Making districts functional for universal health coverage attainment: lessons from Ghana

Ensuring the sub national level in the health system can function effectively is central to attainment of health results in countries. However, the current health agenda has not prioritized how districts can deploy their existing resources effectively, to maximize the efficiency equity and effectiveness in their use. Ghana initiated a self-assessment process to understand the functionality of districts to deliver on health results. The assessment was conducted by health managers in 33 districts during August-October 2022 using tools pre-developed by the World Health Organization. Functionality was explored around service provision, oversight, and management capacities, each with defined dimensions and attributes. The objective of the study was to highlight specific functionality improvements needed by districts in terms of investments and access to service delivery in achieving Universal Health Care. The results showed a lack of correlation between functionality and performance as is currently defined in Ghana; a higher functionality of oversight capacity compared to service provision or management capacities; and specifically low functionality for dimensions relating to capacity to make available quality services, responsiveness to beneficiaries and the systems and three structures for health management. The findings highlight the need to shift from quantitative outcome indicator-based performance approaches to measures of total health and wellbeing of beneficiaries. Specific functionality improvements are needed to improve the engagement and answerability to the beneficiaries, investments in access to services, and in building management architecture.

Impact of community health interventions on maternal and child health indicators in the upper east region of Ghana

BACKGROUND

This paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training.

METHODS

A mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus-post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process.

RESULTS

After intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI).

CONCLUSIONS

A pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance.

Effects of the COVID-19 pandemic on essential health and nutrition service utilisations in Ghana: interrupted time-series analyses from 2016 to 2020

OBJECTIVES

This study aimed to assess the national-level and subnational-level effects of the COVID-19 pandemic on essential health and nutrition service utilisation in Ghana.

DESIGN

Interrupted time-series.

SETTING AND PARTICIPANTS

This study used facility-level data of 7950 governmental and non-governmental health facilities in Ghana between January 2016 and November 2020.

OUTCOME MEASURES

As the essential health and nutrition services, we selected antenatal care (ANC); institutional births, postnatal care (PNC); first and third pentavalent vaccination; measles vaccination; vitamin A supplementations (VAS); and general outpatient care. We performed segmented mixed effects linear models for each service with consideration for data clustering, seasonality and autocorrelation. Losses of patient visits for essential health and nutrition services due to the COVID-19 pandemic were estimated as outcome measures.

RESULTS

In April 2020, as an immediate effect of the COVID-19 pandemic, the number of patients for all the services decreased except first pentavalent vaccine. While some services (ie, institutional birth, PNC, third pentavalent and measles vaccination) recovered by November 2020, ANC, VAS and outpatient services had not recovered to prepandemic levels. The total number of lost outpatient visits in Ghana was estimated to be 3 480 292 (95% CI: -3 510 820 to -3 449 676), followed by VAS (-180 419, 95% CI: -182 658 to -177 956) and ANC (-87 481, 95% CI: -93 644 to -81 063). The Greater Accra region was the most affected region by COVID-19, where four out of eight essential services were significantly disrupted.

CONCLUSION

COVID-19 pandemic disrupted the majority of essential healthcare services in Ghana, three of which had not recovered to prepandemic levels by November 2020. Millions of outpatient visits and essential ANC visits were lost. Furthermore, the immediate and long-term impacts of the COVID-19 pandemic on service utilisation varied by service type and region.

Non-HDL-C and LDL-C/HDL-C are associated with self-reported cardiovascular disease in a rural West African population: Analysis of an array of lipid metrics in an AWI-Gen sub-study

Few studies have compared the utility of serum levels of lipid fractions in cardiovascular disease (CVD) risk assessment in sub-Saharan Africa (SSA). The current study interrogated this question among men and women aged 40-60 years in rural northern Ghana. This was a cross-sectional study in which data was collected on socio-demography, behaviour, health history, anthropometry and lipid levels. Adjusted multivariable logistic regression models were used to assess the association of various lipid metrics with CVD. All tests were considered statistically significant at P<0.05. Data were available for 1839 participants. The prevalence of self-reported CVD was 1.6% (n = 29). Non-HDL-C (median (interquartile range): 2.4 (1.9-3.0) vs 2.0 (1.6-2.5) mmol/L; P = 0.009), LDL-C/HDL-C (1.8 (1.4-2.4) vs 1.5 (1.1-2.6); P = 0.019) and TC/HDL-C (3.3 (2.9-3.9) vs 2.9 (2.4-3.5); P = 0.003) were all significantly higher in participants with self-reported CVD compared to those without. However, after adjusting for socioeconomic status (SES) and meals from vendors in a logistic regression model, only non-HDL-C (odds ratio [95% CIs]): (1.58 [1.05, 2.39]), P = 0.029 and LDL-C/HDL-C levels (odds ratio [95% CIs]): (1.26 [1.00, 1.59]), P = 0.045 remained significantly associated with self-reported CVD. While our findings suggest non-HDL-C and LDL-C/HDL-C measures may be appropriate biomarkers for assessing CVD risk in this population, further studies using established clinical endpoints are required to validate these findings in sub-Saharan Africans.

Engaging community members in setting priorities for nutrition interventions in rural northern Ghana

This study used "Choosing All Together" (CHAT), a deliberative engagement tool to prioritise nutrition interventions and to understand reasons for intervention choices of a rural community in northern Ghana. The study took an exploratory cross-sectional design and used a mixed method approach to collect data between December 2020 and February 2021. Eleven nutrition interventions were identified through policy reviews, interaction with different stakeholders and focus group discussions with community members. These interventions were costed for a modified CHAT tool-a board-like game with interventions represented by colour coded pies and the cost of the interventions represented by sticker holes. Supported by trained facilitators, six community groups used the tool to prioritise interventions. Discussions were audio-recoded, transcribed and thematically analysed. The participants prioritised both nutrition-sensitive and nutrition-specific interventions, reflecting the extent of poverty in the study districts and the direct and immediate benefits derived from nutrition-specific interventions. The prioritised interventions involved livelihood empowerment, because they would create an enabling environment for all-year-round agricultural output, leading to improved food security and income for farmers. Another nutrition-sensitive, education-related priority intervention was male involvement in food and nutrition practices; as heads of household and main decision makers, men were believed to be in a position to optimise maternal and child nutrition. The prioritised nutrition-specific intervention was micronutrient supplementation. Despite low literacy, participants were able to use CHAT materials and work collectively to prioritize interventions. In conclusion, it is feasible to modify and use the CHAT tool in public deliberations to prioritize nutrition interventions in rural settings with low levels of literacy. These communities prioritised both nutrition-sensitive and nutrition-specific interventions. Attending to community derived nutrition priorities may improve the relevance and effectiveness of nutrition health policy, since these priorities reflect the context in which such policy is implemented.

Community perspectives on maternal and child health during nutrition and economic transition in sub-Saharan Africa

OBJECTIVE

To explore community perceptions on maternal and child nutrition issues in Sub-Saharan Africa.

DESIGN

Thirty focus groups with men and women from three communities facilitated by local researchers.

SETTING

One urban (Soweto, South Africa) and two rural settings (Navrongo, Ghana and Nanoro, Burkina Faso) at different stages of economic transition.

PARTICIPANTS

Two hundred thirty-seven men and women aged 18-55 years, mostly subsistence farmers in Navrongo and Nanoro and low income in Soweto.

RESULTS

Differences in community concerns about maternal and child health and nutrition reflected the transitional stage of the country. Community priorities revolved around poor nutrition and hunger caused by poverty, lack of economic opportunity and traditional gender roles. Men and women felt they had limited control over food and other resources. Women wanted men to take more responsibility for domestic chores, including food provision, while men wanted more involvement in their families but felt unable to provide for them. Solutions suggested focusing on ways of increasing control over economic production, family life and domestic food supplies. Rural communities sought agricultural support, while the urban community wanted regulation of the food environment.

CONCLUSIONS

To be acceptable and effective, interventions to improve maternal and child nutrition need to take account of communities' perceptions of their needs and address wider determinants of nutritional status and differences in access to food reflecting the stage of the country's economic transition. Findings suggest that education and knowledge are necessary but not sufficient to support improvements in women's and children's nutritional status.

Culture and community perceptions on diet for maternal and child health: a qualitative study in rural northern Ghana

Background

This study explored cultural and community perceptions of optimal diet for maternal and child health in northern Ghana.

Methods

This was an exploratory cross-sectional study using qualitative methods for data collection. Data were collected between March and April 2019 consisting of 10 focus group discussions with men and women community members between 18 and 50 years in the Kassena-Nankana districts of Ghana. Data were organised using QSR NVivo 12 qualitative software to facilitate thematic analysis.

Results

All study participants recognised the importance of an optimal diet for mother, child and better pregnancy and breastfeeding outcomes. However, there were different cultural beliefs and taboos about what foods are healthy and non-healthy for women at different stages of the reproductive period. Foods perceived to be unhealthy for pregnant women were fatty foods and fresh meat (uncooked or unprocessed meat) due to the belief that they can lead to delivery complications, which many women feared. In addition, some participants relayed the cultural belief that pregnant woman should not eat eggs because it would make the child a thief. Lactating mothers are not to eat foods such as vigna subterranean known locally as bambara bean and “gari” (local meal made from cassava) because it is believed to inhibit breastmilk production. Participants emphasised that food insecurity and economic constraints meant women could not achieve optimal diet and could not afford to be selective in food choices.

Conclusion

Community members recognized the importance of optimal nutrition but were constrained by poverty and cultural barriers. A dual approach which targets improvements of local food production and economic empowerment in combination with community-based discussion and education of the impacts of food taboos on health, should facilitate improvement in the diets of women and future generations.

Prevalence and socio-demographic correlates of tobacco and alcohol use in four sub-Saharan African countries: a cross-sectional study of middle-aged adults

BACKGROUND

Substance misuse is a global public health problem. In addition to social and economic concerns, consumption of tobacco and alcohol is associated with susceptibility to cardiovascular, respiratory, and infectious diseases, cancers, and risk of transition to substance use disorders. African data suggest regional differences in the prevalence and patterns of substance use, but a number of key questions remain. This cross-sectional population-based study of middle-aged adults aims to examine prevalence and socio-demographic correlates of substance use in four sub-Saharan African countries, in rural and urban settings.

METHODS

Participants aged between 40 and 60 years were recruited from six research centres as part of the Africa Wits-INDEPTH partnership for Genomic Research study. Data on patterns of tobacco and alcohol consumption was captured, and the latter further assessed using the CAGE (cut-annoyed-guilty-eye) questionnaire.

RESULTS

Data from 10,703 participants suggested that more men (68.4%) than women (33.3%) were current substance users. The prevalence of current smoking was significantly higher in men than in women (34.5% vs 2.1%, p < 0.001). Smokeless tobacco was used more by women than men (14.4% vs 5.3%, p < 0.001). Current smoking was associated with alcohol consumption in men, and smoking cessation in men was associated with being a former drinker, having higher socio-economic status, and if married or cohabiting. Current alcohol consumption was higher in men, compared to women (60.3% vs 29.3%), and highest in men from Soweto (70.8%) and women from Nanoro (59.8%). The overall prevalence of problematic alcohol consumption among men was 18.9%, and women 7.3%. Men were significantly more likely to develop problematic drinking patterns, and this was more common in those who were divorced or widowed, and in current smokers.

CONCLUSIONS

Regional variation in the patterns and prevalence of substance use was observed across study sites, and in rural and urban settings. The high levels of substance use recorded in this study are of concern due to the increased risk of associated morbidities. Further longitudinal data will be valuable in determining trends in substance misuse in Africa.

Assessing selection procedures and roles of Community Health Volunteers and Community Health Management Committees in Ghana's Community-based Health Planning and Services program

Background

Community participation in health care delivery will ensure service availability and accessibility and guarantee community ownership of the program. Community-based strategies such as the involvement of Community Health Volunteers (CHVs) and Community Health Management Committees (CHMCs) are likely to advance primary healthcare in general, but the criteria for selecting CHVs, CHMCs and efforts to sustain these roles are not clear 20 years after implementing the Community-based Health Planning Services program. We examined the process of selecting these cadres of community health workers and their current role within Ghana’s flagship program for primary care–the Community-based Health Planning and Services program.

Methods

This was an exploratory study design using qualitative methods to appraise the health system and stakeholder participation in Community-based Health Planning and Services program implementation in the Upper East region of Ghana. We conducted 51 in-depth interviews and 33 focus group discussions with health professionals and community members.

Results

Community Health Volunteers and Community Health Management Committees are the representatives of the community in the routine implementation of the Community-based Health Planning and Services program. They are selected, appointed, or nominated by their communities. Some inherit the position through apprenticeship and others are recruited through advertisement. The selection is mostly initiated by the health providers and carried out by community members. Community Health Volunteers lead community mobilization efforts, support health providers in health promotion activities, manage minor illnesses, and encourage pregnant women to use maternal health services. Community Health Volunteers also translate health messages delivered by health providers to the people in their local languages. Community Health Management Committees mobilize resources for the development of Community-based Health Planning and Services program compounds. They play a mediatory role between health providers in the health compounds and the community members. Volunteers are sometimes given non-financial incentives but there are suggestions to include financial incentives.

Conclusion

Community Health Volunteers and Community Health Management Committees play a critical role in primary health care. The criteria for selecting Community Health Volunteers and Community Health Management Committees vary but need to be standardized to ensure that only self-motivated individuals are selected. Thus, CHVs and CHMCs should contest for their positions and be endorsed by their community members and assigned roles by health professionals in the CHPS zones. Efforts to sustain them within the health system should include the provision of financial incentives.

Community engagement and feedback of results in the H3Africa AWI-Gen project: Experiences from the Navrongo Demographic and Health Surveillance site in Northern Ghana

Community and Public engagement (CE) have gained traction as an ethical best practice for the conduct of genomics research, particularly in the context of Africa. In the past 10 years, there has been growing scholarship on the value and practice of engaging key stakeholders including communities involved in genomics research. However, not much has been documented on how research teams, particularly in international collaborative research projects, are navigating the complex process of engagement including the return of key research findings. This paper is part of a series of papers describing the CE processes used in the AWI-Gen study sites. We describe the key processes of engagement, challenges encountered and the major lessons learned. We pay particular attention to the experiences in returning research results to participants and communities within the Demographic and Health Surveillance site in northern Ghana.

Candidate Gene Analysis Reveals Strong Association of CETP Variants With High Density Lipoprotein Cholesterol and PCSK9 Variants With Low Density Lipoprotein Cholesterol in Ghanaian Adults: An AWI-Gen Sub-Study

Variations in lipid levels are attributed partly to genetic factors. Genome-wide association studies (GWASs) mainly performed in European, African American and Asian cohorts have identified variants associated with LDL-C, HDL-C, total cholesterol (TC) and triglycerides (TG), but few studies have been performed in sub-Saharan Africans. This study evaluated the effect of single nucleotide variants (SNVs) in eight candidate loci (ABCA1, LCAT, LPL, PON1, CETP, PCSK9, MVK, and MMAB) on lipid levels among 1855 Ghanaian adults. All lipid levels were measured directly using an automated analyser. DNA was extracted and genotyped using the H3Africa SNV array. Linear regression models were used to test the association between SNVs and log-transformed lipid levels, adjusting for sex, age and waist circumference. In addition Bonferroni correction was performed to account for multiple testing. Several variants of CETP, LCAT, PCSK9, and PON1 (MAF > 0.05) were associated with HDL-C, LDL-C and TC levels at p < 0.05. The lead variants for association with HDL-C were rs17231520 in CETP (β = 0.139, p < 0.0001) and rs1109166 in LCAT (β = −0.044, p = 0.028). Lower LDL-C levels were associated with an intronic variant in PCSK9 (rs11806638 [β = −0.055, p = 0.027]) and increased TC was associated with a variant in PON1 (rs854558 [β = 0.040, p = 0.020]). In silico functional analyses indicated that these variants likely influence gene function through their effect on gene transcription. We replicated a strong association between CETP variants and HDL-C and between PCSK9 variant and LDL-C in West Africans, with two potentially functional variants and identified three novel variants in linkage disequilibrium in PON1 which were associated with increasing TC levels in Ghanaians.

Classical Cardiovascular Risk Factors and HIV are Associated With Carotid Intima-Media Thickness in Adults From Sub-Saharan Africa: Findings From H3Africa AWI-Gen Study

Background Studies on the determinants of carotid intima-media thickness ( CIMT ), a marker of sub-clinical atherosclerosis, mostly come from white, Asian, and diasporan black populations. We present CIMT data from sub-Saharan Africa, which is experiencing a rising burden of cardiovascular diseases and infectious diseases. Methods and Results The H3 (Human Hereditary and Health) in Africa's AWI-Gen (African-Wits-INDEPTH partnership for Genomic) study is a cross-sectional study conducted in adults aged 40 to 60 years from Burkina Faso, Kenya, Ghana, and South Africa. Cardiovascular disease risk and ultrasonography of the CIMT of right and left common carotids were measured. Multivariable linear and mixed-effect multilevel regression modeling was applied to determine factors related to CIMT. Data included 8872 adults (50.8% men), mean age of 50±6 years with age- and sex-adjusted mean (±SE) CIMT of 640±123μm. Participants from Ghana and Burkina Faso had higher CIMT compared with other sites. Age (β = 6.77, 95%CI [6.34-7.19]), body mass index (17.6[12.5-22.8]), systolic blood pressure (7.52[6.21-8.83]), low-density lipoprotein cholesterol (5.08[2.10-8.06]) and men (10.3[4.75- 15.9]) were associated with higher CIMT. Smoking was associated with higher CIMT in men. High-density lipoprotein cholesterol (-12.2 [-17.9- -6.41]), alcohol consumption (-13.5 [-19.1--7.91]) and HIV (-8.86 [-15.7--2.03]) were inversely associated with CIMT. Conclusions Given the rising prevalence of cardiovascular diseases risk factors in sub-Saharan Africa, atherosclerotic diseases may become a major pan-African epidemic unless preventive measures are taken particularly for prevention of hypertension, obesity, and smoking. HIV -specific studies are needed to fully understand the association between HIV and CIMT in sub-Saharan Africa.

Persistent female genital mutilation despite its illegality: Narratives from women and men in northern Ghana

BACKGROUND

Globally, an estimated two million women have undergone Female Genital Mutilation (FGM), and approximately four percent of women who have been circumcised live in Ghana. In the Bawku Municipality and Pusiga District, sixty one percent of women have undergone the procedure. This study therefore aimed at identifying the factors that sustain the practice of FGM despite its illegality, in the Bawku Municipality and the Pusiga District.

METHOD

This study used a descriptive qualitative design based on grounded theory. We used purposive sampling to identify and recruit community stakeholders, and then used the snowball sampling to identify, recruit, and interview circumcised women. We then used community stakeholders to identify two types of focus group participants: men and women of reproductive age and older men and women from the community. In-depth interviews and focus group discussions were conducted and qualitative analysis undertaken to develop a conceptual framework for understanding both the roots and the drivers of FGM.

RESULTS

Historical traditions and religious rites preserve FGM and ensure its continuity, and older women and peers are a source of support for the practice through the pressure they exert. The easy movement of women across borders (to where FGM is still practice) helps to perpetuate the practice, as does the belief that FGM will preserve virginity and reduce promiscuity. In addition, male dominance and lack of female autonomy ensures continuation of the practice.

CONCLUSION

Female Genital Mutilation continues to persist despite its illegality because of social pressure on women/girls to conform to social norms, peer acceptance, fear of criticism and religious reasons. Implementing interventions targeting border towns, religious leaders and their followers, older men and women and younger men and women will help eradicate the practice.

Is the decline in neonatal mortality in northern Ghana, 1996-2012, associated with the decline in the age of BCG vaccination? An ecological study

OBJECTIVE

To examine the association between early Bacille Calmette-Guerin (BCG) vaccination and neonatal mortality in northern Ghana.

METHODS

This ecological study used vaccination and mortality data from the Navrongo Health and Demographic Surveillance System. First, we assessed and compared changes in neonatal mortality rates (NMRs) and median BCG vaccination age from 1996 to 2012. Second, we compared the changes in NMR and median BCG vaccination age from 2002 to 2012 by delivery place when data on delivery place were available.

RESULTS

Neonatal mortality rates declined from 46 to 12 per 1000 live births between 1996 and 2012 (trend test: p<0.001). Within the same period, median BCG vaccination age declined from 46 to 4 days (trend test: p<0.001). Among home deliveries, BCG vaccination age declined from 39 days in 2002 to 7 days in 2012 (trend test: p<0.001) and neonatal mortality declined by 24/1000 (trend test: p<0.001). Among health facility deliveries, BCG vaccination age was stable around 3 days from 2002 to 2012 (trend test: p=0.49) and neonatal mortality declined by 9/1000 (trend test: p=0.04). In a small study of children whose vaccination cards were inspected within the first 28 days of life, the HR for BCG-vaccinated compared with BCG-unvaccinated children was 0.55 (95% CI 0.12 to 2.40).

CONCLUSION

The data support the hypothesis that early BCG vaccination may be associated with a decrease in neonatal mortality. However, as suggested by WHO, randomised control trials are required to address the question of whether there is indeed a causal association between early BCG vaccination and neonatal mortality.

The burden of dyslipidaemia and factors associated with lipid levels among adults in rural northern Ghana: An AWI-Gen sub-study

Dyslipidaemia is a primary risk factor for cardiometabolic disease, causing over 17 million deaths globally in 2015. However, the burden of dyslipidaemia and factors associated with lipid levels remain unknown in many rural African populations. Therefore, this study evaluated the association of socio-demographic, anthropometric and behavioural factors with lipid levels in rural Ghana. The prevalence of hypercholesterolaemia, hypertriglyceridaemia and elevated LDL-C in the total population of 1839 (846 men and 993 women) was 4.02%, 2.12%, and 5.55% respectively and did not differ between genders. The prevalence of low HDL-C levels was 60.30% and differed (p = 0.005) between men (56.86%) and women (63.24%). Subcutaneous abdominal fat was associated with TC (β = 0.067, p = 0.015) and TG (β = 0.137, p<0.001) among women and LDL-C (β = 0.139, p = 0.006) and TC (β = 0.071, p = 0.048) among men. Body mass index was associated with TC (β = 0.010, p = 0.043) among men while waist circumference was associated with LDL-C (β = 0.116, p<0.001) and TG (β = 0.094, p<0.001) among women. Hip circumference was negatively associated (β = -0.053, p = 0.043) while visceral fat was positively associated with TG (β = 0.033, p = 0.022) among women. Socioeconomic status, education, being unmarried and employment were associated with HDL-C (β = 0.081, p = 0.004), LDL-C (β = 0.095, p = 0.004) and TG (β = 0.095, p = 0.001) all among women, and TC (β = 0.070, p = 0.010) among men, respectively. Nankana women had lower TC (β = -0.069, p = 0.001), and men lower TG levels (β = -0.084, p = 0.008) than the other ethnic groups. Tobacco smoking (β = 0.066, p = 0.024) and alcohol intake (β = 0.084, p = 0.001) were associated with HDL-C levels among men and women respectively. Further studies are required to investigate whether high prevalence of low HDL-C levels in this population presents with any adverse cardiovascular disease outcomes. Associations of education, employment and adiposity with lipid levels suggest that future societal advances and increases in the prevalence of obesity may lead to associated adverse health consequences. Monitoring and interventions are required to limit these effects.

Prevalence and factors associated with female genital mutilation among women of reproductive age in the Bawku municipality and Pusiga District of northern Ghana

BACKGROUND

Globally, three million girls are at risk of female genital mutilation (FGM) and an estimated 200 million girls and women in the world have undergone FGM. While the overall prevalence of FGM in Ghana is 4%, studies have shown that the overall prevalence in the Upper East Region is 38%, with Bawku municipality recording the highest at 82%.

METHODS

This study used a cross-sectional design with a quantitative approach: a survey with women of reproductive age (15-49).

RESULTS

Among all respondents, 830 women who participated in the study, 61% reported having undergone FGM. Of those circumcised, 66% indicated their mothers influenced it. Three quarters of the women think FGM could be stopped through health education. Women who live in the Pusiga district (AOR: 1.66; 95% CI: 1.16-2.38), are aged 35-49 (AOR: 4.24; 95% CI: 2.62-6.85), and have no formal education (AOR: 2.78; 95% CI: 1.43-5.43) or primary education (AOR: 2.10; 95% CI: 1.03-4.31) were more likely to be circumcised relative to those who reside in Bawku Municipal, are aged 15-24, and had tertiary education. Likewise, married women (AOR: 3.82; 95% CI: 2.53-5.76) were more likely to have been circumcised compared with unmarried women. At a site-specific level, factors associated with FGM included age and marital status in Bawku, and age, marital status, and women's education in Pusiga.

CONCLUSION

Female Genital Mutilation is still being practiced in the Bawku Municipality and the Pusiga District of northern Ghana, particularly among women with low socio-economic status. Implementing interventions that would provide health education to communities and promote girl-child education beyond the primary level could help end the practice.

Determinants of attending antenatal care at least four times in rural Ghana: analysis of a cross-sectional survey

BACKGROUND

Improving maternal health is a global challenge. In Ghana, maternal morbidity and mortality rates remain high, particularly in rural areas. Antenatal care (ANC) attendance is known to improve maternal health. However, few studies have updated current knowledge regarding determinants of ANC attendance.

OBJECTIVE

This study examined factors associated with ANC attendance in predominantly rural Ghana.

METHODS

We conducted a cross-sectional study at three sites (i.e. Navrongo, Kintampo, and Dodowa) in Ghana between August and September 2013. We selected 1500 women who had delivered within the two years preceding the survey (500 from each site) using two-stage random sampling. Data concerning 1497 women's sociodemographic characteristics and antenatal care attendance were collected and analyzed, and factors associated with attending ANC at least four times were identified using logistic regression analysis.

RESULTS

Of the 1497 participants, 86% reported attending ANC at least four times, which was positively associated with possession of national health insurance (AOR 1.64, 95% CI: 1.14-2.38) and having a partner with a high educational level (AOR 1.64, 95% CI: 1.02-2.64) and negatively associated with being single (AOR 0.39, 95% CI: 0.22-0.69) and cohabiting (AOR 0.57, 95% CI: 0.34-0.97). In site-specific analyses, factors associated with ANC attendance included marital status in Navrongo; marital status, possession of national health insurance, partners' educational level, and wealth in Kintampo; and preferred pregnancy timing in Dodowa. In the youngest, least educated, and poorest women and women whose partners were uneducated, those with health insurance were more likely to report at least four ANC attendances relative to those who did not have insurance.

CONCLUSIONS

Ghanaian women with low socioeconomic status were less likely to report at least four ANC attendances during pregnancy if they did not possess health insurance. The national health insurance scheme should include a higher number of deprived women in predominantly rural communities.

Measles Vaccination Supports Millennium Development Goal 4: Increasing Coverage and Increasing Child Survival in Northern Ghana, 1996-2012

Background

Measles vaccine (MV) administered as the last vaccine after the third dose of diphtheria-tetanus-pertussis (DTP) may be associated with better child survival unrelated to prevention of measles infection. Other studies have shown that MV administered after DTP was more beneficial and was associated with lower mortality compared with DTP administered after MV or DTP administered simultaneously with MV. We compared the difference in mortality between measles vaccinated after DTP3 and measles-unvaccinated children in Navrongo, Ghana.

Methods

This was a follow-up study involving annual cohort of children aged 9–23 months from 1996 to 2012. We assessed survival in relation to the measles vaccination status within the first 12 months from interview date and until 5 years of age using Cox proportional hazards models.

Results

In all, 38,333 children were included in the study. The proportion of children vaccinated with MV-after-DTP3 increased from 45% in 1996 to 95% in 2012. The adjusted hazard ratio (HR) for measles unvaccinated compared with MV-after-DTP3 vaccinated children was 1.38 (1.15–1.66) in the first 12 months after assessment of vaccination status and 1.22 (1.05–1.41) with follow-up to 5 years of age. The national immunization days campaigns with oral polio vaccine or MV might have reduced the effect of being MV-after-DTP3 vaccinated vs MV-unvaccinated. For 12 months of follow-up, the HR before a campaign for MV-unvaccinated children was 1.63 (1.23–2.17) compared to those who received MV-after-DTP3. After the campaign, the HR reduced to 1.23 (0.97–1.54). Stratifying the analysis by sex, measles-unvaccinated boys had a HR of 1.69 (1.33–2.61) compared to measles-unvaccinated girls who had a HR 1.06 (0.79–1.40) during 1-year follow-up. In 1989, only 7% of children in the area had received MV-after-DTP3; the increase in MV-after-DTP3 coverage from 1989 to 2012 may have lowered mortality rate among children aged 9 months to 3 years by 24%.

Conclusion

Though an observational study, our findings suggest that measles vaccination, administered in the recommended sequence, is associated with improved child survival and may have contributed importantly to the mortality decline toward the achievement of Millennium Development Goal 4.

Socio-demographic and behavioural determinants of body mass index among an adult population in rural Northern Ghana: the AWI-Gen study

BACKGROUND

Obesity and associated cardiometabolic diseases are increasing in urban sub-Saharan Africa due to a complex epidemiological and nutritional transition. Related data on rural communities is scarce.

OBJECTIVES

The study characterized the socio-demographic and behavioural factors influencing body mass index (BMI) among adults in rural Northern Ghana Methods: A population-based cross-sectional study involving adults aged 40-60 years residing in the Kassena-Nankana districts was undertaken. Demographic, socio-economic and behavioural data were collected along with measures of anthropometry. We determined factors associated with BMI among women and men.

RESULTS

A total of 2014 adults were studied. The median age was 51 (IQR 45-57) years and 54% were women. The prevalence of overweight/obesity was higher among women than men (18.4% vs. 7.2%; p < 0.001), whilst underweight was more prevalent in men (18.3% vs. 13.1%; p = 0.001). Participants with the highest level of education and a high household socio-economic status had higher BMIs than those in the lowest strata in both men (β = 0.074, p = 0.028 and β = 0.072, p < 0.001, respectively) and women (β = 0.174, p = 0.001 and β = 0.109, p < 0.001, respectively). Men (β = -0.050; p < 0.001) and women (β = -0.073; p < 0.001) of the Nankana ethnic group had a lower BMI than the Kassena ethnic group. Among men, alcohol consumption (β = -0.021; p = 0.001) and smoking (β = -0.216; p < 0.001) were associated with lower BMI. Smokeless tobacco was associated with lower BMI among women. Pesticide exposure was associated with higher BMI (β = 0.022; p = 0.022) among men.

CONCLUSION

Age, sex, ethno-linguistic group and prevailing socio-demographic and behavioural factors within this rural community in Northern Ghana influence BMI. The observed positive association between pesticide use and BMI warrants further investigation.

Variations in disability and quality of life with age and sex between eight lower income and middle-income countries: data from the INDEPTH WHO-SAGE collaboration

Background

Disability and quality of life are key outcomes for older people. Little is known about how these measures vary with age and gender across lower income and middle-income countries; such information is necessary to tailor health and social care policy to promote healthy ageing and minimise disability.

Methods

We analysed data from participants aged 50 years and over from health and demographic surveillance system sites of the International Network for the Demographic Evaluation of Populations and their Health Network in Ghana, Kenya, Tanzania, South Africa, Vietnam, India, Indonesia and Bangladesh, using an abbreviated version of the WHO Study on global AGEing survey instrument. We used the eight-item WHO Quality of Life (WHOQoL) tool to measure quality of life and theWHO Disability Assessment Schedule, version 2 (WHODAS-II) tool to measure disability. We collected selected health status measures via the survey instrument and collected demographic and socioeconomic data from linked surveillance site information. We performed regression analyses to quantify differences between countries in the relationship between age, gender and both quality of life and disability, and we used anchoring vignettes to account for differences in interpretation of disability severity.

Results

We included 43 935 individuals in the analysis. Mean age was 63.7 years (SD 9.7) and 24 434 (55.6%) were women. In unadjusted analyses across all countries, WHOQoL scores worsened by 0.13 points (95% CI 0.12 to 0.14) per year increase in age and WHODAS scores worsened by 0.60 points (95% CI 0.57 to 0.64). WHODAS-II and WHOQoL scores varied markedly between countries, as did the gradient of scores with increasing age. In regression analyses, differences were not fully explained by age, socioeconomic status, marital status, education or health factors. Differences in disability scores between countries were not explained by differences in anchoring vignette responses.

Conclusions

The relationship between age, sex and both disability and quality of life varies between countries. The findings may guide tailoring of interventions to individual country needs, although these associations require further study.

Fewer out-of-sequence vaccinations and reduction of child mortality in Northern Ghana

BACKGROUND

Studies suggest that diphtheria-tetanus-pertussis (DTP) vaccine administered simultaneously with measles vaccine (MV) or DTP administered after MV are associated with higher child mortality than having MV-after-DTP3 as most recent vaccination. We tested this in Northern Ghana where the prevalence of such out-of-sequence vaccinations has declined.

METHODS

Using annual cohort data of children aged 12-23months from 1996 to 2012 and Cox proportional hazards models, we assessed survival in relation to the most recent vaccination status within the next 12months and until five years of age. We assessed whether mortality in children aged 12-59months was higher when the most recent vaccine was non-live (DTP) rather than live (MV or OPV).

RESULTS

Out-of-sequence vaccinations with DTP-containing vaccines and MV declined from 86% in 1989 to 24% in 1996 and 0.7% in 2012. Between 1996 and 2012, 38 070 children had their vaccinations status assessed: the adjusted hazard ratio (HR) for out-of-sequence vaccinations (DTP>=MV) compared with the recommended sequence of MV-after-DTP3 was 1.42(1.06-1.90) during the first 12months after assessment of vaccination status and 1.29(1.03-1.60) with follow-up to five years of age; the HR was 2.58(1.14-5.84) before OPV or MV campaigns and 1.37(1.02-1.85) after the campaigns.

CONCLUSION

Out-of-sequence vaccinations with DTP and MV are associated with higher mortality than MV as most recent vaccination; the effect is unlikely to be due to confounding. Hence, the reduction in out-of-sequence vaccinations may have lowered child mortality. It is recommended not to give DTP with MV or DTP after MV.

Regional and Sex Differences in the Prevalence and Awareness of Hypertension: An H3Africa AWI-Gen Study Across 6 Sites in Sub-Saharan Africa

BACKGROUND

There is a high prevalence of hypertension and related cardiovascular diseases in sub-Saharan Africa, yet few large studies exploring hypertension in Africa are available. The actual burden of disease is poorly understood and awareness and treatment to control it is often suboptimal.

OBJECTIVES

The study sought to report the prevalence of measured hypertension and to assess awareness and control of blood pressure among older adults in rural and urban settings in 6 sites located in West, East, and Southern Africa. In addition, we examined regional, sex, and age differences related to hypertension.

METHODS

A population-based cross-sectional study was performed at 6 sites in 4 African countries: Burkina Faso (Nanoro), Ghana (Navrongo), Kenya (Nairobi), and South Africa (Agincourt, Dikgale, Soweto). Blood pressure measurements were taken using standardized procedures on 10,696 adults 40 to 60 years of age. Hypertension was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or taking antihypertensive medication.

RESULTS

The mean prevalence of hypertension ranged from 15.1% in Nanoro to 54.1% in Soweto. All 3 of the South African sites had a mean prevalence of hypertension of over 40.0%, significantly higher than in Nairobi (25.6%) and Navrongo (24.5%). Prevalence increased with age in both sexes and at all sites. A significantly higher prevalence of hypertension was observed in women in Agincourt, Dikgale, and Nairobi, whereas in Nanoro this trend was reversed. Within the hypertensive group the average proportion of participants who were aware of their blood pressure status was only 39.4% for men and 53.8% for women, and varied widely across sites.

CONCLUSIONS

Our study demonstrates that the prevalence of hypertension and the level of disease awareness differ not only between but also within sub-Saharan African countries. Each nation must tailor their regional hypertension awareness and screening programs to match the characteristics of their local populations.

Child Wanted and When? Fertility Intentions, Wantedness, and Child Survival in Rural Northern Ghana

Panel survey data collected in rural northern Ghana asked women about the "wantedness" status of their children. Parous women were asked whether they wanted more children, while those who had never had a child were asked whether they wanted to have children in the future; those who said that they did not want to have any more children in the future were asked whether they wanted to become pregnant when they last became pregnant and, if so, whether they wanted to become pregnant at the time, or would have preferred to be pregnant earlier or later. This article analyzes longitudinal responses to these questions over a 10-year period. Birth and survival histories of subsequently born children linked to preference data permit investigation of the question: are "wanted" children more likely to survive than "unwanted" children? Hazard models are estimated to determine whether children born to women who indicated that they did not want to have a child at the time they did, or did not want any more children in the future, have a higher risk of mortality relative to children who were reported wanted at the time of pregnancy. Results show no significant differences in adjusted mortality risks between children who were reported to be wanted and those reported to be unwanted.

The Evolving Demographic and Health Transition in Four Low- and Middle-Income Countries: Evidence from Four Sites in the INDEPTH Network of Longitudinal Health and Demographic Surveillance Systems

This paper contributes evidence documenting the continued decline in all-cause mortality and changes in the cause of death distribution over time in four developing country populations in Africa and Asia. We present levels and trends in age-specific mortality (all-cause and cause-specific) from four demographic surveillance sites: Agincourt (South Africa), Navrongo (Ghana) in Africa; Filabavi (Vietnam), Matlab (Bangladesh) in Asia. We model mortality using discrete time event history analysis. This study illustrates how data from INDEPTH Network centers can provide a comparative, longitudinal examination of mortality patterns and the epidemiological transition. Health care systems need to be reconfigured to deal simultaneously with continuing challenges of communicable disease and increasing incidence of non-communicable diseases that require long-term care. In populations with endemic HIV, long-term care of HIV patients on ART will add to the chronic care needs of the community.

Continuum of Care in a Maternal, Newborn and Child Health Program in Ghana: Low Completion Rate and Multiple Obstacle Factors

Background

Slow progress has been made in achieving the Millennium Development Goals 4 and 5 in Ghana. Ensuring continuum of care (at least four antenatal visits; skilled birth attendance; postnatal care within 48 hours, at two weeks, and six weeks) for mother and newborn is crucial in helping Ghana achieve these goals and beyond. This study examined the levels and factors associated with continuum of care (CoC) completion among Ghanaian women aged 15–49.

Methods

A retrospective cross-sectional survey was conducted among women who experienced live births between January 2011 and April 2013 in three regions of Ghana. In a two-stage random sampling method, 1,500 women with infants were selected and interviewed about maternal and newborn service usage in line with CoC. Multiple logistic regression models were used to assess factors associated with CoC completion.

Results

Only 8.0% had CoC completion; the greatest gap and contributor to the low CoC was detected between delivery and postnatal care within 48 hours postpartum. About 95% of women had a minimum of four antenatal visits and postnatal care at six weeks postpartum. A total of 75% had skilled assisted delivery and 25% received postnatal care within 48 hours. Factors associated with CoC completion at 95% CI were geographical location (OR = 0.35, CI 0.13–0.39), marital status (OR = 0.45; CI 0.22–0.95), education (OR = 2.71; CI 1.11–6.57), transportation (OR = 1.97; CI 1.07–3.62), and beliefs about childhood illnesses (OR = 0.34; CI0.21–0.61).

Conclusion

The continuum of care completion rate is low in the study site. Efforts should focus on increasing postnatal care within 48 hours and overcoming the known obstacles to increasing the continuum of care completion rate.

An exploration of moral hazard behaviors under the national health insurance scheme in Northern Ghana: a qualitative study

Background

The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 through an Act of Parliament (Act 650) as a strategy to improve financial access to quality basic health care services. Although attendance at health facilities has increased since the introduction of the NHIS, there have been media reports of widespread abuse of the NHIS by scheme operators, service providers and insured persons. The aim of the study was to document behaviors and practices of service providers and clients of the NHIS in the Kassena-Nankana District (KND) of Ghana that constitute moral hazards (abuse of the scheme) and identify strategies to minimize such behaviors.

Methods

Qualitative methods through 14 Focused Group Discussions (FGDs) and 5 individual in-depth interviews were conducted between December 2009 and January 2010. Thematic analysis was performed with the aid of QSR NVivo 8 software.

Results

Analysis of FGDs and in-depth interviews showed that community members, health providers and NHIS officers are aware of various behaviors and practices that constitute abuse of the scheme. Behaviors such as frequent and ‘frivolous’ visits to health facilities, impersonation, feigning sickness to collect drugs for non-insured persons, over charging for services provided to clients, charging clients for services not provided and over prescription were identified. Suggestions on how to minimize abuse of the NHIS offered by respondents included: reduction of premiums and registration fees, premium payments by installment, improvement in the picture quality of the membership cards, critical examination and verification of membership cards at health facilities, some ceiling on the number of times one can seek health care within a specified time period, and general education to change behaviors that abuse the scheme.

Conclusion

Attention should be focused on addressing the identified moral hazard behaviors and pursue cost containment strategies to ensure the smooth operation of the scheme and enhance its sustainability.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1133-4) contains supplementary material, which is available to authorized users.

A retrospective analysis of the association between tobacco smoking and deaths from respiratory and cardiovascular diseases in the Kassena-Nankana districts of Northern Ghana

BACKGROUND

Tobacco use is a public health problem, responsible for approximately six million deaths annually worldwide. It is a risk factor for many diseases including cancers, respiratory and cardiovascular diseases. In low-and middle-income countries, respiratory and cardiovascular diseases are important causes of death. Tobacco use is prevalent in Ghana, but no study had examined the relationship between tobacco use and deaths from respiratory and cardiovascular diseases in the Upper East Region of Northern Ghana. Hence the paper assessed the association between tobacco use and deaths from respiratory and cardiovascular diseases in that region.

METHODS

The study used verbal autopsy data collected from the Kassena-Nankana East and West districts of the Upper East Region of Northern Ghana. Data from deceased individuals aged 15 to 59 years whose deaths occurred between January 1, 2004 and December 31, 2011 and with a known cause as well as smoking status were analyzed. Two binary outcome variables were generated from the cause of death data; whether an individual died from respiratory diseases or not, and from cardiovascular diseases or not. Multiple logistic regression models were used to assess the relationship between tobacco use and deaths from respiratory and cardiovascular diseases.

RESULTS

Out of 3,492 deaths with a known cause of death and smoking status, a third of them smoked. About 16.6% of smokers and 8.1% of non-smokers died from respiratory diseases. Approximately, 10.7% of smokers died from cardiovascular diseases compared to 10.6% of non-smokers. In multivariate analyses, individuals with a history of smoking had two-fold increased odds [OR=2.18, 95% CI (1.6-2.9)] of dying from respiratory diseases. Besides, the number of years of smoking as well as the frequency of smoking is significantly associated with deaths from respiratory diseases. No association existed between tobacco use and deaths from cardiovascular diseases.

CONCLUSIONS

Within our study we identified a strong relationship between tobacco use and deaths from respiratory diseases, but not an association with deaths from cardiovascular diseases. Our findings highlight the need to make appropriate health interventions to control tobacco use and thus help reduce premature deaths from respiratory and other tobacco linked diseases.

Adult non-communicable disease mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites

Background

Mortality from non-communicable diseases (NCDs) is a major global issue, as other categories of mortality have diminished and life expectancy has increased. The World Health Organization's Member States have called for a 25% reduction in premature NCD mortality by 2025, which can only be achieved by substantial reductions in risk factors and improvements in the management of chronic conditions. A high burden of NCD mortality among much older people, who have survived other hazards, is inevitable. The INDEPTH Network collects detailed individual data within defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.

Objective

To describe patterns of adult NCD mortality from INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories, with separate consideration of premature (15–64 years) and older (65+ years) NCD mortality.

Design

All adult deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates.

Results

A total of 80,726 adult (over 15 years) deaths were documented over 7,423,497 person-years of observation. NCDs were attributed as the cause for 35.6% of these deaths. Slightly less than half of adult NCD deaths occurred in the 15–64 age group. Detailed results are presented by age and sex for leading causes of NCD mortality. Per-site rates of NCD mortality were significantly correlated with rates of HIV/AIDS-related mortality.

Conclusions

These findings present important evidence on the distribution of NCD mortality across a wide range of African and Asian settings. This comes against a background of global concern about the burden of NCD mortality, especially among adults aged under 70, and provides an important baseline for future work.

Pregnancy-related mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites

Background

Women continue to die in unacceptably large numbers around the world as a result of pregnancy, particularly in sub-Saharan Africa and Asia. Part of the problem is a lack of accurate, population-based information characterising the issues and informing solutions. Population surveillance sites, such as those operated within the INDEPTH Network, have the potential to contribute to bridging the information gaps.

Objective

To describe patterns of pregnancy-related mortality at INDEPTH Network Health and Demographic Surveillance System sites in sub-Saharan Africa and southeast Asia in terms of maternal mortality ratio (MMR) and cause-specific mortality rates.

Design

Data on individual deaths among women of reproductive age (WRA) (15–49) resident in INDEPTH sites were collated into a standardised database using the INDEPTH 2013 population standard, the WHO 2012 verbal autopsy (VA) standard, and the InterVA model for assigning cause of death.

Results

These analyses are based on reports from 14 INDEPTH sites, covering 14,198 deaths among WRA over 2,595,605 person-years observed. MMRs varied between 128 and 461 per 100,000 live births, while maternal mortality rates ranged from 0.11 to 0.74 per 1,000 person-years. Detailed rates per cause are tabulated, including analyses of direct maternal, indirect maternal, and incidental pregnancy-related deaths across the 14 sites.

Conclusions

As expected, these findings confirmed unacceptably high continuing levels of maternal mortality. However, they also demonstrate the effectiveness of INDEPTH sites and of the VA methods applied to arrive at measurements of maternal mortality that are essential for planning effective solutions and monitoring programmatic impacts.

The non-specific effects of vaccines and other childhood interventions: the contribution of INDEPTH Health and Demographic Surveillance Systems

Most childhood interventions (vaccines, micronutrients) in low-income countries are justified by their assumed effect on child survival. However, usually the interventions have only been studied with respect to their disease/deficiency-specific effects and not for their overall effects on morbidity and mortality. In many situations, the population-based effects have been very different from the anticipated effects; for example, the measles-preventive high-titre measles vaccine was associated with 2-fold increased female mortality; BCG reduces neonatal mortality although children do not die of tuberculosis in the neonatal period; vitamin A may be associated with increased or reduced child mortality in different situations; effects of interventions may differ for boys and girls. The reasons for these and other contrasts between expectations and observations are likely to be that the immune system learns more than specific prevention from an intervention; such training may enhance or reduce susceptibility to unrelated infections. INDEPTH member centres have been in an ideal position to document such additional non-specific effects of interventions because they follow the total population long term. It is proposed that more INDEPTH member centres extend their routine data collection platform to better measure the use and effects of childhood interventions. In a longer perspective, INDEPTH may come to play a stronger role in defining health research issues of relevance to low-income countries.

Cultural imperatives and the ethics of verbal autopsies in rural Ghana

Background

Due to a paucity of statistics from vital registration systems in developing countries, the verbal autopsy (VA) approach has been used to obtain cause-specific mortality data by interviewing lay respondents on the signs and symptoms experienced by the deceased prior to death. In societies where the culture of mourning is adhered to, the use of VA could clash with traditional norms, thus warranting ethical consideration by researchers.

Objective

The study was designed to explore the ethics and cultural context of collecting VA information through a demographic and health surveillance system in the Kassena-Nankana District (KND) of Ghana.

Study Design

Data were collected through qualitative in-depth interviews (IDIs) with four field staff involved in the routine conduct of VAs, four physicians who code VAs, 20 selected respondents to the VA tool, and eight opinion leaders in the KND. The interviews were supplemented with observation by the researchers and with the field notes of field workers. Interviews were audio-recorded, and local language versions transcribed into English. Thematic analysis was performed using QSR NVivo 8 software.

Results

The data indicate that cultural sensitivities in VA procedures at both the individual and family levels need greater consideration not only for ethical reasons but also to ensure the quality of the data. Discussions of some deaths are culturally prohibited and therefore lead to refusal of interviews. Families were also concerned about the confidentiality of information because of the potential of blame for the death. VA teams do not necessarily engage in culturally appropriate bereavement practices such as the presentation of tokens. The desire by families for feedback on the cause of death, which is currently not provided by researchers, was frequently expressed. Finally, no standard exists on the culturally acceptable time interval between death and VA interviews.

Conclusion

Ethical issues need to be given greater consideration in the collection of cause of death data, and this can be achieved through the establishment of processes that allow active engagement with communities, authorities of civil registrations, and Institutional Review Boards to take greater account of local contexts.

Use of anchoring vignettes to evaluate health reporting behavior amongst adults aged 50 years and above in Africa and Asia--testing assumptions

Background

Comparing self-rating health responses across individuals and cultures is misleading due to different reporting behaviors. Anchoring vignettes is a technique that allows identifying and adjusting self-rating responses for reporting heterogeneity (RH).

Objective

This article aims to test two crucial assumptions of vignette equivalence (VE) and response consistency (RC) that are required to be met before vignettes can be used to adjust self-rating responses for RH.

Design

We used self-ratings, vignettes, and objective measures covering domains of mobility and cognition from the WHO study on global AGEing and adult health, administered to older adults aged 50 years and above from eight low- and middle-income countries in Africa and Asia. For VE, we specified a hierarchical ordered probit (HOPIT) model to test for equality of perceived vignette locations. For RC, we tested for equality of thresholds that are used to rate vignettes with thresholds derived from objective measures and used to rate their own health function.

Results

There was evidence of RH in self-rating responses for difficulty in mobility and cognition. Assumptions of VE and RC between countries were violated driven by age, sex, and education. However, within a country context, assumption of VE was met in some countries (mainly in Africa, except Tanzania) and violated in others (mainly in Asia, except India).

Conclusion

We conclude that violation of assumptions of RC and VE precluded the use of anchoring vignettes to adjust self-rated responses for RH across countries in Asia and Africa.

Profile of the Navrongo Health and Demographic Surveillance System

Located in the Kassena-Nankana districts of northern Ghana, the Navrongo health and demographic surveillance system (NHDSS) was established in 1992 by the Navrongo health research centre (NHRC). The NHRC is one of three research centres of the Ghana health service. The activities and potential of the NHDSS for collaborative research are described. The NHDSS monitors health and demographic dynamics of the two Kassena-Nankana districts of northern Ghana and facilitates evaluation of the morbidity and mortality impact of health and social interventions. The total population currently under surveillance is 152 000 residing in 32 000 households. Events monitored routinely include pregnancies, births, morbidity, deaths, migration, marriages and vaccination coverage. Data updates are done every 4 months by trained fieldworkers. The NHRC also undertakes biomedical and socio-economic studies. Additional features of the NHDSS include the community key informant system where trained volunteers routinely report key events, such as births and deaths as they occur in their locality and the verbal autopsy (VA) system for determining the probable causes of deaths that occur at the community level. Data from the NHDSS are shared with funders and collaborators and partners in the INDEPTH Network. The Director of the NHDSS is the contact person for potential collaboration with the NHDSS and the use of its data.

Non-specific effects of diphtheria-tetanus-pertussis and measles vaccinations? An analysis of surveillance data from Navrongo, Ghana

OBJECTIVES

Studies from low-income countries have suggested that routine vaccinations may have non-specific effects on child mortality; measles vaccine (MV) is associated with lower mortality and diphtheria-tetanus-pertussis (DTP) with relatively higher mortality. We used data from Navrongo, Ghana, to examine the impact of vaccinations on child mortality.

METHODS

Vaccination status was assessed at the initiation of a trial of vitamin A supplementation and after 12 and 24 months of follow-up. Within the placebo group, we compared the mortality over the first 4 months and the full 2 years of follow-up for different vaccination status groups with different likelihoods of additional vaccinations during follow-up. The frequency of additional vaccinations was assessed among children whose vaccination card was seen at 12 and 24 months of follow-up.

RESULTS

Among children with a vaccination card, more than 75% received missing DTP or MV during the first 12 months of follow-up, whereas only 25% received these vaccines among children with no vaccination card at enrollment. Children without a card at enrollment had a significant threefold higher mortality over the 2-year follow-up period than those fully vaccinated. The small group of children with DTP3-4 but no MV at enrollment had lower mortality than children without a card and had the same mortality as fully vaccinated children. In contrast, children with 1-2 DTP doses but no MV had a higher mortality during the first 4 months than children without a card [MRR = 1.65 (0.95, 2.87)]; compared with the fully vaccinated children, they had significantly higher mortality after 4 months [MRR = 2.38 (1.07, 5.30)] and after 2 years [MRR = 2.41 (1.41, 4.15)]. Children with 0-2 DTP doses at enrollment had higher mortality after 4 months (MRR = 1.67 (0.82, 3.43) and after 2 years [MRR = 1.85 (1.16, 2.95)] than children who had all three doses of DTP at enrollment.

CONCLUSIONS

As hypothesised, DTP vaccination was associated with higher child mortality than measles vaccination. To optimise vaccination policies, routine vaccinations need to be evaluated in randomised trials measuring the impact on survival.

Review of Antenatal-Linked Voluntary Counseling and HIV Testing in Sub-Saharan Africa: Lessons and Options for Ghana

SummaryVoluntary counselling and HIV testing has become an integral part of HIV prevention and care programs in many countries in sub-Saharan Africa. A number of interventions offer potential to reduce mother-to-child HIV transmission. These interventions, including antenatal and or intrapartum administration of antiretroviral drugs require the integration of voluntary counselling and HIV testing for pregnant women into antenatal care. Ghana's strategic framework for HIV control calls for the integration of voluntary counselling and HIV testing to antenatal care nationwide. It sets as target, the year 2005 when VCT would be widely available and accessible in the country. This paper reviews medline-indexed publications on antenatal-linked VCT programs of sub-Saharan Africa. Four critical themes were used in the medline search. These are acceptability, rates of return for test, disclosure of results vis-à-vis confidentiality and cost effectiveness. The growing consensuses on these issues are discussed in relations to the findings of a recent study conducted among 270 pregnant women in Navrongo in the Kassena-Nankana district of northern Ghana. Suggestions are made to guide the on-going pilot VCT and prevention of mother-to-child programs in Ghana. It is also suggested on the basis of the review and the findings of the Navrongo study that Ghana should explore options likely to promote universal access and overall acceptability. These include couple counselling, guarantee of confidentiality, free testing and continuum of care for mothers who are test positive.

Self-reported health and functional limitations among older people in the Kassena-Nankana District, Ghana

Background

Ghana is experiencing significant increases in its ageing population, yet research on the health and quality of life of older people is limited. Lack of data on the health and well-being of older people in the country makes it difficult to monitor trends in the health status of adults and the impact of social policies on their health and welfare. Research on ageing is urgently required to provide essential data for policy formulation and programme implementation.

Objective

To describe the health status and identify factors associated with self-rated health (SRH) among older adults in a rural community in northern Ghana.

Methods

The data come from a survey on Adult Health and Ageing in the Kassena-Nankana District involving 4,584 people aged 50 and over. Survey participants answered questions pertaining to their health status, including self-rated overall health, perceptions of well-being and quality of life, and self-reported assessment of functioning on a range of different health domains. Socio-demographic information such as age, sex, marital status and education were obtained from a demographic surveillance database.

Results

The majority of older people rated their health status as good, with the oldest old reporting poorer health. Multivariate regression analysis showed that functional ability and sex are significant factors in SRH status. Adults with higher levels of functional limitations were much more likely to rate their health as being poorer compared with those having lower disabilities. Household wealth was significantly associated with SRH, with wealthier adults more likely to rate their health as good.

Conclusion

The depreciation in health and daily functioning with increasing age is likely to increase people's demand for health care and other services as they grow older. There is a need for regular monitoring of the health status of older people to provide public health agencies with the data they need to assess, protect and promote the health and well-being of older people.

Ageing and adult health status in eight lower-income countries: the INDEPTH WHO-SAGE collaboration

BACKGROUND

Globally, ageing impacts all countries, with a majority of older persons residing in lower- and middle-income countries now and into the future. An understanding of the health and well-being of these ageing populations is important for policy and planning; however, research on ageing and adult health that informs policy predominantly comes from higher-income countries. A collaboration between the WHO Study on global AGEing and adult health (SAGE) and International Network for the Demographic Evaluation of Populations and Their Health in developing countries (INDEPTH), with support from the US National Institute on Aging (NIA) and the Swedish Council for Working Life and Social Research (FAS), has resulted in valuable health, disability and well-being information through a first wave of data collection in 2006-2007 from field sites in South Africa, Tanzania, Kenya, Ghana, Viet Nam, Bangladesh, Indonesia and India.

OBJECTIVE

To provide an overview of the demographic and health characteristics of participating countries, describe the research collaboration and introduce the first dataset and outputs.

METHODS

Data from two SAGE survey modules implemented in eight Health and Demographic Surveillance Systems (HDSS) were merged with core HDSS data to produce a summary dataset for the site-specific and cross-site analyses described in this supplement. Each participating HDSS site used standardised training materials and survey instruments. Face-to-face interviews were conducted. Ethical clearance was obtained from WHO and the local ethical authority for each participating HDSS site.

RESULTS

People aged 50 years and over in the eight participating countries represent over 15% of the current global older population, and is projected to reach 23% by 2030. The Asian HDSS sites have a larger proportion of burden of disease from non-communicable diseases and injuries relative to their African counterparts. A pooled sample of over 46,000 persons aged 50 and over from these eight HDSS sites was produced. The SAGE modules resulted in self-reported health, health status, functioning (from the WHO Disability Assessment Scale (WHODAS-II)) and well-being (from the WHO Quality of Life instrument (WHOQoL) variables). The HDSS databases contributed age, sex, marital status, education, socio-economic status and household size variables.

CONCLUSION

The INDEPTH WHO-SAGE collaboration demonstrates the value and future possibilities for this type of research in informing policy and planning for a number of countries. This INDEPTH WHO-SAGE dataset will be placed in the public domain together with this open-access supplement and will be available through the GHA website (www.globalhealthaction.net) and other repositories. An improved dataset is being developed containing supplementary HDSS variables and vignette-adjusted health variables. This living collaboration is now preparing for a next wave of data collection.

Health inequalities among older men and women in Africa and Asia: evidence from eight Health and Demographic Surveillance System sites in the INDEPTH WHO-SAGE Study

Background

Declining rates of fertility and mortality are driving demographic transition in all regions of the world, leading to global population ageing and consequently changing patterns of global morbidity and mortality. Understanding sex-related health differences, recognising groups at risk of poor health and identifying determinants of poor health are therefore very important for both improving health trajectories and planning for the health needs of ageing populations.

Objectives

To determine the extent to which demographic and socio-economic factors impact upon measures of health in older populations in Africa and Asia; to examine sex differences in health and further explain how these differences can be attributed to demographic and socio-economic determinants.

Methods

A total of 46,269 individuals aged 50 years and over in eight Health and Demographic Surveillance System (HDSS) sites within the INDEPTH Network were studied during 2006–2007 using an abbreviated version of the WHO Study on global AGEing and adult health (SAGE) Wave I instrument. The survey data were then linked to longitudinal HDSS background information. A health score was calculated based on self-reported health derived from eight health domains. Multivariable regression and post-regression decomposition provide ways of measuring and explaining the health score gap between men and women.

Results

Older men have better self-reported health than older women. Differences in household socio-economic levels, age, education levels, marital status and living arrangements explained from about 82% and 71% of the gaps in health score observed between men and women in South Africa and Kenya, respectively, to almost nothing in Bangladesh. Different health domains contributed differently to the overall health scores for men and women in each country.

Conclusion

This study confirmed the existence of sex differences in self-reported health in low- and middle-income countries even after adjustments for differences in demographic and socio-economic factors. A decomposition analysis suggested that sex differences in health differed across the HDSS sites, with the greatest level of inequality found in Bangladesh. The analysis showed considerable variation in how differences in socio-demographic and economic characteristics explained the gaps in self-reported health observed between older men and women in African and Asian settings. The overall health score was a robust indicator of health, with two domains, pain and sleep/energy, contributing consistently across the HDSS sites. Further studies are warranted to understand other significant individual and contextual determinants to which these sex differences in health can be attributed. This will lay a foundation for a more evidence-based approach to resource allocation, and to developing health promotion programmes for older men and women in these settings.

Postpartum abstinence and risk of HIV among young mothers in the Kassena-Nankana District of Northern Ghana

This study explored the role and shaping of postpartum abstinence on young mothers' sexual conduct and vulnerability to HIV infection in a rural setting of Northern Ghana. Young mothers in their mid-twenties to early-thirties and men married to young mothers were purposively selected for repeated semi-structured interviews. The interviews were tape-recorded, transcribed and Nvivo software was used to organize and manage the data for analysis. In this setting, postpartum abstinence was perceived as a risk period for STIs due to increased male infidelity during this period. Yet, women's urge to take action to mitigate the risk of STIs is compromised by childbearing obligations. More assertive women, however, employ crafty and nifty protective strategies including the masturbation of their male partner when they perceive themselves at risk. We conclude that the advent of HIV and AIDS, coupled with improved access to sexual and reproductive health information and modern contraception, has eroded the logic of observance of postpartum abstinence in the Kassena-Nankana District of Northern Ghana. Efforts should be made to facilitate easy access to modern contraceptives and HIV protection by rural women.

Coping strategies of young mothers at risk of HIV/AIDS in the Kassena-Nankana district of Northern Ghana

This qualitative study draws on interpretative principles with emphasis on understanding young mothers' vulnerability to HIV/AIDS and explores coping strategies used to mitigate risk of infection in a poor rural setting of Ghana. Young mothers in their mid-twenties to early thirties and their male partners were purposively selected with the assistance of key informants for repeated semi-structured interviews. Respondents included those in monogamous and polygynous marriages with two or more living children, and those with and without formal education. Young mothers in this study setting are confronted with complex realities as childbearing obligations make protective sex less optional. However, more assertive women insist their husbands use condoms when they perceive themselves at risk. We conclude that the advent of HIV may advance the cause of women's reproductive health empowerment by providing women with very strong reasons to minimize HIV risk within marriage.

The effect of community nurses and health volunteers on child mortality: the Navrongo Community Health and Family Planning Project

BACKGROUND

Despite effective treatments and preventive measures for the major causes of child illness and death in less wealthy nations, child mortality remains high in resource-poor settings due in part to ineffective health service delivery models.

METHODS

The Navrongo Community Health and Family Planning Project is a longitudinal community trial of alternative organizational strategies for health service delivery in a rural, impoverished area of Ghana. In one area, nurses are placed in communities with doorstep visitation and service responsibilities. A second area includes training of a local health volunteer and community involvement in health delivery. A third area combines both strategies. Under-five mortality rates were calculated and Poisson regression was used to adjust for potential confounding characteristics.

RESULTS

In areas with village-based community nurse services, under-five child mortality fell by 14% during five years of program implementation compared with before the intervention, with reductions in infant (5%), early child (18%), and late child (39%) mortality. The volunteer intervention was associated with a 14% increase in mortality, primarily driven by a 135% increase in early child mortality. Areas with both nurses and volunteers saw an 8% increase, with small increases in all age groups. Mortality in a comparison area with standard Ministry of Health services fell by 4% during the same time period.

CONCLUSIONS

These results suggest that convenient, accessible professional nursing care can reduce child mortality in impoverished African settings. However, they do not demonstrate a beneficial effect of community volunteers and suggest a possible negative impact on children's survival.

Using lay counsellors to promote community-based voluntary counselling and HIV testing in rural northern Ghana: a baseline survey on community acceptance and stigma

Access to voluntary counselling and HIV testing (VCT) remains limited in most parts of Ghana with rural populations being the least served. Services remain facility-based and employ the use of an ever-dwindling number of health workers as counsellors. This study assessed approval for the use of lay counsellors to promote community-based voluntary counselling and testing for HIV and the extent of HIV/AIDS-related stigma in the Kassena-Nankana district of rural northern Ghana. A cross-sectional questionnaire survey was conducted. Logistic regression was used to identify predictors of the tendency to stigmatize people living with HIV/AIDS (PLWHAs). Focus group discussions were held and analytical coding of the data performed. The majority (91.1%) of the 403 respondents indicated a desire to know their HIV status. Most (88.1%) respondents considered locations outside of the health facility as preferred places for VCT. The majority (98.7%) of respondents approved the use of lay counsellors. About a quarter (24%) of respondents believed that it was possible to acquire HIV through sharing a drinking cup with a PLWHA. About half (52.1%) of the respondents considered that a teacher with HIV/AIDS should not be allowed to teach, while 77.2% would not buy vegetables from a PLWHA. Respondents who believed that sharing a drinking cup with a PLWHA could transmit HIV infection (OR 2.50, 95%CI 1.52-4.11) and respondents without formal education (OR 2.94, 95%CI 1.38-6.27) were more likely to stigmatize PLWHAs. In contrast, respondents with knowledge of the availability of antiretroviral (ARV) drugs were less likely to do so (OR 0.40, 95%CI 0.22-0.73). Findings from the thirteen focus group discussions reinforced approval for community-based VCT and lay counsellors but revealed concerns about stigma and confidentiality. In conclusion, community-based VCT and the use of lay counsellors may be acceptable options for promoting access. Interventional studies are required to assess feasibility and cost-effectiveness.

Migrant fertility in Ghana: selection versus adaptation and disruption as causal mechanisms

The aim of the study presented in this paper is to disentangle the roles of three mechanisms -- selection, adaptation, and disruption -- in influencing migrant fertility in Ghana. Using data from the 1998 Ghana Demographic and Health Survey, we fit Poisson and sequential logit regression models to discern the effects of the above mechanisms on cumulative fertility and annual probabilities of birth. Characteristics of migrants from four types of migration stream are examined and compared with those of non-migrants at origin and destination. We find substantial support for the selection hypothesis among both rural-urban and urban-rural migrants. Disruption is evident only in the fertility timing of second and higher-order births in Ghana. Our finding that migrants bear children at about the same rates as the natives at destination implies that the growth rate of cities will slow down quickly and that the rural population will continue to have high fertility. Thus to achieve a reduction in the national fertility level, family planning activities need to be directed towards rural areas.

Gate-keeping and women's health seeking behaviour in Navrongo, northern Ghana

Among the Kassena-Nankana of northern Ghana, compound heads and husbands impede women's prompt access to modern health care. This paper shows that such gate-keeping systems have a negative effect on child survival. To investigate the social construction of compound-based gate-keeping systems, the authors relied on a series of qualitative interviews conducted in the Kassena-Nankana district These data reveal that whilst compound heads are gate-keepers for spiritual reasons, husbands play such role for economic reasons. But more important, this article presents health interventions that are on trial in Navrongo (northen Ghana) and how they undermine such gate-keeping systems.

The impact of the Navrongo Project on contraceptive knowledge and use, reproductive preferences, and fertility

The Navrongo Community Health and Family Planning Project is a quasi-experimental study designed to test the hypothesis that introducing health and family planning services in a traditional African societal setting will introduce reproductive change. This article presents the impact of the initial three years of project exposure on contraceptive knowledge, awareness of supply sources, reproductive preferences, contraceptive use, and fertility. Findings show that knowledge of methods and supply sources increased as a result of exposure to project activities and that deployment of nurses to communities was associated with the emergence of preferences to limit childbearing. Fertility impact is evident in all treatment cells, most prominently in areas where nurse-outreach activities are combined with strategies for involving traditional leaders and male volunteers in promoting the program. In this combined cell, the initial three years of project exposure reduced the total fertility rate by one birth, comprising a 15 percent fertility decline relative to fertility levels in comparison communities.

Cultural factors constraining the introduction of family planning among the Kassena-Nankana of northern Ghana

This study presents a focus group investigation of reasons why women in a rural, Sahelian community are reluctant to adopt family planning even when convenient services are made freely available. First, women opting to practice contraception must do so at considerable risk of social ostracism or familial conflict. Implementing individual preference is something that must be done without the support of others. Second, few women view personal decisions about contraceptives as theirs to make. Women and children are the property of the corporate family-kin and community militate against reproductive control. Third, although children are highly valued for a variety of economic, social, and cultural reasons, mortality risks remain extremely high. Low fertility imposes the unacceptable risk that a woman will have no surviving children at the end of her reproductive life. Taken together, these findings attest to the inadequacy of service strategies focused on the contribution of distribution, individual agency, or personal choice. Outreach should also build a sense of community legitimacy for the program, collective health action, and traditional leadership support for family planning behavior.

Developing a culturally appropriate family planning program for the Navrongo experiment

This article describes the first six months of the strategic planning process to develop a culturally appropriate community health and family planning program for a traditional community in a district of northern Ghana, served by the Navrongo Health Research Centre. To explain the context within which fertility decisions are made, this article describes the district's severe ecological, social, economic, and health constraints to family planning. It discusses related programmatic obstacles and presents the strategies developed to respond to them. A system of care has been developed that is closely coordinated with traditional leaders and communication networks. Management systems support outreach workers by emphasizing the importance of peer leadership, supervisory support, and community liaison in the implementation of village-based services. A large-scale experiment will be fielded to test the demographic impact of this approach.