Cost-effectiveness of a Community-based Hypertension Improvement Project (ComHIP) in Ghana: results from a modelling study

OBJECTIVE

To undertake a cost-effectiveness analysis of a Community-based Hypertension Improvement Project (ComHIP) compared with standard hypertension care in Ghana.

DESIGN

Cost-effectiveness analysis using a Markov model.

SETTING

Lower Manya Krobo, Eastern Region, Ghana.

INTERVENTION

We evaluated ComHIP, an intervention with multiple components, including: community-based education on cardiovascular disease (CVD) risk factors and healthy lifestyles; community-based screening and monitoring of blood pressure by licensed chemical sellers and CVD nurses; community-based diagnosis, treatment, counselling, follow-up and referral of hypertension patients by CVD nurses; telemedicine consultation by CVD nurses and referral of patients with severe hypertension and/or organ damage to a physician; information and communication technologies messages for healthy lifestyles, treatment adherence support and treatment refill reminders for hypertension patients; Commcare, a cloud-based health records system linked to short-message service (SMS)/voice messaging for treatment adherence, reminders and health messaging. ComHIP was evaluated under two scale-up scenarios: (1) ComHIP as currently implemented with support from international partners and (2) ComHIP under full local implementation.

MAIN OUTCOME MEASURES

Incremental cost per disability-adjusted life-year (DALY) averted from a societal perspective over a time horizon of 10 years.

RESULTS

ComHIP is unlikely to be a cost-effective intervention, with current ComHIP implementation and ComHIP under full local implementation costing on average US$12 189 and US$6530 per DALY averted, respectively. Results were robust to uncertainty analyses around model parameters.

CONCLUSIONS

High overhead costs and high patient costs in ComHIP suggest that the societal costs of ensuring appropriate hypertension care are high and may not produce sufficient impact to achieve cost-effective implementation. However, these results are limited by the evidence quality of the effectiveness estimates, which comes from observational data rather than from randomised controlled study design.

'What the herbal medicine can do for me in a week, the orthodox does in a year': Perceived efficacy of local alternative therapies influences medication adherence in patients with atherosclerotic cardiovascular disease

Background

There is strong evidence that anti‐platelet therapy, ACE inhibitors, beta‐blockers and statins are cost‐effective in reducing subsequent cardiovascular disease (CVD) events in patients with atherosclerotic cardiovascular disease (ACVD). In some settings, only a low proportion of people have access to these medications, and even lower adhere to them. The current study explored and presents data on the causes of poor adherence to orthodox medication and motivations for alternative therapies in patients with established atherosclerotic cardiovascular disease (ACVD).

Methods

The study was conducted among city‐dwelling adults with ACVD in Accra – Ghana's capital city. Eighteen interviews were conducted with patients with established ACVD. A follow‐up focus group discussion was conducted with some of them. The protocol was approved by two ethics review committees based in Ghana and in the United Kingdom. All participants were interviewed after informed consent. Analysis was done with the Nvivo qualitative data analysis software.

Results

We identified motivations for use of alternatives to orthodox therapies. These cover the five dimensions of adherence: social and economic, health‐care system, condition‐related, therapy‐related, and patient‐related dimensions. Perceived inability of an orthodox medication to provide immediate benefit is an important motivator for use of alternative forms of medication.

Conclusions

A multiplicity of factors precipitate non‐adherence to orthodox therapies. Perceived efficacy and easy access to local alternative therapies such as herbal and faith‐based therapies are important motivators.

Barriers and facilitators to the implementation of a community-based hypertension improvement project in Ghana: a qualitative study of ComHIP

BACKGROUND

Globally, hypertension is a leading cause of cardiovascular disease and mortality, with the majority of deaths occurring in low- and middle-income countries. Because the burden of hypertension is increasing in low resource settings with restricted infrastructure, it is imperative that new models for hypertension care are realised. One such model is the Community-based Hypertension Improvement Project (ComHIP) which employs a community-based method of task-shifting for managing hypertension. This study is a qualitative analysis of the barriers and facilitators of the main components of ComHIP.

METHODS

We purposively selected 55 informants for semi-structured interviews or focus group discussions, which were carried out bythree trained local researchers in Krobo, Twi or English. Informants included patients enrolled in ComHIP, health care providers and Licensed Chemical Sellers trained by ComHIP, and Ghana Health Service employees. Data were analysed using a multi-step thematic analysis.

RESULTS

While results of the effectiveness of the intervention are pending, overall, patients and nurses reported positive experiences within ComHIP, and found that it helped enable them to manage their hypertension. Healthcare providers appreciated the additional training, but had some gaps in their knowledge. Ghana Health Service employees were cautiously optimistic about the programme, but expressed some worries about the sustainability of the programme. Many informants expressed concerns over the inability of community nurses and workers to dispense anti-hypertensives, due to legal restrictions.

CONCLUSIONS

The WHO recommends task-sharing as a technique for managing chronic conditions such as hypertension in resource constrained settings. ComHIP presents an example of a task-sharing programme with a high level of acceptability to all participants. Going forward, we recommend greater levels of communication and dialogue to allow community-based health workers to be allowed to dispense anti-hypertensives.

Health system challenges to hypertension and related non-communicable diseases prevention and treatment: perspectives from Ghanaian stakeholders

BACKGROUND

Hypertension, itself a cardiovascular condition, is a significant risk factor for other cardiovascular diseases. Hypertension is recognized as a major public health challenge in Ghana. Beginning in 2014, a collaborative team launched the community-based hypertension improvement program (ComHIP) in one health district in Ghana. The ComHIP project, a public-private partnership, tests a community-based model that engages the private sector and utilizes information and communication technology (ICT) to control hypertension. This paper, focuses on the various challenges associated with managing hypertension in Ghana, as reported by ComHIP stakeholders.

METHODS

A total of 55 informants - comprising patients, health care professionals, licensed chemical sellers (LCS), national and sub-national policymakers - were purposively selected for interview and focus group discussions (FGDs). Interviews were audio-recorded and transcribed verbatim. Where applicable, transcriptions were translated directly from local language to English. The data were then analysed using two-step thematic analysis. The protocol was approved by the two ethics review committees based in Ghana and the third, based in the United Kingdom. All participants were interviewed after giving informed consent.

RESULTS

Our data have implications for the on-going implementation of ComHIP, especially the importance of policy maker buy-in, and the benefits, as well as drawbacks, of the program to different stakeholders. While our data show that the ComHIP initiative is acceptable to patients and healthcare providers - increasing providers' knowledge on hypertension and patients' awareness of same- there were implementation challenges identified by both patients and providers. Policy level challenges relate to task-sharing bottlenecks, which precluded nurses from prescribing or dispensing antihypertensives, and LCS from stocking same. Medication adherence and the phenomenon of medical pluralism in Ghana were identified challenges. The perspectives from the national level stakeholders enable elucidation of whole of health system challenges to ComHIP and similarly designed programmes.

CONCLUSIONS

This paper sheds important light on the patient/individual, and system level challenges to hypertension and related non-communicable disease prevention and treatment in Ghana. The data show that although the ComHIP initiative is acceptable to patients and healthcare providers, policy level task-sharing bottlenecks preclude optimal implementation of ComHIP.

Can a nurse-led community-based model of hypertension care improve hypertension control in Ghana? Results from the ComHIP cohort study

OBJECTIVES

To evaluate the effectiveness of the Community-based Hypertension Improvement Project (ComHIP) in increasing hypertension control.

SETTING

Lower Manya Krobo, Eastern Region, Ghana.

PARTICIPANTS

All adult hypertensive community members, except pregnant women, were eligible for inclusion in the study. We enrolled 1339 participants, 69% of whom were female. A total of 552 had a 6-month visit, and 338 had a 12-month visit.

INTERVENTIONS

We report on a package of interventions where community-based cardiovascular disease (CVD) nurses were trained by FHI 360. CVD nurses confirmed diagnoses of known hypertensives and newly screened individuals. Participants were treated according to the clinical guidelines established through the project's Technical Steering Committee. Patients received three types of reminder and adherence messages. We used CommCare, a cloud-based system, as a case management and referral tool.

PRIMARY OUTCOME

Hypertension control defined as blood pressure (BP) under 140/90 mm Hg.

SECONDARY OUTCOMES

changes in BP and knowledge of risk factors for hypertension.

RESULTS

After 1 year of intervention, 72% (95% CI: 67% to 77%) of participants had their hypertension under control. Systolic BP was reduced by 12.2 mm Hg (95% CI: 14.4 to 10.1) and diastolic BP by 7.5 mm Hg (95% CI: 9.9 to 6.1). Due to low retention, we were unable to look at knowledge of risk factors. Factors associated with remaining in the programme for 12 months included education, older age, hypertension under control at enrolment and enrolment date. The majority of patients who remained in the programme were on treatment, with two-thirds taking at least two medications.

CONCLUSIONS

Patients retained in ComHIP had increased BP control. However, high loss to follow-up limits potential public health impact of these types of programmes. To minimise the impact of externalities, programmes should include standard procedures and backup systems to maximise the possibility that patients stay in the programme.

Best practices in scaling digital health in low and middle income countries

Healthcare challenges in low and middle income countries (LMICs) have been the focus of many digital initiatives that have aimed to improve both access to healthcare and the quality of healthcare delivery. Moving beyond the initial phase of piloting and experimentation, these initiatives are now more clearly focused on the need for effective scaling and integration to provide sustainable benefit to healthcare systems.Based on real-life case studies of scaling digital health in LMICs, five key focus areas have been identified as being critical for success. Firstly, the intrinsic characteristics of the programme or initiative must offer tangible benefits to address an unmet need, with end-user input from the outset. Secondly, all stakeholders must be engaged, trained and motivated to implement a new initiative, and thirdly, the technical profile of the initiative should be driven by simplicity, interoperability and adaptability. The fourth focus area is the policy environment in which the digital healthcare initiative is intended to function, where alignment with broader healthcare policy is essential, as is sustainable funding that will support long-term growth, including private sector funding where appropriate. Finally, the extrinsic ecosystem should be considered, including the presence of the appropriate infrastructure to support the use of digital initiatives at scale.At the global level, collaborative efforts towards a less-siloed approach to scaling and integrating digital health may provide the necessary leadership to enable innovative solutions to reach healthcare workers and patients in LMICs. This review provides insights into best practice for scaling digital health initiatives in LMICs derived from practical experience in real-life case studies, discussing how these may influence the development and implementation of health programmes in the future.

The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review

BACKGROUND

The evidence on the economic burden of cardiovascular disease (CVD) in low- and middle- income countries (LMICs) remains scarce. We conducted a comprehensive systematic review to establish the magnitude and knowledge gaps in relation to the economic burden of CVD and hypertension on households, health systems and the society.

METHODS

We included studies using primary or secondary data to produce original economic estimates of the impact of CVD. We searched sixteen electronic databases from 1990 onwards without language restrictions. We appraised the quality of included studies using a seven-question assessment tool.

RESULTS

Eighty-three studies met the inclusion criteria, most of which were single centre retrospective cost studies conducted in secondary care settings. Studies in China, Brazil, India and Mexico contributed together 50% of the total number of economic estimates identified. The quality of the included studies was generally low. Reporting transparency, particularly for cost data sources and results, was poor. The costs per episode for hypertension and generic CVD were fairly homogeneous across studies; ranging between $500 and $1500. In contrast, for coronary heart disease (CHD) and stroke cost estimates were generally higher and more heterogeneous, with several estimates in excess of $5000 per episode. The economic perspective and scope of the study appeared to impact cost estimates for hypertension and generic CVD considerably less than estimates for stroke and CHD. Most studies reported monthly costs for hypertension treatment around $22. Average monthly treatment costs for stroke and CHD ranged between $300 and $1000, however variability across estimates was high. In most LMICs both the annual cost of care and the cost of an acute episode exceed many times the total health expenditure per capita.

CONCLUSIONS

The existing evidence on the economic burden of CVD in LMICs does not appear aligned with policy priorities in terms of research volume, pathologies studied and methodological quality. Not only is more economic research needed to fill the existing gaps, but research quality needs to be drastically improved. More broadly, national-level studies with appropriate sample sizes and adequate incorporation of indirect costs need to replace small-scale, institutional, retrospective cost studies.

Evaluation of a community-based hypertension improvement program (ComHIP) in Ghana: data from a baseline survey

BACKGROUND

Ghana faces an increasing burden of non-communicable disease with rates of hypertension estimated as high as 36% in adults. Despite these high rates, hypertension control remains very poor in Ghana (4%). The current project aims to implement and evaluate a community-based programme to raise awareness, and to improve treatment and control of hypertension in the Eastern Region of Ghana. In this paper, we present the findings of the baseline cross-sectional survey focusing on hypertension prevalence, awareness, treatment, and control.

METHODS

To evaluate the ComHIP project, a quasi-experimental design consisted of a before and after evaluations are being implemented in the intervention and comparison districts. A cohort study component is being implemented in the intervention district to assess hypertension control. Background anthropometric and clinical data collected as part of the baseline survey were analyzed in STATA Version 11. We examined the characteristics of individuals, associated with the baseline study outcomes using logistic regression models.

RESULTS

We interviewed 2400 respondents (1200 each from the comparison and intervention districts), although final sample sizes after data cleaning were 1170 participants in the comparison district and 1167 in the intervention district. With the exception of ethnicity, the control and intervention districts compare favorably. Overall 32.4% of the study respondents were hypertensive (31.4% in the control site; and 33.4% in the intervention site); 46.2% of hypertensive individuals were aware of a previous diagnosis of hypertension (44.7% in the control site, and 47.7% in the intervention site), and only around 9% of these were being treated in either arm. Hypertension control was 1.3% overall (0.5% in the comparison site, and 2.1% in the intervention site). Age was a predictor of having hypertension, and so was increasing body mass index (BMI), waist, and hip circumferences. After adjusting for age, the risk factors with the greatest association with hypertension were being overweight (aOR = 2.30; 95% CI 1.53-3.46) or obese (aOR = 3.61; 95% CI 2.37-5.51). Older individuals were more likely to be aware of their hypertension status than younger people. After adjusting for age people with a family history of hypertension or CVD, or having an unhealthy waist hip ratio, were more likely to be aware of their hypertension status.

CONCLUSIONS

The high burden of hypertension among the studied population, coupled with high awareness, yet very low level of hypertension treatment and control requires in-depth investigation of the bottlenecks to treatment and control. The low hypertension treatment and control rates despite current and previous general educational programs particularly in the intervention district, may suggest that such programs are not necessarily impactful on the health of the population.

Innovating healthcare delivery to address noncommunicable diseases in low-income settings: the example of hypertension

London Dialogue event, The Hospital Club, 24 Endell St, London, WC2H 9HQ, London, UK, 1 December 2015 Hypertension is a global health issue causing almost 10 million deaths annually, with a disproportionate number occurring in low- and middle-income countries. The condition can be managed effectively, but there is a need for innovation in healthcare delivery to alleviate its burden. This paper presents a number of innovative delivery models from a number of different countries, including Kenya, Ghana, Barbados and India. These models were presented at the London Dialogue event, which was cohosted by the Novartis Foundation and the London School of Hygiene & Tropical Medicine Centre for Global Noncommunicable Diseases on 1 December 2015. It is argued that these models are applicable not only to hypertension, but provide valuable lessons to address other noncommunicable diseases.

Towards a comprehensive global approach to prevention and control of NCDs

BACKGROUND

The "25×25" strategy to tackle the global challenge of non-communicable diseases takes a traditional approach, concentrating on a few diseases and their immediate risk factors.

DISCUSSION

We propose elements of a comprehensive strategy to address NCDs that takes account of the evolving social, economic, environmental and health care contexts, while developing mechanisms to respond effectively to local patterns of disease. Principles that underpin the comprehensive strategy include: (a) a balance between measures that address health at the individual and population level; (b) the need to identify evidence-based feasible and effective approaches tailored to low and middle income countries rather than exporting questionable strategies developed in high income countries; (c) developing primary health care as a universal framework to support prevention and treatment; (d) ensuring the ability to respond in real time to the complex adaptive behaviours of the global food, tobacco, alcohol and transport industries; (e) integrating evidence-based, cost-effective, and affordable approaches within the post-2015 sustainable development agenda; (f) determination of a set of priorities based on the NCD burden within each country, taking account of what it can afford, including the level of available development assistance; and (g) change from a universal "one-size fits all" approach of relatively simple prevention oriented approaches to more comprehensive multi-sectoral and development-oriented approaches which address both health systems and the determinants of NCD risk factors.

SUMMARY

The 25×25 is approach is absolutely necessary but insufficient to tackle the the NCD disease burden of mortality and morbidity. A more comprehensive approach is recommended.

Normal CD4+ T Lymphocyte Levels in HIV Seronegative Individuals in the Manya/Yilo Krobo Communities in the Eastern Region of Ghana

The goal of this study was to determine the normal levels of CD4+ T lymphocytes in healthy individuals who were HIV seronegative in the Manya and Yilo Krobo Districts of Ghana's Eastern Region. This enabled comparisons with normal CD4 count ranges established by the World Health Organization (WHO). The study population consisted of 249 HIV-seronegative clients from a mobile free Voluntary Counseling and Testing (VCT) service in communities of the two districts during a one-month period. The mean CD4 count of these individuals was 1067 cells/microl with women demonstrating higher baseline CD4 counts than men. This study found a WHO comparable HIV seronegative baseline CD4 count as well as gender-based differences in the CD4 count and CD4/CD8 ratio. Establishment of the adult baseline for the country provides important demographic data and indicates the appropriateness of current global treatment guidelines with regards to CD4 levels in Ghana.

Scaling up AIDS treatment: what is the potential impact and what are the risks?

Lamptey and Wilson discuss the implications of a new study showing that combining treatment with prevention is the best approach to tackling the HIV pandemic.

Evaluation of a targeted AIDS prevention intervention to increase condom use among prostitutes in Ghana

OBJECTIVE

To assess the short- and long-term impact of a 6-month pilot intervention program on condom use among prostitutes in Accra, Ghana.

DESIGN

The 4-year prospective study follows-up cohorts enrolled in the intervention in 1987 and 1988, comparing condom use in 1991 with that among a comparison group not enrolled in the intervention.

SETTING

The community-based intervention was initiated in Accra, Ghana in 1987.

PARTICIPANTS

Self-identified female prostitutes who volunteered participation.

INTERVENTION

The educational intervention used local health workers to train and support selected prostitutes to be health educators and condom distributors to their peers.

OUTCOME MEASURES

Self-reported condom use with clients.

RESULTS

Reported condom use increased dramatically between 1987 and 1988 during the first 6 months of the intervention. In 1991, after 3 years of program relapse, 107 (43%) of the 248 women who had enrolled in 1987 or 1988 were still in prostitution and located for interview. Their level of condom use in 1991 was higher than pre-enrollment but similar to use among prostitutes never enrolled. Sixty-four per cent of those followed-up reported always using condoms with clients in 1991. These 'always users' were more likely to have maintained informal contact with project staff, know that HIV can be transmitted by healthy clients, and report that clients frequently initiate condom use.

CONCLUSIONS

Findings support the development of long-range educational strategies that recognize the career longevity of prostitutes, available channels for informal program diffusion, individual changes in condom use over time, and the role of clients in condom negotiation.

Do the benefits of breastfeeding outweigh the risk of postnatal transmission of HIV via breastmilk?

Conflicting recommendations have been offered about whether HIV+ mothers should breastfeed. Since there is a strong precedent for US infant feeding practices to be imitated in developing countries, a model was constructed to estimate infant mortality if the CDC admonition for HIV+ mothers not to breastfeed were upheld in less developed settings. Estimates are given for infant mortality in the presence and absence of breastfeeding across several baseline levels of infant mortality and across several theoretical rates of transmission through breastfeeding. The infant mortality associated with HIV infection acquired through breastfeeding is estimated to be lower than the mortality associated with the diseases of infancy that would result if breastmilk were withheld. The difference in these estimates is greater in areas with high baseline levels of infant mortality.

Tubal ligation at cesarean delivery in five Asian centers: a comparison with tubal ligation soon after vaginal delivery

Increasingly more tubal sterilizations are being performed at the time of cesarean section in the United States and probably also in developing countries. This descriptive study provides us with hitherto unavailable information on the impact of this combined procedure on the women undergoing it. Five Asian centers were included for study. In these centers, 618 women had concurrent tubal ligation at cesarean section in 1973 and 1974. During this period, 3399 women had tubal ligation soon after term vaginal deliveries. The much higher morbidity and mortality in the former group were judged to be attributable to the indications leading to, or the complications of, cesarean section and not to the concurrent tubal ligation. Women undergoing the combined procedure of tubal ligation and cesarean section were more likely to have characteristics associated with later regretting the sterilization.

The percutaneous electrocoagulation vasectomy technique--a comparative trial with the standard incision technique at Marie Stopes House, London

One-hundred-and-one men requesting vasectomy in 1985 for the purpose of limiting family size were admitted to a study of standard incision and monopolar diathermy, and a new percutaneous electrocoagulation vasectomy procedure. Semen specimens were tested at 10 and 12 weeks after surgery. Men were telephoned at 2, 12 and 24 weeks post-surgery to elicit complications and complaints. Half of the men having the standard incision procedure and about one-third of the men undergoing the percutaneous procedure complained of discomfort during the surgery. At the two-week telephone contact, 23% of those having the standard incision and 66% of those having the percutaneous procedure reported complications. There were few complications or complaints reported at the long-term follow-up contacts with either method; although twice as many men in the percutaneous group were not declared sterile by the end of the study period. Failure rates were 2.0% for the standard incision procedure and 7.8% for the percutaneous approach.

Technical failures in female sterilization using the tubal ring: a case-control analysis

To delineate characteristics of women predisposing to sterilization technical failures, we performed an analysis of 20 technical failures that occurred during tubal ring procedures and 80 control ring procedures matched on planned surgical approach and study site. None of the women had recently been pregnant (interval procedures). The odds ratios (ORs) were elevated for women wearing an IUD in the three months prior to sterilization (OR = 5.0, 90% confidence interval [CI] 2.2, 11.2) and for women with a history of spontaneous abortion (OR = 4.3, 90% CI 1.8, 9.8). A history of pelvic inflammatory disease (PID) and/or current evidence of PID was strongly associated with technical failure (X2 = 25.0, p less than 0.001). The combined effect of any two of these three factors increased the risk synergistically. We examined these factors prospectively and confirmed the elevated risks (relative risk [RR] = 5.0, 5.5 and 22.7 for recent IUD wearing, spontaneous abortion history and history/evidence of PID, respectively). The prospective analysis also found that previous abdominal surgery is associated with technical failure (RR = 6.7).

Physician attitudes and family planning in Nigeria

This study examines family planning attitudes and practices of 681 Nigerian physicians selected from cities in which large university teaching hospitals are located. About half of the physicians were practicing family planning; the method of choice was the IUD. Obstetrician/gynecologists and general practitioners were more likely to provide methods to their patients than were other types of physicians. The physicians were concerned about population growth and favored family planning, yet a substantial minority believed that family planning is foreign to the culture and that it promotes promiscuity. Physicians were reluctant to promote family planning on a wide scale; many disapproved of non-physicians providing oral contraceptives or IUDs.

A comparative study of Neo Sampoon, Ortho Vaginal Tablets and Emko Vaginal Tablets in Accra, Ghana

Neo Sampoon is an effervescent contraceptive vaginal tablet manufactured in Japan that contains 60 mg of the spermicide menfegol. Ortho Vaginal Tablets (OVT) and Emko Vaginal Tablets (EVT), both containing 100 mg of the spermicide nonoxynol-9, were manufactured in the USA. The three products were compared in a randomized clinical trial conducted at the family planning clinics of the Korle-Bu Teaching Hospital and the Kotobaabi Polyclinic in Accra, Ghana. Three-hundred volunteers participated. At 12 months, the life-table pregnancy rates were 9.6, 11.3 and 12.5 per 100 women in the Neo Sampoon, OVT and EVT groups, respectively (p greater than 0.10). More EVT than Neo Sampoon or OVT users discontinued because of discomfort as well as for other product-related reasons (p less than 0.01). The most common reason for discontinuation was the temporary absence of sexual partner, with more than 40% of the women overall terminating for this reason. The 12-month life-table continuation rates per 100 women were higher for the Neo Sampoon group (62.4) than the OVT group (48.6) or the EVT group (38.5) (p less than 0.01). The effectiveness of the three products seems to be similar, but Neo Sampoon and OVT appear to be more acceptable than EVT in this Ghanaian population.

Abortion experience among obstetric patients at Korle-Bu Hospital, Accra, Ghana

Among obstetric patients with at least one previous pregnancy, over 20% reported having at least one induced abortion. Abortion experience was more common among women at lower gravidities and among women with the highest levels of education, suggesting that abortion is most used to delay the first birth, particularly for young women still at school. This is in contrast to the situation in Latin America where abortion is used most often to limit family size.

The proportion of women who reported that they used contraception prior to the pregnancy was low, suggesting that knowledge of attitudes towards and availability of family planning services needs to be improved.

An evaluation of male contraceptive acceptance in rural Ghana

To evaluate the effect of male contraceptive acceptance on fertility, the Danfa Family Planning Project in rural Ghana studied a sample of its male family planning acceptors. The findings show that half of the survey respondents accepted foam for use by their partners and half accepted the condom. The continuation rate (69 percent at 12 months) and use-effectiveness rate (80 percent at 12 months) reported by men were higher than those reported by women program acceptors. It is felt that men can play a significant role in affecting fertility through their influence on a couple's choosing to use contraception and as a result of their motivation to obtain contraception and see that it is used. It is urged that increasing emphasis be placed on providing family planning services for men in African programs.