Effectiveness of two community-based strategies on disease knowledge and health behaviour regarding malaria, diarrhoea and pneumonia in Ghana.

BACKGROUND: Ghana has developed two community-based strategies that aim to increase access to quality treatment for malaria, diarrhoea and suspected pneumonia, and to improve household and family practices: integrated Community Case Management (iCCM) and Community-based Health Planning and Services (CHPS). The objective of the study was to assess the effectiveness of iCCM and CHPS on disease knowledge and health behaviour regarding malaria, diarrhoea and pneumonia. METHODS: A household survey was conducted two and eight years after implementation of iCCM in the Volta and Northern Regions of Ghana respectively, and more than ten years of CHPS implementation in both regions. The study population included 1356 carers of children under- five years of age who had fever, diarrhoea and/or cough in the two weeks prior to the interview. Disease knowledge was assessed based on the knowledge of causes and identification of signs of severe disease and its association with the sources of health education messages received. Health behaviour was assessed based on reported prompt care seeking behaviour, adherence to treatment regime, utilization of mosquito nets and having improved sanitation facilities, and its association with the sources of health education messages received. RESULTS: Health education messages from community-based agents (CBAs) in the Northern Region were associated with the identification of at least two signs of severe malaria (adjusted Odds Ratio (OR) 1.8, 95%CI 1.0, 3.3, p = 0.04), two practices that can cause diarrhoea (adjusted OR 4.7, 95%CI 1.4, 15.5, p = 0.02) 0and two signs of severe pneumonia (adjusted OR 7.7, 95%CI2.2, 26.5, p = 0.01)-the later also associated with prompt care seeking behaviour (p = 0.04). In the Volta Region, receiving messages on diarrhoea from CHPS was associated with the identification of at least two signs of severe diarrhoea (adjusted OR 3.6, 95%CI 1.4, 9.0), p = 0.02). iCCM was associated with prompt care seeking behaviour in the Volta Region and CHPS with prompt care seeking behaviour in the Northern Region (p < 0.5). CONCLUSIONS: Both iCCM and CHPS were associated with disease knowledge and health behaviour, but this was more pronounced for iCCM and in the Northern Region. HBC should continue to be considered as the strategy through which community-IMCI is implemented

Missed opportunities for tuberculosis investigation in a municipal hospital in Ghana: evidence from patient exit interviews.

BACKGROUND: We assessed coverage of symptom screening and sputum testing for tuberculosis (TB) in hospital outpatient clinics in Ghana. METHODS: In a cross-sectional study, we enrolled adults (≥18 years) exiting the clinics reporting ≥1 TB symptom (cough, fever, night sweats or weight loss). Participants reporting a cough ≥2 weeks or a cough of any duration plus ≥2 other TB symptoms (per national criteria) and those self-reporting HIV-positive status were asked to give sputum for testing with Xpert MTB/RIF. RESULTS: We enrolled 581 participants (median age 33 years [IQR: 24-48], 510/581 [87.8%] female). The most common symptoms were fever (348, 59.9%), chest pain (282, 48.5%) and cough (270, 46.5%). 386/581 participants (66.4%) reported symptoms to a healthcare worker, of which 157/386 (40.7%) were eligible for a sputum test per national criteria. Only 31/157 (19.7%) had a sputum test requested. Thirty-two additional participants gave sputum among 41 eligible based on positive HIV status. In multivariable analysis, symptom duration ≥2 weeks (adjusted odds ratio [aOR] 6.99, 95% confidence interval [CI] 2.08-23.51) and previous TB treatment (aOR: 6.25, 95% CI: 2.24-17.48) were the strongest predictors of having a sputum test requested. 6/189 (3.2%) sputum samples had a positive Xpert MTB/RIF result. CONCLUSION: Opportunities for early identification of people with TB are being missed in health facilities in Ghana

Barriers to tuberculosis case finding in primary and secondary health facilities in Ghana: perceptions, experiences and practices of healthcare workers.

BACKGROUND: Ghana's national tuberculosis (TB) prevalence survey conducted in 2013 showed higher than expected TB prevalence indicating that many people with TB were not being identified and treated. Responding to this, we assessed barriers to TB case finding from the perspective, experiences and practices of healthcare workers (HCWs) in rural and urban health facilities in the Volta region, Ghana. METHODS: We conducted structured clinic observations and in-depth interviews with 12 HCWs (including five trained in TB case detection) in four rural health facilities and a municipal hospital. Interview transcripts and clinic observation data were manually organised, triangulated and analysed into health system-related and HCW-related barriers. RESULTS: The key health system barriers identified included lack of TB diagnostic laboratories in rural health facilities and no standard referral system to the municipal hospital for further assessment and TB testing. In addition, missed opportunities for early diagnosis of TB were driven by suboptimal screening practices of HCWs whose application of the national standard operating procedures (SOP) for TB case detection was inconsistent. Further, infection prevention and control measures in health facilities were not implemented as recommended by the SOP. HCW-related barriers were mainly lack of training on case detection guidelines, fear of infection (exacerbated by lack of appropriate personal protective equipment [PPE]) and lack of motivation among HCWs for TB work. Solutions to these barriers suggested by HCWs included provision of at least one diagnostic facility in each sub-municipality, provision of transport subsidies to enable patients' travel for testing, training of newly-recruited staff on case detection guidelines, and provision of appropriate PPE. CONCLUSION: TB case finding was undermined by few diagnostic facilities; inconsistent referral mechanisms; poor implementation, training and quality control of a screening tool and guidelines; and HCWs fearing infection and not being motivated. We recommend training for and quality monitoring of TB diagnosis and treatment with a focus on patient-centred care, an effective sputum transport system, provision of the TB symptom screening tool and consistent referral pathways from peripheral health facilities

The coverage of continuum of care in maternal, newborn and child health: a cross-sectional study of woman-child pairs in Ghana.

INTRODUCTION: The continuum of care has recently received attention in maternal, newborn and child health. It can be an effective policy framework to ensure that every woman and child receives timely and appropriate services throughout the continuum. However, a commonly used measurement does not evaluate if a pair of woman and child complies with the continuum of care. This study assessed the continuum of care based on two measurements: continuous visits to health facilities (measurement 1) and receiving key components of services (measurement 2). It also explored individual-level and area-level factors associated with the continuum of care achievement and then investigated how the continuum of care differed across areas. METHODS: In this cross-sectional study in Ghana in 2013, the continuum of care achievement and other characteristics of 1401 pairs of randomly selected women and children were collected. Multilevel logistic regression was used to estimate the factors associated with the continuum of care and its divergence across 22 areas. RESULTS: Throughout the pregnancy, delivery and post-delivery stages, 7.9% of women and children achieved the continuum of care through continuous visits to health facilities (measurement 1). Meanwhile, 10.3% achieved the continuum of care by receiving all key components of maternal, newborn and child health services (measurement 2). Only 1.8% of them achieved it under both measurements. Women and children from wealthier households were more likely to achieve the continuum of care under both measurements. Women's education and complications were associated with higher continuum of care services-based achievement. Variance of a random intercept was larger in the continuum of care services-based model than the visit-based model. CONCLUSIONS: Most women and children failed to achieve the continuum of care in maternal, newborn and child health. Those who consistently visited health facilities did not necessarily receive key components of services

Social autopsy: INDEPTH Network experiences of utility, process, practices, and challenges in investigating causes and contributors to mortality

<p>Abstract</p> <p>Background</p> <p>Effective implementation of child survival interventions depends on improved understanding of cultural, social, and health system factors affecting utilization of health care. Never the less, no standardized instrument exists for collecting and interpreting information on how to avert death and improve the implementation of child survival interventions.</p> <p>Objective</p> <p>To describe the methodology, development, and first results of a standard social autopsy tool for the collection of information to understand common barriers to health care, risky behaviors, and missed opportunities for health intervention in deceased children under 5 years old.</p> <p>Methods</p> <p>Under the INDEPTH Network, a social autopsy working group was formed to reach consensus around a standard social autopsy tool for neonatal and child death. The details around 434 child deaths in Iganga/Mayuge Health and Demographic Surveillance Site (HDSS) in Uganda and 40 child deaths in Dodowa HDSS in Ghana were investigated over 12 to 18 months. Interviews with the caretakers of these children elicited information on what happened before death, including signs and symptoms, contact with health services, details on treatments, and details of doctors. These social autopsies were used to assess the contributions of delays in care seeking and case management to the childhood deaths.</p> <p>Results</p> <p>At least one severe symptom had been recognized prior to death in 96% of the children in Iganga/Mayuge HDSS and in 70% in Dodowa HDSS, yet 32% and 80% of children were first treated at home, respectively. Twenty percent of children in Iganga/Mayuge HDSS and 13% of children in Dodowa HDSS were never taken for care outside the home. In both countries most went to private providers. In Iganga/Mayuge HDSS the main delays were caused by inadequate case management by the health provider, while in Dodowa HDSS the main delays were in the home.</p> <p>Conclusion</p> <p>While delay at home was a main obstacle to prompt and appropriate treatment in Dodowa HDSS, there were severe challenges to prompt and adequate case management in the health system in both study sites in Ghana and Uganda. Meanwhile, caretaker awareness of danger signs needs to improve in both countries to promote early care seeking and to reduce the number of children needing referral. Social autopsy methods can improve this understanding, which can assist health planners to prioritize scarce resources appropriately.</p

Evaluation of Intussusception after Monovalent Rotavirus Vaccination in Africa.

Postlicensure evaluations have identified an association between rotavirus vaccination and intussusception in several high- and middle-income countries. We assessed the association between monovalent human rotavirus vaccine and intussusception in lower-income sub-Saharan African countries.Using active surveillance, we enrolled patients from seven countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) who had intussusception that met international (Brighton Collaboration level 1) criteria. Rotavirus vaccination status was confirmed by review of the vaccine card or clinic records. The risk of intussusception within 1 to 7 days and 8 to 21 days after vaccination among infants 28 to 245 days of age was assessed by means of the self-controlled case-series method.Data on 717 infants who had intussusception and confirmed vaccination status were analyzed. One case occurred in the 1 to 7 days after dose 1, and 6 cases occurred in the 8 to 21 days after dose 1. Five cases and 16 cases occurred in the 1 to 7 days and 8 to 21 days, respectively, after dose 2. The risk of intussusception in the 1 to 7 days after dose 1 was not higher than the background risk of intussusception (relative incidence [i.e., the incidence during the risk window vs. all other times], 0.25; 95% confidence interval [CI], <0.001 to 1.16); findings were similar for the 1 to 7 days after dose 2 (relative incidence, 0.76; 95% CI, 0.16 to 1.87). In addition, the risk of intussusception in the 8 to 21 days or 1 to 21 days after either dose was not found to be higher than the background risk.The risk of intussusception after administration of monovalent human rotavirus vaccine was not higher than the background risk of intussusception in seven lower-income sub-Saharan African countries. (Funded by the GAVI Alliance through the CDC Foundation.)

Using routine healthcare data to determine the factors associated with hospital length of stay for hypertensive inpatients in Ghana, 2012–2017

Objective Hospitalisation for hypertension continues to rise in Ghana. It has been revealed that in Ghana, patients hospitalised for hypertension spend between 1 and 91 days on admission. This study therefore sought to estimate the hospital length of stay (LoS) of hypertensive patients and individual or health-related factors that may influence the hospitalisation duration in Ghana.Methods We employed a retrospective study design that used routinely collected health data on hospitalised hypertensive patients in Ghana from the District Health Information Management System database between 2012 and 2017 to model LoS using survival analysis. The cumulative incidence function for discharge stratified by sex was computed. To investigate the factors that influence hospitalisation duration, multivariable Cox regression was used.Results Out of a total of 106 372 hypertension admissions, about 72 581 (68.2%) were women. The mean age of the patients was 55.3 (SD=17.5) years. Overall, the median LoS was 3 days with almost 90% of all patients being discharged by the 10th day of admission. Patients admitted in Volta region (HR: 0.89, p&lt;0.001) and Eastern region (HR: 0.96, p=0.002) experienced late discharge as compared with patients admitted in Greater Accra. It was revealed that women (HR: 1.09, p&lt;0.001) were discharged earlier than men. However, having a surgical procedure (HR: 1.07, p&lt;0.001) and having comorbidities such as diabetes (HR: 0.76, p&lt;0.001) and cardiovascular diseases other than hypertension (HR: 0.77, p&lt;0.001) increased the LoS of patients.Conclusion This study provides the first comprehensive assessment of factors influencing hospitalisation duration of admissions due to hypertension in Ghana. Female sex, all regions except Volta region and Eastern region, experienced early discharge. However, patients with a surgical intervention and comorbidity experienced late discharge

Data for "Where are patients missed in the tuberculosis diagnostic cascade? A prospective cohort study in Ghana"

Dataset produced as part of a study to identify gaps in the tuberculosis (TB) diagnostic cascade prior to starting treatment conducted in urban and rural health facilities in south-east Ghana among presumptive TB patients routinely identified by a health worker as requiring a sputum TB test. The dataset contains 428 records with 30 variables. Each row refers to a study participant and contains variables of the type of health facility attended, age, educational level, place of residence, socioeconomic status, symptoms of TB (cough, fever, night sweat and weight loss), duration of symptoms, number of symptoms, HIV status, history of diabetes, body mass index, Karnofsky score, ever treated for TB, stigma and distance from residence to health facility. There are also variables on whether a sputum sample was submitted for the test, results received, test results, started TB treatment, duration from test request to sputum submission, reason for not submitting a sputum sample, number of health care providers visited included for each participant