Risk factors and causes of adult deaths in the Ifakara health and demographic surveillance system population, 2003-2007

MSc (Med), Population-Based Field Epidemiology, School of Public Health, Faculty of health Sciences, University of the WitwatersrandIntroduction: The achievements of the United Nations’ millennium development goals (MDGs) are not possible in isolation. Adult health and mortality with the exception of maternal health is one of the health issues that were openly missing among the list of MDGs. But eradicating extreme poverty and hunger would not be possible if the economically active population is not supported to be healthy and to live longer. Little has been done on adult health, especially to reduce mortality as compared to child health. Adult mortality is expected to equal or exceed child mortality in sub-Saharan Africa if nothing is done. There are varying factors associated with specific-causes of adult deaths within and among different settings. Obtaining more and better data on adult deaths and understanding issues relating to adult deaths in Africa are crucial for long life and development. Objectives: The study seeks to (i) describe causes of adult mortality, (ii) estimate adult cause-specific mortality rates and trends and (iii) identify risk factors of cause-specific mortality in the Ifakara Health and Demographic Surveillance System (IHDSS) population from 2003 – 2007 among adults aged 15 – 59 years. Methodology: The data for the study was extracted from the database of the Ifakara Health and Demographic Surveillance System (IHDSS) in Tanzania from 2003-2007. It was an open cohort study. The cohort was selected based on age (15-59years) and active residency from 1st January 2003 to 31st December 2007. Survival estimates were computed using Kaplan-Meier survival technique and adult mortality rates were estimated expressed per 1000 person years observed (PYO). Verbal autopsy method was used to ascertain causes of deaths. Cox proportional hazards method was used to identify socio-demographic factors associated with specific-causes of adult deaths. v Findings: A total 65,548 adults were identified and followed up, yielding a total of 184,000 person years. A total of 1,352 deaths occurred during the follow-up. The crude adult mortality rate (AMR) estimated over the period was 7.3/1000PYO. There was an insignificant steady increase in annual AMR over the period. The AMR in 2007 increased by 11% over year 2003. Most people died from HIV/AIDS (20.4%) followed by Malaria (13.2%). The AMR for the period was 2.49 per 1000PYO for communicable disease (CD) causes, 1.21 per 1000PYO for non communicable disease (NCD) causes and 0.53 per 1000PYO for causes related to accidents/injuries. Over the study period, deaths resulting from NCDs increased significantly by 50%. The proportion of deaths due to NCDs in 2003 was 16% increasing to 24% in year 2007. Adult deaths from Accidents/Injuries were significantly higher among men (hazard ratio (HR) = 2.2) after adjusting for socioeconomic status (SES), level of education and household size. For communicable and NCDs, most people died at home while for Accidents/Injuries most people died elsewhere (neither home nor health facility). The risk factors that were found to be associated with adult deaths due to NCDs were age and level of education. An improvement in level of education saw a reduction in the risk of dying from NCDs ((HR(Primary)=0.67, 95%CI:0.49, 0.92) and (HR(beyond Primary)=0.11, 95%CI:0.02, 0.40) after adjusting for age and sex. Age, SES and “entry type” were the factors found to be associated with dying from communicable diseases among the adults. In-migrants were 1.7 times more likely to die from communicable disease causes than residents having adjusted for age, household size, educational level, employment status of the head of household and SES. Conclusion: HIV/AIDS is the leading cause of adult deaths in IHDSS area followed by malaria. Most adult deaths occurred outside health facility in rural areas. This could probably be explained by the health seeking behavior and or health care accessibility in vi the rural area of sub-Saharan Africa. NCDs are increasing as a result of demographic and epidemiological transitions taking place in most African countries including Tanzania. Without preventions the rural community in Tanzania will soon face increased triple disease burden; (CD), NCD and Accident/Injuries. Policies on accident/injury preventions in developing countries will be effective if based on local evidence and research

Factors influencing choice of care-seeking for acute fever comparing private chemical shops with health centres and hospitals in Ghana: a study using case-control methodology.

BACKGROUND: Several public health interventions to improve management of patients with fever are largely focused on the public sector yet a high proportion of patients seek care outside the formal healthcare sector. Few studies have provided information on the determinants of utilization of the private sector as against formal public sector. Understanding the differences between those who attend public and private health institutions, and their pathway to care, has significant practical implications. The chemical shop is an important source of care for acute fever in Ghana. METHODS: Case-control methodology was used to identify factors associated with seeking care for fever in the Dangme West District, Ghana. People presenting to health centres, or hospital outpatients, with a history or current fever were compared to counterparts from the same community with fever visiting a chemical shop. RESULTS: Of 600 patients, 150 each, were recruited from the district hospital and two health centres, respectively, and 300 controls from 51 chemical shops. Overall, 103 (17.2 %) patients tested slide positive for malaria. Specifically, 13.7 % (41/300) of chemical shop patients, 30.7 % (46/150) health centre and 10.7 % (16/150) hospital patients were slide positive. While it was the first option for care for 92.7 % (278/300) chemical shop patients, 42.7 % (64/150) of health centre patients first sought care from a chemical shop. More health centre patients (61.3 %; 92/150) presented with fever after more than 3 days than chemical shop patients (27.7 %; 83/300) [AOR = 0.19; p < 0.001 CI 0.11-0.30]. Although the hospital was the first option for 83.3 % (125/150) of hospital patients, most (63.3 %; 95/150) patients arrived there over 3 days after their symptoms begun. Proximity was significantly associated with utilization of each source of care. Education, but not other socioeconomic or demographic factors were significantly associated with chemical shop use. CONCLUSIONS: The private drug retail sector is the first option for the majority of patients, including poorer patients, with fever in this setting. Most patients with fever arrive at chemical shops with less delay and fewer signs of severity than at public health facilities. Improving chemical shop skills is a good opportunity to diagnose, treat or refer people with fever early

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

Rapid testing for malaria in settings where microscopy is available and peripheral clinics where only presumptive treatment is available: a randomised controlled trial in Ghana

Objective To test in West Africa the impact of rapid diagnostic tests on the prescription of antimalarials and antibiotics both where microscopy is used for the diagnosis of malaria and in clinical (peripheral) settings that rely on clinical diagnosis

Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial

Evelyn Ansah and colleagues report on whether removing user fees has an impact on health care-seeking behavior and health outcomes in households with children in Ghana

The global burden of cancer attributable to risk factors, 2010-19 : a systematic analysis for the Global Burden of Disease Study 2019

Background Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally. Methods The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented. Findings Globally, in 2019, the risk factors included in this analysis accounted for 4.45 million (95% uncertainty interval 4.01-4.94) deaths and 105 million (95.0-116) DALYs for both sexes combined, representing 44.4% (41.3-48.4) of all cancer deaths and 42.0% (39.1-45.6) of all DALYs. There were 2.88 million (2.60-3.18) risk-attributable cancer deaths in males (50.6% [47.8-54.1] of all male cancer deaths) and 1.58 million (1.36-1.84) risk-attributable cancer deaths in females (36.3% [32.5-41.3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20.4% (12.6-28.4) and DALYs by 16.8% (8.8-25.0), with the greatest percentage increase in metabolic risks (34.7% [27.9-42.8] and 33.3% [25.8-42.0]). Interpretation The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.Peer reviewe

Factors influencing the implementation of TB screening among PLHIV in selected HIV clinics in Ghana: a qualitative study

Abstract Background Decreasing the burden of Tuberculosis (TB) among PLHIV through TB screening is an effective intervention recommended by the World Health Organization (WHO). However, after over a decade of implementation in Ghana, the intervention does not realize the expected outcomes. It is also not well understood whether this lack of success is due to implementation barriers. Our study, therefore, sought to examine the factors influencing the implementation of the intervention among people living with HIV (PLHIV) attending HIV clinics at district hospitals in Ghana. Methods This was a qualitative study conducted from 6th to 31 May 2019 in three regions of Ghana. We conducted 17 in-depth interviews (IDIs – comprising two regional, six districts and nine facility TB/HIV coordinators) and eight focus group discussions (FGD – consisting of a total of 65 participants) with HIV care providers. The Consolidated Framework for Implementation Research (CFIR) guided the design of interview guides, data collection and analysis. All responses were digitally audio-recorded and transcribed verbatim for coding and analysis using the Framework Approach. Participants consented to the interview and recording. Results The main barriers to TB screening relate to the low commitment of the implementers to screen for TB and limited facility infrastructure for the screening activities. Facilitators of TB screening include (1) ease in TB screening, (2) good communication and referral channels, (3) effective goals and feedback mechanisms, (4) health workers recognizing the need for the intervention and (5) the role of chemical sellers. Conclusions Key barriers and facilitators to the intervention are revealed. The study has shown that there is a need to increase HIV care providers and institutional commitment towards TB screening interventions. In addition, cost issues need to be assessed as they are drivers of sustainability. Our study also advances the field of implementation science through CFIR to better understand the factors influencing the implementation