Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic.

METHODS

The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic.

FINDINGS

Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021.

INTERPRETATION

Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades.

FUNDING

Bill & Melinda Gates Foundation.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

Lay beliefs of COVID-19 vaccine refusal among intercity commercial drivers in the Volta region of Ghana: recommendations for improved vaccine uptake

BACKGROUND

The COVID-19 vaccine has faced increased hesitancy in Ghana and the Volta region in particular since its rollout. Acceptance of the vaccine among intercity commercial drivers is crucial, especially in the Volta region, as they transport people within and outside the country and could fuel the transmission of the virus if not vaccinated.

OBJECTIVE

We therefore established lay beliefs surrounding COVID-19 vaccine refusal among intercity commercial drivers in the Volta region of Ghana, as well as their recommendations for improved vaccine uptake.

METHODS

We purposively interviewed twenty-five (25) intercity commercial drivers who had not been vaccinated for COVID-19 in the Volta region of Ghana using a semi-structured interview guide and analysed their responses thematically using the ATLAS.ti software.

RESULTS

Various (ten) beliefs surrounding COVID-19 vaccine refusal were identified. These include the nonexistence of COVID-19, being immune to COVID-19, and the belief in the nonexistence of vaccines and vaccines being meant for the sick. Other beliefs identified were the belief that the COVID-19 vaccine is meant to reduce Africa's population, that the vaccine triggers other health complications leading to death, the belief that vaccination could cause financial loss, political mistrust, that the COVID-19 vaccine is not permitted by God, and the belief that prayer prevents COVID-19 infection. They also suggested that the adoption of persuasive communication techniques, the publication of information on those who died of COVID-19, providing evidence of tests conducted on the vaccine, testing people before vaccination, provision of care to those who may experience side effects from the vaccine, and being able to explain why varied vaccines are used for the same virus could help improve vaccine uptake.

CONCLUSION

Our findings show that there is a general lack of understanding and mistrust surrounding the COVID-19 vaccine among intercity commercial drivers in the Volta region. Hence, health promotion officers and communicators in the region need to be knowledgeable on the vaccine as well as on the conspiracy theories thwarting its uptake to provide comprehensive education to the public and intercity commercial drivers to improve its uptake.

Sociodemographic and health systems determinants of antiretroviral therapy adherence among human immunodeficiency virus-positive patients in the Volta Region of Ghana: A multi-centre study

Objectives

Optimal adherence to antiretroviral therapy is required for viral load suppression. This study investigated the sociodemographic (age, sex, marital status, level of education, monthly income, settlement type, distance to the antiretroviral therapy-providing site, ethnicity) and health system (antiretroviral therapy-providing site) determinants of antiretroviral therapy adherence among human immunodeficiency virus-positive patients in the Volta Region, Ghana.

Methods

A cross-section design was adopted, collecting data from 1729 human immunodeficiency virus patients and analysing them using STATA version 17 at level 0.05.

Results

Antiretroviral therapy adherence was poor (51.2%). Being divorced (Adjusted odds ratio (AOR) = 0.65), widow (AOR = 0.58), cohabiting (AOR = 0.22), Ewe (AOR = 3.7), Ga/Dangbe (AOR = 2.27), living in a rural area (AOR = 1.54) and an urban area (AOR = 0.64), having a monthly income of GH₵1000 or less (AOR = 3.21), covering a distance of 51 km and above to the antiretroviral therapy centre (AOR = 1.79), receiving antiretroviral therapy from Ketu South Municipal Hospital (AOR = 0.09), Hohoe Municipal Hospital (AOR = 0.03), Ho Municipal Hospital (AOR = 0.02) and Ho Teaching Hospital (AOR = 0.09) were the determinants of antiretroviral therapy adherence.

Conclusion

Antiretroviral therapy adherence was low. Interventions to improve antiretroviral therapy adherence should target these significant determinants.

Experiences of care-seeking behaviour for sexually transmitted infections among gay and bisexual men: A phenomenological study

Gay and bisexual men (GBM) are stigmatized in the Ghanaian society and that negatively affect their care-seeking behaviour. We sought to understand the experiences of care-seeking behaviour (CSB) for STIs among gay and bisexual men in Sunyani, capital of Bono Region, Ghana. A respondent-driven sampling was used to collect data from 17 gay and bisexual men in Sunyani based on phenomenological qualitative approach. The data were thematically analysed using the Atlas.ti software. Results were presented under various themes with appropriate accompanying excerpts. Two broad themes emerged from the data - personal and health system experiences of treating STIs. Personal experiences such as economic conditions, knowledge on STI, marital experiences and bisexual's partner awareness of sexual orientation had influences on CSB. Experience with cost of treatment, stigmatisation by health care workers (HCW) and perceived quality healthcare were the health system factors found to influence CSB. To help improve STIs care-seeking behaviour, government need to encourage and economically empower GBM, while at the same time, improving their knowledge on STI prevention and control. The National Health Authority should intensify and monitor the implementation of the national health insurance at the private healthcare sectors without favour and discrimination for gay and bisexual men.

Challenges and opportunities for improved contact tracing in Ghana: experiences from Coronavirus disease-2019-related contact tracing in the Bono region

BACKGROUND

In Ghana, contact tracing received heightened attention in the fight against the COVID-19 pandemic during its peak period. Despite the successes achieved, numerous challenges continue to limit the efforts of contact tracing in completely curtailing the effect of the pandemic. Despite these challenges, there are still opportunities that could be harnessed from the COVID-19 contact tracing experience for future eventualities. This study thus identified the challenges and opportunities associated with COVID-19 contact tracing in the Bono Region of Ghana.

METHODS

Using a focus group discussion (FGD) approach, an exploratory qualitative design was conducted in six selected districts of the Bono region of Ghana in this study. The purposeful sampling technique was employed to recruit 39 contact tracers who were grouped into six focus groups. A thematic content analysis approach via ATLAS ti version 9.0 software was used to analyse the data and presented under two broad themes.

RESULTS

The discussants reported twelve (12) challenges that hindered effective contact tracing in the Bono region. These include inadequate personal protective equipment, harassment by contacts, politicisation of the discourse around the disease, stigmatization, delays in processing test results, poor remuneration and lack of insurance package, inadequate staffing, difficulty in locating contacts, poor quarantine practices, poor education on COVID-19, language barrier and transportation challenges. Opportunities for improving contact tracing include cooperation, awareness creation, leveraging on knowledge gained in contact tracing, and effective emergency plans for future pandemics.

CONCLUSION

There is a need for health authorities, particularly in the region, and the state as a whole to address contact tracing-related challenges while simultaneously harnessing the recommended opportunities for improved contact tracing in the future for effective pandemic control.

Cell-surface contacts determine volume and mechanical properties of human embryonic kidney 293 T cells

Alterations in the organization of the cytoskeleton precede the escape of adherent cells from the framework of cell-cell and cell-matrix interactions into suspension. With cytoskeletal dynamics being linked to cell mechanical properties, many studies elucidated this relationship under either native adherent or suspended conditions. In contrast, tethered cells that mimic the transition between both states have not been the focus of recent research. Using human embryonic kidney 293 T cells we investigated all three conditions in the light of alterations in cellular shape, volume, as well as mechanical properties and relate these findings to the level, structure, and intracellular localization of filamentous actin (F-actin). For cells adhered to a substrate, our data shows that seeding density affects cell size but does not alter their elastic properties. Removing surface contacts leads to cell stiffening that is accompanied by changes in cell shape, and a reduction in cellular volume but no alterations in F-actin density. Instead, we observe changes in the organization of F-actin indicated by the appearance of blebs in the semi-adherent state. In summary, our work reveals an interplay between molecular and mechanical alterations when cells detach from a surface that is mainly dominated by cell morphology.

Protective Behavioural Mechanisms Against Cannabis Use Among Adolescents in Cannabis-Growing Settings of South Africa: Insights Into Adolescent Cannabis Use Prevention

We aimed to explore the behavioural protective mechanisms against cannabis use among adolescents living in South African illicit cannabis-growing communities, based on the Self Determination Theory (SDT). Exploratory qualitative design techniques were followed in conducting the study. The snowball sampling technique was used to recruit thirty (30) non-cannabis smoking adolescents from 2 purposively selected communities and grouped into 4 focus groups and interviewed. A semi-structured focus group interview guide was used to moderate the discussions. Data were analysed inductively, using the ATLAS. ti software. Nine behavioural coping mechanisms, grouped under intrinsic and extrinsic protective behavioural mechanisms, protected participants from using cannabis. Intrinsically, participants' determination not to engage in bad behaviours, focus on their academic work during their free periods, their non-financial dependence on cannabis-using peers, self-preservation to ensure good marriages, and religious beliefs on substance abuse motivated them to not use cannabis. On the other hand, the concept of Ukuphoxa (preservation of family dignity), fear of arrest, fear of being tagged a social deviant, and the fear of contracting illnesses such as lung cancer served as protective behavioural mechanisms against cannabis use. Health promotion and education programmes for adolescents on non-cannabis use in communities where illicit cannabis abounds must identify and draw on contextual intrinsic and extrinsic motivations that ensure non-cannabis use.

Switching in the expression pattern of actin isoforms marks the onset of contractility and distinct mechanodynamic behavior during cardiomyocyte differentiation

Differentiation of cardiac progenitor cells (CPC) into cardiomyocytes is a fundamental step in cardiogenesis, which is marked by changes in gene expression responsible for remodeling of the cytoskeleton and in altering the mechanical properties of cells. Here we have induced the differentiation of CPC derived from human pluripotent stem cells into immature cardiomyocytes (iCM) which we compare with more differentiated cardiomyocytes (mCM). Using atomic force microscopy and real-time deformability cytometry, we describe the mechanodynamic changes that occur during the differentiation process and link our findings to protein expression data of cytoskeletal proteins. Increased levels of cardiac-specific markers as well as evolution of cytoskeletal morphology and contractility parameters correlated with the expected extent of cell differentiation that was accompanied by hypertrophic growth of cells. These changes were associated with switching in the balance of the different actin isoforms where β-actin is predominantly found in CPC, smooth muscle α-actin is dominant in iCM cells and sarcomeric α-actin is found in significantly higher levels in mCM. We link these cytoskeletal changes to differences in mechano-dynamic behavior of cells that translate to changes in Young's modulus that depend on the cell adherence. Our results demonstrate that the intracellular balance of actin isoform expression can be used as a sensitive ruler to determine the stage of differentiation during early phases of cardiomyocyte differentiation that correlates with an increased expression of sarcomeric proteins and is accompanied by changes in cellular elasticity.

Use and awareness of emergency contraceptives among women of reproductive age in sub-Saharan Africa: a scoping review

BACKGROUND

Emergency contraception (EC) is a method used to avoid pregnancy after unprotected sexual intercourse. Emergency contraceptives can reduce the risk of unintended pregnancy by up to over 95% when taken within 72 h of sexual intercourse. EC is helpful to women who have experienced method failure, incorrect use of contraceptives, raped or have consented to unplanned, and unprotected sexual intercourse. We set out to systematically review the current literature on the awareness and usage patterns of ECs among women of reproductive age in Sub-Saharan Africa.

METHOD

Eight hundred and sixty-seven (867) articles were selected from EMBASE and Google Scholar databases after a search was conducted. Sixty (60) full-text articles were checked for eligibility and 27 articles met our inclusion criteria. Manual data extraction on excel sheets was used to extract the authors' names, year of publication, country, sample size, study type, objectives, awareness levels, and the EC types.

FINDINGS

Awareness rates ranged from 10.1 to 93.5% (both reported from Ethiopia). The level of use was relatively low (ranging from 0% in DR Congo and Ethiopia to 54.1% in Nigeria). The most used types of EC were Postinor 2 (levonorgestrel), EC pills such as Norlevo (levonorgestrel only) and Nodette (levonorgestrel and estradiol), and intrauterine contraceptive device (IUCD).

CONCLUSIONS

Although variations in use and awareness do exist between countries in SSA according to the year of study, the general level of EC awareness has been on the increase. On the other hand, the level of EC use was lower compared to the level of awareness. Postinor 2 (levonorgestrel-only pills) was reported as the most type used EC. Further, studies could be done to find out the effect of culture, religion and believes on the use of contraceptive methods. It is important to understanding barriers to EC use despite high awareness rates. Emergency Contraceptive awareness and use should be promoted among women of reproductive age in SSA to reduce unwanted pregnancies and their complications.

Diffusion of platform thinking as an innovation in the construction supply chain

The construction industry has received long-standing criticism over its fragmented approach to supply chain management, adversarial relationships and ongoing defects. Platform thinking has been observed in other industries as a phenomenon that offers reinvention from the traditional perspectives on the supply chain. In this study, a literature review of platform thinking is presented. A database search of 656 papers across 15 journals, along with 3 sources from a Google search and 12 sources from a manual review of the reference lists were reviewed in relation to platform thinking in construction. While many variants of platforms exist, the literature review demonstrates a focus on product platforms that has historical precedents. This paper highlights the benefits of platform thinking while linking to the lessons of the past. This also provides a valuable insight for future implications of platform thinking and contributes to the limited literature on platform thinking in the construction industry by linking historical examples with present and potential future investigation.

Structural elements´ availability for the provision of Prevention of Mother-to-Child Transmission of HIV services among health facilities in the Volta Region of Ghana

Introduction

despite advancement in global efforts to prevent mother-to-child transmission (PMTCT) of HIV, more work needs to be done to achieve the desired results in most African countries including Ghana. Inadequate structural elements can hinder the progress made so far in PMTCT of HIV. This study assessed the availability of structural elements for the provision of PMTCT of HIV services among health facilities in the Volta region of Ghana.

Methods

a descriptive cross-sectional design was used among thirty-two health facilities. Data obtained were analysed using Stata version 14.0 and the Chi-square test was used to determine associations at the 0.05 level of significance.

Results

a majority of the health facilities were Health Centers (50.0%) and most (43.8%) were located in rural areas. Only 9.5% of health practitioners at the Community Health Planning and Services (CHPS) Compounds and Mission-based Hospitals were trained in PMTCT, while 50.5% and 30.5% of health practitioners providing services at the Health Centers and District Hospitals respectively were trained in PMTCT. About 40.0% of District Hospitals had one room with auditory and visual privacy for PMTCT services. While all Mission-based and District Hospitals had ART regimens, no CHPS compound had, and only 8 (50.0%) of the Health Centers had ART regimens.

Conclusion

there is a need for regular training of the health care practitioners providing PMTCT services. Also, programme managers should invest in PMTCT commodities, especially ART regimens, at the lower levels of healthcare for a holistic PMTCT service provision.

Contextual influences of illicit adolescent marijuana cultivation and trading in the Inqguza Hill local municipality of South Africa: implications for public health policy

Background

Although commercial cultivation and trading of marijuana, commonly known as cannabis or dagga in the South African context, remains an illicit practice, adolescents actively engage in it. However, contextual influences that sustain adolescent involvement in illicit marijuana-related activties remain empirically unascertained.

Objective

This study sought to ascertain the various contextual influences of adolescent illicit marijuana cultivation and trading in two communities in the Ingquza Hill Local Municipality (IHLM) of South Africa, using the tenets of the Socio-Ecological Model (SEM).

Methods

The study utilised focus group discussions approach to interview thirty-three purposefully sampled participants who were recruited through the snowball sampling technique. A semi-structured interview guide was used to conduct the interviews, while thematic content analysis was used to analyse the data.

Results

We found that illicit adolescent marijuana cultivation and trading was influenced by eleven contextual factors that are grouped under four levels of socio-ecological influence. These include intrapersonal influences (knowledge and skills in marijuana cultivation and courage), interpersonal influences (peer and family influences), communal level influences (economic reasons, early childhood exposure to marijuana activities, protection of family lands, the topography of the area and soil fertility) and policy-related influences (lack of communal bylaws on marijuana activities and laxity in law enforcement).

Conclusion

It is recommended that substance abuse prevention policies and programmes focus on discouraging children from engaging in illicit marijuana activities in IHLM across the four tenets of SEM and curtailing adolescent involvement in marijuana cultivation and trading. There is also the need to incorporate the law enforcement approach into demand reduction strategies of the National Drug Master Plan (NDMP), which employs only an educative approach in its current form. Working agreements between municipal authorities, law enforcement agents and social service professionals also need to be strengthened to push demand reduction strategies for marijuana in communities to protect the rights of children as enshrined in the Children’s Act, 38 of 2005.

Prevalence and predictors of depression, anxiety, and stress among adults in Ghana: A community-based cross-sectional study

Introduction

Over the past two decades, there have been several global interventions including the Sustainable Development Goals (SDGs), aimed at improving health outcomes. Despite efforts by countries to achieve the SDG targets, mental health challenges remain major public health concerns globally. We examined the prevalence and predictors of depression, anxiety, and stress as well as the comorbidities of these mental health issues among adults.

Materials and methods

This was a community-based cross-sectional study conducted among 2456 adults in four districts of the Volta Region of Ghana using data from the UHAS-Yonsei University Partnership Project. We analysed the data using frequency, percentage, mean, standard deviation, correlation, and binary logistic regression.

Results

Overall, 51.8% of the participants had at least one of the mental health issues examined. The prevalence of a mental health issue was 25.2%, 53.3%, and 9.7% for depression, anxiety, and stress respectively. Participants constituting 8.3% experienced all three mental health issues as comorbidities. Participants’ level of formal education and income significantly predicted depression, anxiety, and stress respectively at the multivariable level. Adults with a tertiary level of education were, for instance, 68% (AOR = 0.32, 95%CI = 0.15–0.66), 65% (AOR = 0.35, 95%CI = 0.17–0.73), and 50% (AOR = 0.50, 95%CI = 0.33–0.76) less likely to experience depression, anxiety, and stress, respectively compared with those who had no formal education.

Conclusion

The majority of our study participants either experienced depression, anxiety, or stress. There were quite high comorbidities of the mental health issues among the adult population. To accelerate progress towards the achievement of SDG 3.4 target of promoting mental health and wellbeing for all by the year 2030, there is a need for effective implementation of the country’s 2012 Mental Health Act which makes provisions for the establishment of a Mental Health Fund. This could improve the financial circumstances of indigenes as income has been realised in the present study as an important factor influencing depression, anxiety, and stress among the adult population.

Theoretical understanding of contextual motivations for sustained adolescent marijuana use in South Africa

Background

Although various reasons for adolescent marijuana use have extensively been explored, contextual factors that sustain the practice in settings where the plant is illegally cultivated, especially in South Africa, remain a grey area.

Aim

We aimed to explore the contextual factors of sustained adolescent marijuana use in two illicit marijuana-growing settings of the Ingquza Hill Local Municipality of South Africa, based on the differential opportunity theory (DOT) and subcultural theory (SCT).

Setting

The study was conducted in two illicit marijuana-growing communities in the Ingquza Hill Local Municipality of the Eastern Cape Province of South Africa.

Methods

Exploratory qualitative research, using focus group discussions approach, was conducted amongst 37 participants, four focus groups and in two communities in the Ingquza Hill Municipality of the Eastern Cape Province of South Africa. Purposive and snowball sampling techniques were used to select the communities and participants, respectively. The data were analysed using a thematic content analysis approach and presented under various themes.

Results

Nine themes, grouped under two broad factors, DOT influences (availability and affordability of marijuana, idleness and means of dealing with personal problems) and SCT influences (peer conformity, the pleasure derived from marijuana smoking, manipulation of appetite, health reasons, for higher cognitive function and addiction), emerged from the analysis.

Conclusion

As marijuana has been identified to be a gateway drug for the use of other illicit drugs, its sustained usage amongst adolescents poses a health challenge to the user, community and the country’s healthcare system at large. Hence, there is the need to intensify adolescent marijuana use prevention campaigns in illicit marijuana-growing contexts of South Africa, focussing on the differential opportunities and subcultural inclinations that promote the behaviour in those contexts.

Perspectives of illicit marijuana growers and traders on commercial legalisation of marijuana in South Africa: considerations for policy formulation

Background

Over the years, there has been a clarion call for legalising marijuana cultivation and trading for commercial purposes in South Africa. Proponents of the call argue that the criminalisation of commercial marijuana cultivation and trading has failed to halt illicit marijuana cultivation and trading. However, the views of those who economically benefit from the illicit marijuana trade on its legalisation remain empirically unsolicited.

Objective

This study aimed to solicit the views of illegal marijuana growers and traders from two selected communities in the Eastern Cape Province of South Africa regarding the commercial legalisation of marijuana cultivation and trading to inform policy on the debate.

Methods

In-depth key informant interview approach was used to interview 18 purposively sampled participants that were selected through the snowball sampling technique. The data were analysed using the thematic content analysis approach.

Results

Participants had both positive and negative perceptions of the possible legalisation of marijuana cultivation and trading. On the positive side, participants indicated freedom from police, the opportunity to grow marijuana on a larger scale, capital acquisition for commercial marijuana cultivation and trading, and regulation of marijuana prices through unionisation as some of the benefits they would derive from the commercial legalisation of marijuana cultivation and trading. On the negative side, loss of their source of livelihood, fall in the price of marijuana and perceived increase in school drop-out rates were the concerns raised.

Conclusion

While participants relished improvement in their economic fortunes upon commercial legalisation of marijuana cultivation and trading, they were also apprehensive about this policy due to the perceived consequences it may have on their livelihoods and communities. We, therefore, recommend that future discussions of the commercial legalisation of marijuana cultivation and trading in South Africa should be done in consultation with illicit marijuana growers and traders to ensure that their interests are safeguarded by such a policy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00391-w.

Socio-ecological influences of adolescence marijuana use initiation: Qualitative evidence from two illicit marijuana-growing communities in South Africa

Background

Adolescence has been identified as a critical risk period for substance use initiation, such as marijuana. Although several factors have been cited for adolescent marijuana use, those that influence initiation, especially in an African setting where illicit marijuana activities are rife, have not been contextually explored.

Aim

We ascertained the factors that influence adolescent marijuana use initiation in two marijuana-growing communities in the Eastern Cape province of South Africa, based on the constructs of the socio-ecological model.

Setting

The study was conducted in two selected illicit marijuana growing communities in the Ingquza Hill Local Municipality of the Eastern Cape province of South Africa.

Methods

Focus group discussions (FGDs) were conducted among 37 participants, grouped into four focus groups. Purposive and snowball sampling techniques were used to select the communities and participants, respectively. An FGD guide was used to collect the data. The data were analysed using thematic content analysis approach and presented under various themes.

Results

Twelve influences of adolescent marijuana use initiation, grouped under three main levels of socio-ecological influence, personal characteristics (curiosity, shyness and fulfilment of personal need), micro-level influences (peer pressure, negative school climate, presence of marijuana in households and parental or sibling marijuana use) and macro-level influences (child labour, poverty, presence of marijuana in communities, presence of negative adult role models and breakdown in communal restrictions against marijuana use), were found.

Conclusion

Health promotion programmes, targeting socio-ecological motives of adolescent marijuana use initiation in the two communities, should be intensified to break the cycle of adolescent marijuana use. Also, alternative livelihood schemes should be implemented in the affected communities to break the cycle of illegal marijuana cultivation that promotes adolescent marijuana use.

Community utilisation and satisfaction with the community-based health planning and services initiative in Ghana: a comparative study in two system learning districts of the CHPS+ project

BACKGROUND

To strengthen the implementation of the Community-based Health Planning and Services (CHPS) programme which is Ghana's key primary health care delivery strategy, the CHPS+ Project was initiated in 2017. We examined community utilisation and satisfaction with CHPS services in two System Learning Districts (SLDs) of the project.

METHODS

This community-based descriptive study was conducted in the Nkwanta South Municipality and Central Tongu District of Ghana. Data were collected from 1008 adults and analysed using frequency, percentage, chi-square, and logistic regression models.

RESULTS

While the level of utilisation of CHPS services was 65.2%, satisfaction was 46.1%. Utilisation was 76.7% in Nkwanta South and 53.8% in Central Tongu. Satisfaction was also 55.2% in Nkwanta South and 37.1% in Central Tongu. Community members in Nkwanta South were more likely to utilise (AOR = 3.17, 95%CI = 3.98-9.76) and be satisfied (AOR = 2.77, 95%CI = 1.56-4.90) with CHPS services than those in Central Tongu. Females were more likely to utilise (AOR = 1.75, 95%CI = 1.27-2.39) but less likely to be satisfied [AOR = 0.47, 95%CI = 0.25-0.90] with CHPS services than males. Even though subscription to the National Health Insurance Scheme (NHIS) was just 46.3%, NHIS subscribers were more likely to utilise (AOR = 1.51, 95%CI = 1.22-2.03) and be satisfied (AOR = 1.45, 95%CI = 0.53-1.68) with CHPS services than non-subscribers.

CONCLUSION

Ghana may not be able to achieve the goal of universal health coverage (UHC) by the year 2030 if current levels of utilisation and satisfaction with CHPS services persist. To accelerate progress towards the achievement of UHC with CHPS as the vehicle through which primary health care is delivered, there should be increased public education by the Ghana Health Service (GHS) on the CHPS concept to increase utilisation. Service quality should also be improved by the GHS and other stakeholders in Ghana's health industry to increase satisfaction with CHPS services. The GHS and the National Health Insurance Authority (NHIA) should also institute innovative strategies to increase subscription to the NHIS since it has implications for CHPS service utilisation and satisfaction.

Knowledge and Other Predictors of Child Welfare Clinic Completion among Children Aged 24-59 Months in the Garu-Tempane District of Northern Ghana: A Cross-Sectional Study of Caregivers

BACKGROUND

While completion of the Child Welfare Clinic (CWC) schedule for children remains a crucial factor in the prevention of illness and promotion of better child health, there has been low attendance among caregivers in Ghana. This study examined knowledge of 220 caregivers of children aged 24-59 months on CWC and other factors influencing attendance in the Garu-Tempane District of Northern Ghana.

METHODS

This health facility-based descriptive cross-sectional study was carried out among caregivers of children using a structured questionnaire. Descriptive and inferential statistics comprising frequency, percentage, Fisher's exact test, and logistic regression were adopted in analysing the data.

RESULTS

Less than half (46.9%) of the children completed their CWC schedules. Meanwhile, caregivers' knowledge on CWC was 97.7%. Children aged 37-48 months (AOR = 0.42, 95%CI = 0.21-0.86, p=0.017) and 49-59 months (AOR = 0.27, 95%CI = 0.10-0.77, p=0.014), respectively, had lower odds of completing CWC. Children with caregivers not having any formal education also had lower odds of completing CWC (AOR = 0.45, 95%CI = 0.21-0.95, p=0.036).

CONCLUSION

Educational programmes on the importance of CWC completion should focus on caregivers with children aged 37 months and above and those caregivers with low educational level. It is further recommended that studies be conducted to explore the extent of association between caregivers' marital status, occupation, level of knowledge, and child CWC completion in the Garu-Tempane District.

Self-reported breast and cervical cancer screening practices among women in Ghana: predictive factors and reproductive health policy implications from the WHO study on global AGEing and adult health

BACKGROUND

Breast and cervical cancers constitute the two leading causes of cancer deaths among women in Ghana. This study examined breast and cervical screening practices among adult and older women in Ghana.

METHODS

Data from a population-based cross-sectional study with a sample of 2749 women were analyzed from the study on global AGEing and adult health conducted in Ghana between 2007 and 2008. Binary and multivariable ordinal logistic regression analyses were performed to assess the association between socio-demographic factors, breast and cervical screening practices.

RESULTS

We found that 12.0 and 3.4% of adult women had ever had pelvic screening and mammography respectively. Also, 12.0% of adult women had either one of the screenings while only 1.8% had both screening practices. Age, ever schooled, ethnicity, income quantile, father's education, mother's employment and chronic disease status were associated with the uptake of both screening practices.

CONCLUSION

Nationwide cancer awareness campaigns and education should target women to improve health seeking behaviours regarding cancer screening, diagnosis and treatment. Incorporating cancer screening as a benefit package under the National Health Insurance Scheme can reduce financial barriers for breast and cervical screening.

Volunteer responsibilities, motivations and challenges in implementation of the community-based health planning and services (CHPS) initiative in Ghana: qualitative evidence from two systems learning districts of the CHPS+ project

BACKGROUND

Community volunteerism is essential in the implementation of the Community-based Health Planning and Services (CHPS) in Ghana. We explored the responsibilities, motivations and challenges of community health management committees (CHMCs) in two CHPS+ Project districts in Ghana.

METHODS

We used a qualitative approach to collect data through 4 focus group discussions among a purposive sample of community health volunteers in December 2018 and analysed them thematically.

RESULTS

Community health management committees (CHMCs) were found to provide support in running the CHPS programme through resource mobilisation, monitoring of logistics, assisting the Community Health Officers (CHO) in the planning of CHPS activities, and the resolution of conflicts between CHOs and community members. The value, understanding and protective functions were the key motivations for serving on CHMCs. Financial, logistical and telecommunication challenges, lack of recognition and cooperation from community members, lack of motivation and lack of regular skill development training programmes for CHMC members who serve as traditional birth attendants (TBAs) were major challenges in CHMC volunteerism.

CONCLUSION

Community health volunteerism needs to be prioritised by the Ghana Health Service and other health sector stakeholders to make it attractive for members to give off their best in the discharge of their responsibilities.

The role of built environment practitioners in driving the socio-economic sustainability aspects of sustainable regeneration

In the United Kingdom (UK), over the past three decades efforts have been made to ensure adequate promotion of sustainability objectives through various policy initiatives. However, despite the effort and the existence of these policy initiatives, sustainability projects in particular, regeneration projects are yet to deliver their intended sustainability objectives.  While there is a rise in demand for higher sustainability benefits by stakeholders such as clients, communities and policy makers, the delivery of sustainability benefits from sustainability regeneration projects are yet to meet the expectations of these stakeholders. This article provides an overview of sustainability benefits within the context of the sustainable regeneration projects in the UK from a study that examines the roles and sustainability drivers of construction practitioners towards the promotion of sustainability on their regeneration projects. To do so, a qualitative research approach is adopted using a semi-structured interview technique for the study. The data obtained was analysed using content analysis. The findings revealed that out of the eight socio-economic sustainability drivers presented to practitioners, enhancement of reputation was the most important ‘socio-economic’ sustainability driver while the least important driver was legislative and legal requirement. The findings further revealed that majority of practitioners/ organisations were promoting the socio-economic sustainability driver they believed will enable them to meet their own corporate business objectives.

Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care

BACKGROUND

In 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017.

METHODS

This exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed.

RESULTS

Negative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns.

CONCLUSION

Health-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme.

Cardiomyocyte mechanodynamics under conditions of actin remodelling

The mechanical performance of cardiomyocytes (CMs) is an important indicator of their maturation state and of primary importance for the development of therapies based on cardiac stem cells. As the mechanical analysis of adherent cells at high-throughput remains challenging, we explore the applicability of real-time deformability cytometry (RT-DC) to probe cardiomyocytes in suspension. RT-DC is a microfluidic technology allowing for real-time mechanical analysis of thousands of cells with a throughput exceeding 1000 cells per second. For CMs derived from human-induced pluripotent stem cells, we determined a Young's modulus of 1.25 ± 0.08 kPa which is in close range to previous reports. Upon challenging the cytoskeleton with cytochalasin D (CytoD) to induce filamentous actin depolymerization, we distinguish three different regimes in cellular elasticity. Transitions are observed below 10 nM and above 103 nM and are characterized by a decrease in Young's modulus. These regimes can be linked to cytoskeletal and sarcomeric actin contributions by CM contractility measurements at varying CytoD concentrations, where we observe a significant reduction in pulse duration only above 103 nM while no change is found for compound exposure at lower concentrations. Comparing our results to mechanical cell measurements using atomic force microscopy, we demonstrate for the first time to our knowledge, the feasibility of using a microfluidic technique to measure mechanical properties of large samples of adherent cells while linking our results to the composition of the cytoskeletal network. This article is part of a discussion meeting issue 'Single cell ecology'.

Prevalence and associated risk factors of anaemia among women attending antenatal and post-natal clinics at a public health facility in Ghana

BACKGROUND

Anaemia among pregnant women and post-partum mothers is a public health challenge in Ghana, especially in the Volta Region. While literature abounds on anaemia among pregnant women, the same cannot be said for anaemia among post-partum mothers in the region. This study, therefore, examined the prevalence and associated risk factors of anaemia among women attending antenatal care and post-natal care.

METHODS

This descriptive cross-sectional survey recruited 409 pregnant women and 194 post-natal mothers attending antenatal and post-natal care, at the Hohoe Municipal Hospital. Background characteristics were collected using a semi-structured questionnaire, blood samples were analysed for the presence of anaemia and malaria parasitaemia and folders were reviewed for estimated blood loss.

RESULTS

We found the prevalence of anaemia among pregnant women and post-partum mothers to be 33 and 16% respectively. Higher malaria parasitaemia (2%) was found in pregnant women compared with postpartum mothers (1%). We found that 4% of post-partum mothers had abnormal blood loss (301mls-500mls) whereas 5% of them had postpartum haemorrhage (>500mls) during child birth. A univariate logistics regression of anaemia status on some risk factors in pregnant women showed no significant association between anaemia and any of the risk factors. Among post-partum mothers, only mothers' age was statistically significant in the univariate analysis [COR = 0.27 (95% CI:0.103, 0.72);0.008]. Mothers aged 20-29 were 73% less likely to be anaemic.

CONCLUSION

The prevalence of anaemia among pregnant women found in this study points to a situation of moderate public health problem according to WHO cut-off values for the public health significance of anaemia. Strategies should therefore be put in place to encourage thorough health education and promotion programmes among both pregnant and post-partum women.

Dog Owners' Knowledge about Rabies and Other Factors That Influence Canine Anti-Rabies Vaccination in the Upper East Region of Ghana

BACKGROUND

Human rabies, often contracted through dog bites, is a serious but neglected public health problem in the tropics, including Ghana. Due to its high fatality rate, adequate knowledge and vaccination of domestic dogs against the disease are very crucial in reducing its burden. We examined dog owners' knowledge level on rabies and factors that influenced anti-rabies vaccination of dogs in the Upper East Region of Ghana.

METHODS

This descriptive cross-sectional study was conducted among 260 randomly sampled dog owners in six communities from six Districts using a multistage sampling technique, in the Upper East Region of Ghana. An interviewer-administered questionnaire was used to collect data from the respondents. Descriptive and inferential analyses were done using STATA 14.1.

RESULTS

While knowledge about rabies was 199 (76.5%), that about anti-rabies vaccination was 137 (52.7%). District of residence (χ2 = 112.59, p < 0.001), sex (χ2 = 6.14, p = 0.013), education (χ2 = 20.45, p < 0.001) as well as occupation (χ2 = 11.97, p = 0.007) were significantly associated with rabies knowledge. District of residence (χ2 = 57.61, p < 0.001), Educational level (χ2 = 15.37, p = 0.004), occupation (χ2 = 11.66, p = 0.009), religion (χ2 = 8.25, p = 0.016) and knowledge on rabies (χ2 = 42.13, p < 0.001) were also statistically associated with dog vaccination against rabies. Dog owners with good knowledge on rabies for instance, were more likely to vaccinate their dogs against rabies compared to those with poor knowledge [AOR = 1.99 (95% CI: 0.68, 5.86), p = 0.210]. Dog owners with tertiary level of education were also 76.31 times more likely (95% CI: 6.20, 938.49, p = 0.001) to have good knowledge about rabies compared to those with no formal education.

CONCLUSIONS

Dog owners in the Upper East Region of Ghana had good knowledge about rabies. This, however, did not translate into correspondingly high levels of dog vaccination against the disease. Rabies awareness and vaccination campaigns should, therefore, be intensified in the region, especially among the least educated and female dog owners.

Briefing: The role of human values in behavioural safety

While behaviour-based safety (BBS) is not new and is even becoming increasingly common, particularly among large construction organisations, research on BBS and hence its implementation has paid limited attention to the role of innate drivers of behaviour, particularly human values (e.g. individual worker values). It is argued in this paper that there is a need for empirical studies in this area towards the generation of fresh insight that could be valuable for designing more robust interventions for strengthening BBS programmes.

A cognitive approach to trust management in construction

There is a growing body of literature on trust in construction management but only a few studies have focused on how outcomes of the trustworthiness estimation process influences trust development during project execution. Based on an extensive critique of the extant literature, this study aims to explore whether the estimation of contractor's trustworthiness in construction usually aligns with a cynical, realist or gullible outcome and further how such outcomes influence inter-organisational governance and trust development during project execution. It is argued that in construction, cynical outcomes are usually the case and hence the starting point of contractual relationships. Cynical outcomes – conscious underestimation of contractor's trustworthiness so as to safeguard the transaction – impose starting conditions which often result in negative rather than positive spirals of trust during project execution. In practice, such positions could result in over-allocation of resources to safeguard against opportunism while foregoing potential benefits of trust-induced co-operation. Reaching a realist outcome could inform the selection of appropriate control and managerial strategies. This could also help to improve cost performance by reducing the excessive transaction costs involved in establishing and maintaining control-induced co-operation.