性医疗支出的影响因素。.作为一项具有前瞻性和全国代表性研究的一部分，我们研究了所有在怀孕和分娩期间、分娩或终止妊娠 42 天内发生险兆事件的女性，比较了孕产妇险兆事件（包括转诊病例）的治疗费用和可能危及女性生命的情况的治疗费用。我们使用逻辑回归分析来评估导致这笔费用成为灾难性医疗支出的临床、人口统计和家庭因素。.在 3025 名女性中，1180 (39.0%) 名女性经历过孕产妇险兆事件，1845 (61.0%) 名女性经历过可能危及生命的情况。孕产妇险兆事件的治疗费用中位数为 7135 肯尼亚先令（71 美元），而可能危及生命的治疗费用中位数成本则为 2690 肯尼亚先令（27 美元）。在自付费用的女性中，这笔费用对于 26.4%（122/462）的女性来说是灾难性医疗支出。内罗比和中部地区的险兆事件的治疗费用中位数最高（22,220 肯尼亚先令，即 222 美元）患有异位妊娠并发症和妊娠相关感染的女性的治疗费用中位数最高，分别为 7800 肯尼亚先令（78 美元）和 3000 肯尼亚先令（30 美元）。灾难性医疗支出主要与妊娠相关感染、流产、异位妊娠以及在二级和三级机构接受治疗有关。.治疗孕产妇险兆事件的费用很高，所以对于需要自付费用的患者及其家庭而言是一笔灾难性支出。因此，需要扩大全民医疗保险覆盖范围，以确保弱势女性获得财务保障。.Оценить прямые затраты на лечение женщин с осложнениями во время родов, представляющими угрозу для жизни, и с потенциально опасными для жизни состояниями в Кении, а также факторы, связанные с катастрофическими расходами на медицинское обслуживание таких женщин и их домохозяйств.В рамках проспективного, репрезентативного на национальном уровне исследования с участием женщин с осложнениями, представляющими угрозу для жизни во время беременности и родов или в течение 42 дней после родов или прерывания беременности, авторы сравнили затраты на лечение случаев осложнения, представляющих угрозу для жизни женщин, поступивших в специализированные медицинские учреждения, с затратами на лечение женщин с потенциально опасными для их жизни состояниями. Авторы использовали логистический регрессионный анализ для оценки клинических, демографических и бытовых факторов, связанных с катастрофическими расходами на медицинское обслуживание.Из 3025 женщин 1180 (39,0%) имели осложнения, представляющие угрозу для их жизни, а 1845 женщин (61,0%) имели потенциально опасные для их жизни состояния. Средняя стоимость лечения осложнений, представляющих угрозу для жизни, составила 7135 кенийских шиллингов (71 доллар США) по сравнению с 2690 кенийскими шиллингами (27 долларов США) при лечении потенциально опасных для жизни состояний. 26,4% (122/462) женщин, которые оплачивали услуги из собственных средств, понесли катастрофические расходы. Самые высокие средние затраты на лечение осложнений, представляющих угрозу для жизни, отмечены в Найроби и Центральном регионе (22 220 кенийских шиллингов (222 доллара США)). Женщины с осложнениями внематочной беременности и со связанными с беременностью инфекциями имели самые высокие средние затраты на лечение: 7800 кенийских шиллингов (78 долларов США) и 3000 кенийских шиллингов (30 долларов США) соответственно. Инфекции, связанные с беременностью, аборты, внематочная беременность и лечение в учреждениях вторичного и третичного уровня были в значительной степени связаны с катастрофическими расходами.Стоимость лечения осложнений, представляющих угрозу для жизни, достаточно высока и приводит к катастрофическим расходам из-за оплаты услуг из собственных средств. Необходимо расширить всеобщий охват услугами здравоохранения, чтобы гарантировать финансовую защиту уязвимых групп женщин.

Integration of tuberculosis and HIV services in many resource-limited settings, including Ghana, has been far from optimal despite the existence of policy frameworks for integration. A previous study among programme managers and other stakeholders at the national level has documented tardiness in committing to the integration of services. In this paper, we aimed at unravelling pertinent challenges that confront TB-HIV integrated service delivery. Data were obtained from interviews with 31 individual health care providers operating under different models of TB-HIV service delivery. The study is framed around the Complexity Theory. We applied inductive and deductive techniques to code the data and validations were done through inter-rater mechanisms. The analysis was done with the assistance of QSR NVivo version 12. We found evidence of a convivial working relationship between TB-HIV service providers at the facility level. However, the interactions vary across models of care-the lesser the level of integration, the lesser the complexities for interactions that ensued. This had resulted in operational challenges on account of how the two-disease environment interacts with the other components of the health system. These challenges included; weak/inappropriate infrastructure, frail coordination between the two programmes and hospital administrators, under-staffing in comprehensive TB-HIV management, use of community facility under the Directly-Observed Treatment (DOT) protocols, and financial constraints. To fully appropriate the enormous benefits of TB-HIV service integration, there is a need to address these challenges.

At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.

Although the Kenyan government has made efforts to invest in maternal health over the past 15 years, there is no evidence of decline in maternal mortality. To provide necessary evidence to inform maternal health care provision, we conducted a nationally representative study to describe the incidence and causes of maternal near-miss (MNM), and the quality of obstetric care in referral hospitals in Kenya. We collected data from 54 referral hospitals in 27 counties. Individuals admitted with potentially life-threatening conditions (using World Health Organization criteria) in pregnancy, childbirth or puerperium over a three month study period were eligible for inclusion in our study. All cases of severe maternal outcome (SMO, MNM cases and deaths) were prospectively identified, and after consent, included in the study. The national annual incidence of MNM was 7.2 per 1,000 live births and the intra-hospital maternal mortality ratio was 36.2 per 100,000 live births. The major causes of SMOs were postpartum haemorrhage and severe pre-eclampsia/eclampsia. However, only 77% of women with severe preeclampsia/eclampsia received magnesium sulphate and 67% with antepartum haemorrhage who needed blood received it. To reduce the burden of SMOs in Kenya, there is need for timely management of complications and improved access to essential emergency obstetric care interventions.

The timing of first sexual intercourse (FSI) has been linked with subsequent sexual risk-taking behaviours and associated negative health outcomes. Nonetheless, there is a lack of multi-countries studies exploring the relationship between timing of FSI and subsequent number of sexual partnerships. Our aim in this paper was to aggregate evidence from 34 sub-Saharan African countries to investigate the association between age at FSI and lifetime number of sexual partners, using Demographic and Health Survey data. Descriptive and multilevel mixed effects Poisson regression techniques were applied to the data. The findings reveal a significant association between age at FSI and subsequent number of lifetime sexual partners. This association remained post adjusting for education, wealth, marital status and residence for both men and women. Beyond these, the results showed that wealth worked in opposite direction in men and women—higher wealth status was protective for women while it exposed men to higher number of lifetime sexual partners. Higher education exposed both women and men to increased number of lifetime partnerships. We conclude that there is an association between delayed onset of sexual intercourse and number of sexual partners over time, regardless of gender and socio-demographic background. Sexual and reproductive health programmes calling for sexual partner reduction should focus more on age of sexual debut while factoring in the influence of the various socio-demographic dynamics.

Scaling up of integrated tuberculosis (TB)-human immunodeficiency virus (HIV) services remains sub-optimal in many resource-limited countries, including Ghana, where the two conditions take a heavy toll on the financial resources of health systems as well as infected persons. Previous studies have documented several implementation challenges towards TB-HIV service integration, but views of patients on integrated service delivery have not received commensurate research attention. This paper explored the experiences of 40 TB-HIV co-infected patients at different stages of treatment in Ghana. Using Normalisation Process Theory as a framework, data were coded using inter-rater coding technique and analysed inductively and deductively with the help of QSR NVivo 10. For several participants, either of the diseases was diagnosed 'accidentally', leading to inconsistencies in co-therapy administration, constraints regarding separate clinic appointment dates for TB and HIV and prolonged TB treatment due to treatment failure. Put differently, there were widespread negative experiences among TB-HIV co-infected patients with regard to treatment and care, especially among patients who were accessing care in separate facilities or separate units in the same facility. Co-infected patients unanimously support full-service integration. However, they felt powerless to request for reforms on a mode of service delivery.

Background Unmet need for contraception in several sub-Saharan African countries, including Ghana, remains high, with implications for unintended pregnancies and unsafe abortion, associated maternal morbidity and mortality. In this paper, we analysed for any associations between unmet/met need for contraception and the prevalence of abortion. Methods The paper utilizes the 2014 Ghana Demographic Health Survey dataset. Applying descriptive statistics initially, and later, a binary logistic regression, we estimate two different models, taking into account, unmet/met need for contraception (Model 1) and a multivariable one comprising socioeconomic, spatial, cultural and demographic behaviour variables (Model 2) to test the associations between unmet/met need for contraception in Ghana. Results One-fourth (25%) of sampled women in 2014 had ever had an abortion. The bivariate results showed that women who reported “no unmet” considerably tended to report abortion more than the reference category – not married and no sex in the last 30 days. The elevated odds among respondents who indicated “no unmet need” persisted even after controlling for all the relevant confounders. Relatedly, unlike women with an unmet need for spacing, women who desired to limit childbearing had a slightly higher tendency to report an abortion. Conclusion The linkage between unmet need for contraception appears more complex, particularly when the connections are explored post-abortion. Thus, while an abortion episode is most likely due to unintended pregnancy, contraception may still not be used, after an abortion, probably because of failure, side effects or simply, a dislike for any method.

Purpose Within human services, client satisfaction is highly prioritised and considered a mark of responsiveness in service delivery. A large body of research has examined the concept of satisfaction from the perspective of service users. However, not much is known about how service providers construct client satisfaction. The purpose of this paper is to throw light on healthcare professionals’ perspectives on patient satisfaction, using tuberculosis (TB) clinics as a case study. Design/methodology/approach In-depth interviews were conducted with 35 TB clinic supervisors purposively sampled from six out of the ten regions of Ghana. An unstructured interview guide was employed. The recorded IDIs were transcribed, edited and entered into QSR NVivo 10.0 and analysed inductively. Findings Respondents defined service satisfaction as involving education/counselling (on drugs, nature of condition, sputum production, caregivers and contacts of patients), patient follow-up, assignment of reliable treatment supporters as well as being attentive and receptive to patients, service availability (e.g. punctuality at work, availability of commodities), positive assurances about disease prognosis and respect for patients. Practical implications Complementing opinions of health service users with those of providers can offer key performance improvement areas for health managers. Originality/value To the best of the authors’ knowledge, this is a first study that has examined healthcare providers’ views on what makes their clients satisfied with the services they provide.

Body size issues are gaining public health attention because of the fast rising epidemic of overweight and obesity across the globe. This study explored Ghanaian women’s subjective perceptions regarding ideal body size for women. A purposive sampling strategy was employed in recruiting 36 women across the body weight spectrum from Tamale (n = 17) and Accra (n = 19) in Ghana. Qualitative data were obtained from in-depth interviews using a semi-structured interview guide. Data from the interviews were analyzed deductively. The mean body mass index of participants was 33.5 ± 10 kg/m2: sixteen of the participants were obese, eight were overweight, eleven were normal weight, and one was underweight. The participants almost unanimously had a preference for an ideal body size slightly above the normal, but not necessarily obese. Typically described as “not too skinny, but not too fat,” this preferred ideal reflected a fuller, curvier, and shapelier body, as opposed to the Western ideal of thinner body ty...

SummaryThis study aimed to contribute to the evidence on the timing of sexual debut in young people in sub-Saharan African countries. Data were extracted from 34 nationally representative surveys conducted in the region between 2006 and 2014. The study sample comprised unmarried women (n=167,932) and men (n=76,900) aged 15–24 years. Descriptive techniques and Cox proportional regression models were used to estimate the timing of sexual debut, and Kaplan–Meier hazard curves were used to describe the patterns of sexual debut in each country by sex. For the countries studied, sexual debut for both women and men occurred between the ages of 15 and 18 years, with median ages of 16 for women and 17 for men. Overall, education and household wealth provided significant protection against early sexual debut among women, but the reverse was found among men for wealth. Women in rural areas, in female-headed households and in Central, South and West Africa reported higher hazards of early commencement of sexual activity than their counterparts in urban, male-headed households and East Africa. However, the impact of these variables on male sexual debut did not follow a consistent pattern. Varied timing, as well as country-specific risk factors associated with sexual debut for young women and men across sub-Saharan Africa, were identified. Sexual health programmes and interventions for young people may require different approaches for young women and men.

This paper investigates antecedents to demand for household sanitation in Ghana. We employed a sequential, mixed-method approach, relying on the 2011 Ghana Multiple Indicator Cluster Survey (MICS) and primary qualitative data generated from individual and group interviews. The aim was to ascertain the role of household assets (measured by household wealth) in access to improved sanitation in Ghana. The study found that although wealth positively influenced household ownership of improved sanitation, the effect is strongly noticed only at the pinnacle of wealth quintiles (the richest households). From the qualitative data, we find that, beyond poverty, a mix of cultural, social, political and economic nuances influenced and somehow perpetuate low access to improved sanitation in Ghanaian households. We therefore surmise that means targeting of the poor and application of social marketing of sanitation in both rural and urban areas can help trigger awareness and demand for improved sanitation in Ghana.

Mothers are recommended to exclusively breastfeed their infants for the first six months of their lives. Also, after the sixth month, breastfeeding should continue with added complementary foods to the diets of children. Studies designed to sought the views of mothers on breastfeeding practices are limited. The aim of this study was to explore challenges to breastfeeding practices by considering spatial, societal and maternal characteristics in Ghana. Twenty mothers aged 15–49 years were interviewed purposively in selected communities within two regions of the country. Thematic content analytical procedures were applied to interpret and present findings. Challenges (to both exclusive breastfeeding and complementary feeding) spanned across spatial (home and work places), societal, and maternal characteristics. Key themes identified were in relation to household chores, work schedules, family influence, low breast milk production, swollen breasts or sore nipples, access to food items and preparation or giving foods. Addressing these challenges would require co-creation of supportive environments between couples and significant others as well as tackling institutional barriers that obstruct adequate breastfeeding among mothers. On complementary feeding, there is the need to form community health volunteers help educate mothers more on how to appropriately use local foods to feed their children.

The desired results of increasing access and availability of antenatal care (ANC) services may not be realized if the quality of care offered is not adequate. We analyzed the content/quality of antenatal care to determine whether there are socioeconomic (education and wealth) inequalities in the services provided in 59 low and middle income countries in six WHO regions-Africa, East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, Middle East and South Asia. We aggregated the most recent (2005-2015) Demographic and Health Survey for each country. The quality of content was measured on eight recommended ANC services-(1) monitoring of blood pressure; (2) tetanus injection; (3) urine analysis for protein; (4) blood test; (5) information about danger signs (6); weight (7); height measurements and (8) provision of iron-folate supplement. Descriptive and Poisson regression techniques were applied to analyse the data. We found considerable wealth and educational differences prior to controlling for known covariates. Between wealth and education, however, the disparities in the latter are larger than the former. Whereas the socioeconomic differences remained at post adjusting for residence, place and number of antenatal care, parity and region, the magnitude of change was minimal. Higher number of ANC content was provided in "other" forms of private facilities; the Latin America and Caribbean region recorded the highest number of content compared to the other regions. The hypothesized socioeconomic status on content/number of ANC services was generally supported, although the associations are substantially constrained to other variables. Efforts are made to increase the number and timing of ANC services; due recognition is needed for the content offered.