A comprehensive survey of cancer medicines prices, availability and affordability in Ghana

INTRODUCTION

In Ghana, prices for cancer medicines are characterized by high retail markups, forex fluctuations and high variation in prices of medicines. Most patients cannot afford the cancer medicines. There is a problem of unaffordability and limited availability of essential cancer medicines which suggests potential inequity in patient access to cancer medicines. The study objective was to assess the prices, availability, and affordability of cancer medicines in Ghana. Prices of cancer medicines are a major contributor to the cost of treatment for cancer patients and the comparison of these cost was assessed to determine the affordability.

METHOD

The methods developed and standardized by the World Health Organization (WHO) in collaboration with the Health Action International (HAI), was adapted and used to measure prices, availability, and affordability of cancer medicines in Ghana. The availability of cancer medicines was assessed as percentage of health facilities stocked with listed medicines. The price of cancer medicines (of different brands as well as the same medicine manufactured by different pharmaceutical industries) available in the public hospitals, private hospitals, and private pharmacies was assessed, and the percentage variation in prices was calculated. Medicine prices were compared with the Management Sciences Health's International Reference Prices to obtain a Median Price Ratio (MPR). The affordability of cancer medicines was determined using the treatment cost of a course of therapy for cancer conditions in comparison with the daily wage of the unskilled Lowest-Paid Government Worker.

RESULTS

Overall availability of cancer medicines was very low. The availability of Lowest Priced Generic (LPG) in public hospitals, private hospitals, and private pharmacies was 46%, 22%, and 74% respectively. The availability of Originator Brand (OB) in public hospitals, private hospitals, and private pharmacies was 14%, 11%, and 23% respectively. The lowest median price [United States Dollars (USD)] for the LPG was 0.25, and the highest median price was 227.98. For the OB, the lowest median price was 0.41 and the highest median price was 1321.60. The lowest and highest adjusted MPRs of OBs and LPGs was 0.01 and 10.15 respectively. Some prices were 20.60 times more expensive. Affordability calculations showed that patients with colorectal and multiple myeloma cancer would need 2554 days wages (5286.40 USD) and 1642 days wages (3399.82 USD) respectively to afford treatment.

CONCLUSION

The availability of cancer medicines was very low, and less than the WHO target of 80%. There were considerable variations in the prices of different brands of cancer medicines, and affordability remains suboptimal, as most patients cannot afford the cancer medicines. Comprehensive policies, regulations and multifaceted interventions that provides tax incentives, health insurance, and use of generics to improve cancer medicines availability, prices, and affordability, for the masses should be developed and implemented in Ghana.

Measuring Hypertension Progression With Transition Probabilities: Estimates From the WHO SAGE Longitudinal Study

This paper assessed the transition probabilities between the stages of hypertension severity and the length of time an individual might spend at a particular disease state using the new American College of Cardiology/American Heart Association hypertension blood pressure guidelines. Data for this study were drawn from the Ghana WHO SAGE longitudinal study, with an analytical sample of 1884 across two waves. Using a multistate Markov model, we estimated a seven-year transition probability between normal/elevated blood pressure (systolic ≤ 129 mm Hg & diastolic <80 mm Hg), stage 1 (systolic 130-139 mm Hg & diastolic 80-89 mm Hg), and stage 2 (systolic ≥140mm Hg & diastolic≥90 mm Hg) hypertension and adjusted for the individual effects of anthropometric, lifestyle, and socio-demographic factors. At baseline, 22.5% had stage 1 hypertension and 52.2% had stage 2 hypertension. The estimated seven-year transition probability for the general population was 19.0% (95% CI: 16.4, 21.8) from normal/elevated blood pressure to stage 1 hypertension, 31.6% (95% CI: 27.6, 35.4%) from stage 1 hypertension to stage 2 hypertension, and 48.5% (45.6, 52.1%) for remaining at stage 2. Other factors such as being overweight, obese, female, aged 60+ years, urban residence, low education and high income were associated with an increased probability of remaining at stage 2 hypertension. However, consumption of recommended servings of fruits and vegetables per day was associated with a delay in the onset of stage 1 hypertension and a recovery to normal/elevated blood pressure. This is the first study to show estimated transition probabilities between the stages of hypertension severity across the lifespan in sub-Saharan Africa. The results are important for understanding progression through hypertension severity and can be used in simulating cost-effective models to evaluate policies and the burden of future healthcare.

Annual transition probabilities of overweight and obesity in older adults: Evidence from World Health Organization Study on global AGEing and adult health

Overweight/obesity is becoming increasingly prevalent in sub-Saharan Africa including Ghana. However, transition probabilities, an essential component to develop cost-effective measures for weight management is lacking in this population. We estimated annual transition probabilities between three body mass index (BMI) categories: normal weight (BMI ≥18.5 and <25.0 kg/m2), overweight (BMI ≥25.0 and <30.0 kg/m2), and obesity (BMI ≥30.0 kg/m2), among older adults aged ≥50 years in Ghana. Data were used from a nationally representative, multistage sample of 1496 (44.3% females) older adults in both Waves 1 (2007/8) and 2 (2014/15) of the Ghana WHO SAGE. A multistage Markov model was used to estimate annual transition probabilities. We further examined the impact of specific socio-economic factors on the transition probabilities. At baseline, 22.8% were overweight and 11.1% were obese. The annual transition probability was 4.0% (95% CI: 3.4%, 4.8%) from normal weight to overweight, 11.1% (95% CI: 9.5%, 13.0%) from overweight to normal weight and 4.9% (95% CI: 3.8%, 6.2%) from overweight to obesity. For obese individuals, the probability of remaining obese, transitioning to overweight and completely reverting to normal weight was 90.2% (95% CI: 87.7%, 92.3%), 9.2% (95% CI: 7.2%, 11.6%) and 0.6% (95% CI: 0.4%, 0.8%) respectively. Being female, aged 50-65 years, urban residence, having high education and high wealth were associated with increased probability of transitioning into the overweight or obese categories. Our findings highlight the difficulty in transitioning away from obesity, especially among females. The estimated transition probabilities will be essential in health economic simulation models to determine sustainable weight management interventions.

Mammography examination among women aged 40 years or older in Ghana: evidence from wave 2 of the World Health Organization's study on global AGEing and adult health multicountry longitudinal study

OBJECTIVE

To determine the uptake of mammography among Ghanaian women aged 40 years or older and to examine critical risk factors that influence the uptake.

STUDY DESIGN

A cross-sectional survey.

METHODS

A nationally representative sample of 2787 women and 1948 men aged ≥18 years were surveyed in the Wave 2 (2014-2015) of the World Health Organization's multicountry study on AGEing and adult health in Ghana. Of the 2787 women aged ≥18 years, data on a total of 2301 women aged ≥40 years were included in this study. Univariable and multivariable logistic regression models were applied to examine critical risk factors for mammogram examination.

RESULTS

Of the 2301 women sampled, only 83 (3.61%) ever had mammogram. The odds of mammogram examination were lower for women aged ≥70 years (odds ratio [OR] 0.42, 95% confidence interval [CI]: 0.19, 0.93), being self-employed (OR = 0.21, 95% CI: 0.11, 0.42) and being informal sector employee (OR = 0.26, 95% CI: 0.12, 0.57) in the multivariable analyses. Belonging to the Ewe ethnic group (OR=3.41, 95% CI:1.88, 6.16) compared to the Akan group was associated with increased odds of mammogram examination in the multivariable analysis. Women aged ≥70 years, being self-employed, being an informal employee and belonging to the Ewe ethnic group were independently associated with mammography examination.

CONCLUSION

The prevalence of screening for breast cancer using mammography among Ghanaian women aged 40 years and older was 3.6%. Age, type of employer and ethnicity were associated with an older adult woman's likelihood to access mammography screening. Overall, our study provided critical data to encourage and promote good health-seeking behaviour in terms of breast cancer screening among older adult women. Further qualitative studies are warranted to explore why some of these factors influence mammography.

Evaluation of the Association Between Health State Utilities and Obesity in Sub-Saharan Africa: Evidence From World Health Organization Study on Global AGEing and Adult Health Wave 2

BACKGROUND

Obesity is a major public health challenge and its prevalence has increased across the age spectrum from 1980 to date in most parts of the world including sub-Saharan Africa. Studies that derive health state utilities (HSUs) stratified by weight status to support the conduct of economic evaluations and prioritization of cost-effective weight management interventions are lacking in sub-Saharan Africa.

OBJECTIVES

To estimate age- and sex-specific HSUs for Ghana, along with HSUs by weight status. Associations between HSUs and overweight and obesity will be examined.

STUDY DESIGN

Cross-sectional survey of the Ghanaian population.

METHODS

Data were sourced from the World Health Organization Study of Global AGEing and Adult Health (WHO SAGE), 2014 to 2015. Using a "judgment-based mapping" method, responses to items from the World Health Organization Quality-of-Life (WHOQOL-100) used in the WHO SAGE were mapped to EQ-5D-5L profiles, and the Zimbabwe value set was applied to calculate HSUs. Poststratified sampling weights were applied to estimate mean HSUs, and a multivariable linear regression model was used to examine associations between HSUs and overweight or obesity.

RESULTS

Responses from 3966 adults aged 18 to 110 years were analyzed. The mean (95% confidence interval) HSU was 0.856 (95% CI: 0.850, 0.863) for the population, 0.866 (95% CI: 0.857, 0.875) for men, and 0.849 (95% CI: 0.841, 0.856) for women. Lower mean HSUs were observed for obese individuals and with older ages. Multivariable regression analysis showed that HSUs were negatively associated with obesity (-0.024; 95% CI: -0.037, -0.011), female sex (-0.011; 95% CI: -0.020, -0.003), and older age groups in the population.

CONCLUSIONS

The study provides HSUs by sex, age, and body mass index (BMI) categories for the Ghanaian population and examines associations between HSU and high BMI. Obesity was negatively associated with health state utility in the population. These data can be used in future economic evaluations for Ghana and sub-Saharan African populations.

Rapidly increasing prevalence of overweight and obesity in older Ghanaian adults from 2007-2015: Evidence from WHO-SAGE Waves 1 & 2

BACKGROUND

Studies on changes in the prevalence and determinants of obesity in older adults living in sub-Saharan Africa are scarce. We examined recent changes in obesity prevalence and associated factors for older adults in Ghana between 2007/08 and 2014/15.

METHODS

Data on adults aged 50 years and older in Ghana were drawn from the WHO SAGE 2007/08 (Wave 1; n = 4158) and 2014/15 (Wave 2; n = 1663). The weighted prevalence of obesity, overweight, normal weight and underweight, and of high central adiposity were compared in 2007/08 and 2014/15. Multinomial and binomial logistic regressions were used to examine whether the determinants of weight status based on objectively measured body mass index and waist circumference changed between the two time periods.

RESULTS

The prevalence of overweight (2007/08 = 19.6%, 95% CI: 18.0-21.4%; 2014/15 = 24.5%, 95% CI: 21.7-27.5%) and obesity (2007/08 = 10.2%, 95% CI: 8.9-11.7%; 2014/15 = 15.0%, 95% CI: 12.6-17.7%) was higher in 2014/15 than 2007/08 and more than half of the population had high central adiposity (2007/08 = 57.7%, 95% CI: 55.4-60.1%; 2014/15 = 66.9%, 95% CI: 63.7-70.0%) in both study periods. While the prevalence of overweight increased in both sexes, obesity prevalence was 16% lower in males and 55% higher in females comparing 2007/08 to 2014/15. Female sex, urban residence, and high household wealth were associated with higher odds of overweight/obesity and high central adiposity. Those aged 70+ years had lower odds of obesity in both study waves. In 2014/15, females who did not meet the recommended physical activity were more likely to be obese.

CONCLUSION

Over the 7-year period between the surveys, the prevalence of underweight decreased and overweight increased in both sexes, while obesity decreased in males but increased in females. The difference in obesity prevalence may point to differential impacts of past initiatives to reduce overweight and obesity, potential high-risk groups in Ghana, and the need to increase surveillance.

The role of intergenerational educational mobility and household wealth in adult obesity: Evidence from Wave 2 of the World Health Organization's Study on global AGEing and adult health

BACKGROUND

Obesity has emerged as a major risk factor for non-communicable diseases in low and middle-income countries but may not follow typical socioeconomic status (SES)-related gradients seen in higher income countries. This study examines the associations between current and lifetime markers of SES and BMI categories (underweight, normal weight, overweight, obese) and central adiposity in Ghanaian adults.

METHODS

Data from 4,464 adults (2,610 women) who participated in the World Health Organization's Study on global AGEing and adult health (SAGE) Wave 2 were examined. Multilevel multinomial and binomial logistic regression models were used to examine associations. SES markers included parental education, individual education, intergenerational educational mobility and household wealth. Intergenerational educational mobility was classified: stable-low (low parental and low individual education), stable-high (high parental and high individual education), upwardly (low parental and high individual education), or downwardly mobile (high parental and low individual education).

RESULTS

The prevalence of obesity (12.9%) exceeded the prevalence of underweight (7.2%) in the population. High parental and individual education were significantly associated with higher odds of obesity and central adiposity in women. Compared to the stable low pattern, stable high (obesity: OR = 3.15; 95% CI: 1.96, 5.05; central adiposity: OR = 1.75; 95% CI: 1.03, 2.98) and upwardly (obesity: OR = 1.71; 95% CI: 11.13, 2.60; central adiposity: OR = 1.60; 95% CI: 1.08, 2.37) mobile education patterns were associated with higher odds of obesity and central adiposity in women, while stable high pattern was associated with higher odds of overweight (OR = 1.88; 95% CI: 1.11, 3.19) in men. Additionally, high compared to the lowest household wealth was associated with high odds of obesity and central adiposity in both sexes.

CONCLUSION

Stable high and upwardly mobile education patterns are associated with higher odds of obesity and central adiposity in women while the stable high pattern was associated with higher odds of overweight in men.

Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana

BACKGROUND

Previous studies investigating factors associated with healthcare utilization by older Ghanaians lack distinction between public and private health services. The present study examined factors associated with public and private healthcare service use, and the resulting perceived health system responsiveness.

OBJECTIVES

To identify factors associated with public and private healthcare utilization among older adults aged 50 and older in Ghana; and to compare perceived differences in health system responsiveness between the private and public sectors.

METHODS

Cross-sectional data was analyzed from the World Health Organization Study on global AGEing and adult health (SAGE) Wave 1 in Ghana. Using Andersen's conceptual framework, public and private outpatient care utilization was examined using multinomial logistic regression to estimate and identify predictor variables associated with the type of outpatient healthcare facility accessed. Health system responsiveness was compared using chi-square tests.

RESULTS

Of 2517 respondents who used outpatient care in the 12 months preceding interview, 51.7% of respondents used a public facility, 17.8% a private facility, and 30.5% used other facilities. Older age group, higher education and higher wealth were associated with the use of private outpatient healthcare services. Using public outpatient care facilities was associated with having health insurance. Respondents with two or more chronic conditions were more likely to use public and private outpatient care than other facilities. Perceived health system responsiveness was better in private for-profit than in public and private not-for-profit healthcare facilities.

CONCLUSIONS

This study suggested that higher wealth and multimorbidity were significant predictors of public and private outpatient healthcare utilization; however, health insurance was a predictor only for the use of public facilities. Future mixed-method studies could further elucidate factors influencing the choice of public and private outpatient healthcare use.

Leveraging ongoing research to evaluate the health impacts of South Africa's salt reduction strategy: a prospective nested cohort within the WHO-SAGE multicountry, longitudinal study

INTRODUCTION

Attempting to curb the rising epidemic of hypertension, South Africa implemented legislation in June 2016 mandating maximum sodium levels in a range of manufactured foods that contribute significantly to population salt intake. This natural experiment, comparing two African countries with and without salt legislation, will provide timely information on the impact of legislative approaches addressing the food supply to improve blood pressure in African populations. This article outlines the design of this ongoing prospective nested cohort study.

METHODS AND ANALYSIS

Baseline sodium intake was assessed in a nested cohort of the WHO Study on global AGEing and adult health (WHO-SAGE) wave 2 (2014-2015), a multinational longitudinal study on the health and well-being of adults and the ageing process. The South African cohort consisted of randomly selected households (n=4030) across the country. Spot and 24-hour urine samples are collected in a random subsample (n=1200) and sodium, potassium, creatinine and iodine analysed. Salt behaviour and sociodemographic data are captured using face-to-face interviews, alongside blood pressure and anthropometric measures. Ghana, the selected control country with no formal salt policy, provided a nested subsample (n=1200) contributing spot and 24-hour urine samples from the SAGE Ghana cohort (n=5000). Follow-up interviews and urine collection (wave 3) in both countries will take place in 2017 (postlegislation) to assess change in population-level sodium intake and blood pressure.

ETHICS AND DISSEMINATION

SAGE was approved by the WHO Ethics Review Committee (reference number RPC149) with local approval from the North-West University Human Research Ethics Committee and University of the Witwatersrand Human Research Ethics Committee (South Africa), and University of Ghana Medical School Ethics and Protocol Review Committee (Ghana). The results of the study will be published in peer-reviewed international journals, presented at national and international conferences, and summarised as research and policy briefs.

MANAGEMENT OF PROSTATE CANCER IN ACCRA, GHANA

INTRODUCTION

Africans living with prostate cancer in Africa face problems of early diagnosis and appropriate treatment.

AIM

To study the clinical incidence of prostate cancer, risk factors, TNM stage, their management and outcomes.

METHODS

A prospective study of Prostate Cancer cases managed at Korle Bu Teaching Hospital and hospitals in Accra, diagnosed by history, abnormal PSA/DRE, physical examination and histologically confirmed by biopsy from 2004 to 2013 was carried out. The cases were TNM staged and managed by approved protocol.

RESULTS

There were 669 cases with a mean age 70±0.045SE years, median Gleason Score of 7, organ confined Prostate Cancer(PC) in 415(62%), locally advanced in 167(25%) and metastatic Prostate Cancer in 87(13%) cases. The cases were followed for median of 10 months to ≥ 84 months. Organ confined cases were managed by: Radical Prostatectomy (RP) 92 (13.8%) with a mortality of 0.3%; brachytherapy 70 (10.5%) with a mortality of 0.1% and External Beam Radiotherapy (EBRT) 155 (23%) with a mortality 0.7%. In all, 98 men constituting (14.1%) cases with a mean age of 75+0.25SE years, life expectancy <10 years were treated by hormonal therapy with a mortality of 1.7%. Twenty cases who were for active surveillance (GS6), PSA <10ng/ml, life expectancy <10 years later all opted for EBRT. Locally advanced cases 25% all had neoadjuvant hormonal therapy then Brachytherapy in 3 (0.4%) mortality 0.15% and EBRT in 64 (9.5%), mortality 0.59%. Hormonal therapy was given in 100 (15%) locally advanced cases, mortality 5%. Metastatic prostate cancer cases (13%) were managed by hormonal therapy, mortality 6%.

CONCLUSION

Improved facilities and dedicated skilled teams led to a significant rise in proportion of organ confined Prostate Cancer from 15.3% to 62% curable by Radical Prostatectomy, brachytherapy or EBRT with longer disease free survival.

Cataract Surgical Uptake Among Older Adults in Ghana

OBJECTIVES

In sub-Saharan Africa, cataract surgical services are highly inadequate and surgical uptake for cataract is low. This paper describes cataract surgical uptake among older adults in Ghana.

METHODS

This work was based on World Health Organization's multi-country Study on global Ageing and adult health (SAGE), conducted in six countries including Ghana. Wave one of SAGE in Ghana was conducted in 2007-2008 as collaboration between WHO and Department of Community Health, University of Ghana Medical School. A nationally representative sample of 5571 older adults (≥50 years) and a small sample of persons 18-49 years were interviewed. Data was obtained on uptake of cataract surgery in older adults and analyzed using descriptive measures and chi square for associations in categorical outcome measures.

RESULTS

Overall surgical uptake was 48.9% among older adults and was slightly higher among older men (49.1%) than women (48%). Cataract surgical uptake was relatively higher in the 60-69 years group (55%), urban residents (52.6%) and those living without partners (50%). Educational and income levels of older persons did not affect cataract surgical uptake. Regional differences in cataract surgical uptake existed; was less than 60% in all ten regions (except one), and the two regions with most self-reported cataracts (Ashanti and Greater Accra) had less than 50% uptake.

CONCLUSIONS

Intensive public education, engagement of community groups and increased access to cataract surgery at health facilities and outreach services need consideration at national/sub-national levels. Further investigations to garner equity in national eye care efforts are recommended.

Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa

BACKGROUND

The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries.

METHODS

Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa.

RESULTS

This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa.

CONCLUSIONS

Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

The impact of multimorbidity on adult physical and mental health in low- and middle-income countries: what does the study on global ageing and adult health (SAGE) reveal?

BACKGROUND

Chronic diseases contribute a large share of disease burden in low- and middle-income countries (LMICs). Chronic diseases have a tendency to occur simultaneously and where there are two or more such conditions, this is termed as 'multimorbidity'. Multimorbidity is associated with adverse health outcomes, but limited research has been undertaken in LMICs. Therefore, this study examines the prevalence and correlates of multimorbidity as well as the associations between multimorbidity and self-rated health, activities of daily living (ADLs), quality of life, and depression across six LMICs.

METHODS

Data was obtained from the WHO's Study on global AGEing and adult health (SAGE) Wave-1 (2007/10). This was a cross-sectional population based survey performed in LMICs, namely China, Ghana, India, Mexico, Russia, and South Africa, including 42,236 adults aged 18 years and older. Multimorbidity was measured as the simultaneous presence of two or more of eight chronic conditions including angina pectoris, arthritis, asthma, chronic lung disease, diabetes mellitus, hypertension, stroke, and vision impairment. Associations with four health outcomes were examined, namely ADL limitation, self-rated health, depression, and a quality of life index. Random-intercept multilevel regression models were used on pooled data from the six countries.

RESULTS

The prevalence of morbidity and multimorbidity was 54.2 % and 21.9 %, respectively, in the pooled sample of six countries. Russia had the highest prevalence of multimorbidity (34.7 %) whereas China had the lowest (20.3 %). The likelihood of multimorbidity was higher in older age groups and was lower in those with higher socioeconomic status. In the pooled sample, the prevalence of 1+ ADL limitation was 14 %, depression 5.7 %, self-rated poor health 11.6 %, and mean quality of life score was 54.4. Substantial cross-country variations were seen in the four health outcome measures. The prevalence of 1+ ADL limitation, poor self-rated health, and depression increased whereas quality of life declined markedly with an increase in number of diseases.

CONCLUSIONS

Findings highlight the challenge of multimorbidity in LMICs, particularly among the lower socioeconomic groups, and the pressing need for reorientation of health care resources considering the distribution of multimorbidity and its adverse effect on health outcomes.

Predictors of subjective well-being among older Ghanaians

BACKGROUND

Later years of life are accompanied by many physical, emotional and environmental changes which may impact on the well-being of the individual. Many factors are known to influence the subjective well-being of older adults, but most, if not all of this information was the result of studies in the Western world. This study aimed at obtaining and documenting the predictors of subjective well-being (SWB) among older Ghanaians.

METHODS

Data for the study was obtained from the WHO SAGE study. The single item measure of life satisfaction was used to determine subjective well-being. Descriptive statistics as well as logistic regression analysis were carried out to determine the predictors of SWB.

RESULTS

A total of 4724 individuals aged 50 years and above responded to the questionnaires. Of these 50.4% were males. Following multivariate logistic regression analysis, age, sex, educational level, income and ethnic background were found to significantly affect the SWB of older Ghanaians. Being male was associated with higher level of SWB (OR=1.68; CI: 1.39 - 2.03). For those 50 years and above, being younger (50-59 years) was also associated with a high level of SWB (OR=17.72; CI: 10.13-30.98). Earning a low income and having low educational level were both associated with low levels of SWB (OR=0.304; CI: 0.22-0.42; and OR=0.47; CI: 0.37-0.60 respectively). Ewes (p=0.027), Grumas (p=0.002) and Mole-Dagbons (p=0.04) had significantly higher SWB compared to the other ethnic groups.

CONCLUSION

Among older Ghanaians, factors that positively influence SWB are younger age, male sex, high educational level and high income.

Universal health coverage in emerging economies: findings on health care utilization by older adults in China, Ghana, India, Mexico, the Russian Federation, and South Africa

BACKGROUND AND OBJECTIVE

The achievement of universal health coverage (UHC) in emerging economies is a high priority within the global community. This timely study uses standardized national population data collected from adults aged 50 and older in China, Ghana, India, Mexico, the Russian Federation, and South Africa. The objective is to describe health care utilization and measure association between inpatient and outpatient service use and patient characteristics in these six low- and middle-income countries.

DESIGN

Secondary analysis of data from the World Health Organization's Study on global AGEing and adult health Wave 1 was undertaken. Country samples are compared by socio-demographic characteristics, type of health care, and reasons for use. Logistic regressions describe association between socio-demographic and health factors and inpatient and outpatient service use.

RESULTS

In the pooled multi-country sample of over 26,000 adults aged 50-plus, who reported getting health care the last time it was needed, almost 80% of men and women received inpatient or outpatient care, or both. Roughly 30% of men and women in the Russian Federation used inpatient services in the previous 3 years and 90% of men and women in India used outpatient services in the past year. In China, public hospitals were the most frequently used service type for 52% of men and 51% of women. Multivariable regression showed that, compared with men, women were less likely to use inpatient services and more likely to use outpatient services. Respondents with two or more chronic conditions were almost three times as likely to use inpatient services and twice as likely to use outpatient services compared with respondents with no reported chronic conditions.

CONCLUSIONS

This study provides a basis for further investigation of country-specific responses to UHC.

PSYCHO-SOCIAL CHALLENGES OF PATIENTS FOLLOWING ORBITAL EXENTERATION

OBJECTIVE

Orbital exenteration results in devastating functional, aesthetic and psychological losses. We studied the psycho-social challenges of patients following orbital exenteration.

DESIGN

Retrospective descriptive study.

SETTING

Korle-Bu Teaching Hospital, eye clinic, Accra.

SUBJECTS

Ten surviving patients, at least six months post orbital exenteration.

RESULTS

Though all the patients were satisfied with the medical results of the surgery, 50% felt strongly uncomfortable or dissatisfied with the cosmetic effect of the surgery. Sixty percent of the patients suffered unwelcome comments and 50% uncomfortable stare from close friends and relations. Sixty percent were not uncomfortable in the company of friends and close relations.

CONCLUSION

Our findings call for a counseling plan for our patients while it is also necessary to find ways of improving their cosmesis.

Effects of consumer and provider moral hazard at a municipal hospital out-patient department on Ghana's National Health Insurance Scheme

BACKGROUND

In 2003, Ghana introduced the national health insurance scheme (NHIS) to promote access to healthcare. This study determines consumer and provider factors which most influence the NHIS at a municipal health facility in Ghana.

METHOD

This is an analytical cross-sectional study at the Winneba Municipal Hospital (WHM) in Ghana between January-March 2010. A total of 170 insured and 175 uninsured out-patients were interviewed and information extracted from their folders using a questionnaire. Consumers were from both the urban and rural areas of the municipality.

RESULTS

The mean number of visits by insured consumers to a health facility in previous six months was 2.48 +/- 1.007 and that for uninsured consumers was 1.18 +/- 0.387(p-value<0.001). Insured consumers visited the health facility at significantly more frequent intervals than uninsured consumers (χ(2) = 55.413, p-value< 0.001). Overall, insured consumers received more different types of medications for similar disease conditions and more laboratory tests per visit than the uninsured. In treating malaria (commonest condition seen), providers added multivitamins, haematinics, vitamin C and intramuscular injections as additional medications more for insured consumers than for uninsured consumers.

CONCLUSION

Findings suggest consumer and provider moral hazard may be two critical factors affecting the NHIS in the Effutu Municipality. These have implications for the optimal functioning of the NHIS and may affect long-term sustainability of NHIS in the municipality. Further studies to quantify financial/ economic cost to NHIS arising from moral hazard, will be of immense benefit to the optimal functioning of the NHIS.

Patterns of health service utilization at a medical school clinic in Ghana

BACKGROUND

The University of Ghana Medical School (UGMS) Clinic provides healthcare service which is free at point of service to students, staff, retired staff and dependents of staff of the College of Health Sciences. However, since 1983, no in-depth review of health service provision or utilization has been undertaken. This study reviewed client characteristics, utilization and disease patterns at the clinic and also compared the disease patterns to that of other primary health facilities nationwide.

METHODS

This was an analytical cross-sectional study undertaken at the UGMS clinic in Korle-Bu. It was a retrospective review of records of all clients attending the facility from January 2002 to December, 2004.

RESULTS

More males than females attended the clinic and majority (63.9%) of clients were between 15-44 years (median age was 26 years). Dependents of staff constituted the highest attendants (41%) to the clinic. Among staff, junior staffs were in the majority. Malaria, respiratory tract infection and musculoskeletal pain were the most common conditions seen. Overall, 83% of clients were treated and discharged per visit without the need for review visits.

CONCLUSION

Dependents of staff used the facility the most and they live in many different part of the city of Accra, and to ask them to attend the clinic for care is not efficient. It will be better to provide or supplement their securing of insurance so that they could access health care close to their homes and save time and attention to students and staff.

Factors affecting the survival of the "at risk" newborn at Korle Bu Teaching Hospital, Accra, Ghana

High risk pregnancies continue to be associated with high perinatal mortality and morbidity in developing countries. Korle Bu Teaching Hospital is no exception with a perinatal mortality rate of 98.7/1000 births. Multiple factors resulting in this include the high risk nature of the pregnancies resulting in increased incidence of premature deliveries and asphyxiated babies, the delay in transfer of the sick neonate as well as the inadequate mode of transfer. The type of delivery other than the spontaneous vaginal route also affects the outcome, though the relationship was not statistically significant. Logistic regression analysis showed that maturity, birthweight and time from birth to admission to NICU were the most significant factors associated with the survival of the neonate. Proper foetal surveillance both in the antenatal period and during labour cannot be over emphasized and the mere presence of a paediatrician at these high risk deliveries may make a difference. Also, increased vigilance in the special care offered will help reduce mortality.

Impact of health care financing reforms on the management of malaria in Ghana

OBJECTIVE

To determine the impact of the introduction of the 'cash and carry' system on how health care providers manage malaria cases in Ghana.

DESIGN

A cross sectional study of treatment patterns of cases of malaria.

SETTING

Health services in Ghana changed significantly in 1992, from being virtually free to a 'cash and carry' system in which all patients attending government health services had to pay in full for drugs and services. Staff of private companies and parastatal organisations continue to enjoy free health services at other clinics and hospitals.

SUBJECTS

Prescriptions for 9539 cases diagnosed as having malaria at the out-patient departments (OPD) of eight health facilities four in the 'cash and carry' scheme and four outside this scheme were reviewed.

RESULTS

The mean (SD) number of drugs prescribed per case of malaria was higher for the 'cash and carry' group than for the 'free for service' group; 4.5+/-1.3 versus 3.8+/-1.3 (p value <.001). Injection chloroquine was used more frequently in the 'cash and carry' group than in the 'free service' group 56.4% and 28.6% respectively (p value <.001). Second-line antimalarial drugs were however, more often used in the 'free service' group 13.5% versus 7.3% (p value <.001). About 30% of the 'cash and carry' group received antibiotics, compared with 15.5% of the 'Free Service' group. Logistic regression analysis showed that the modality of payment for services contributed significantly to whether a case of malaria was managed with more than three drugs, or received injection chloroquine or antibiotics or a non-steroidal anti-inflammatory drug.

CONCLUSION

Evidence in this study suggests that health care providers tend to pay more attention in treating the symptoms of malaria in cases in which patients pay for service. This leads to unnecessarily high costs of care for the individual and the health system.

Prevalence of children with disabilities in central region, Ghana

A cross sectional survey was conducted in Central Region, Ghana to determine the prevalence of children with disabilities. Forty-seven (1.8%) out of a total of 2,556 children under fifteen years of age had disabilities. About a third, had difficulty with movement of which post poliomyelitis infection disability formed the majority. Twelve children (25.5%) had difficulty with hearing and speech (deaf and dumb). Three children were reported as having epilepsy and 2 others had mental retardation. There was no case of total blindness, however, two children complained of poor vision and three others had a squint. Other disabilities identified, included one child each with kyphosis (hunch back), hydrocephalus (very large head) and extensive facial scars from burns. Disability was more common among children who had not been immunized or who did not have immunization card at the time of interview. The prevalence of disability was higher among female children in the rural community and in children with no formal education. Prevalence of disability increased with age. The prevalence of disability was 14.4 per 1,000 for children (1-5) years, 16.6 per 1000 for children (6-9) years and 3.7 per 1,000 for (10-15) years age group. Younger children had better immunization status and lower disability rates. Thirty percent of the children with disability said they were experiencing discrimination especially among the female children. This study has demonstrated that there is a need to intensify the preventive efforts at reducing the problem of childhood disability and to increase public support to the disabled children by avoiding discrimination and encouraging education and training of the disabled children.

Incidence and management of malaria in two communities of different socio-economic level, in Accra, Ghana

Two adjacent communities of differing socio-economic levels were selected, in Accra, Ghana, for the study of the home management of malaria. The youngest child in each selected household, each of which had a child aged < 5 years, was recruited for weekly follow-up, following informed consent. Malaria was the most common condition reported by the 'caregivers' (mothers of the subjects and others caring for the subjects) in each community, with 2.0 episodes of clinical malaria/child during the 9-month study. Most (89%) of the caregivers in the better-off community had been educated beyond primary-school level, but 55% of the caregivers in the poorer community had either received no formal education or only primary-school education. This difference was also reflected by the educational facilities provided to the children studied: 52% of the those in the better-off community attended nurseries, kindergartens or creches, compared with 8% of the children investigated in the poorer community. The proportion of caregivers who purchased drugs without prescription or used left-over drugs to treat clinical malaria in the children was higher in the poorer community (82% v. 53%), and a child from the poorer community was less likely to have been taken to a clinic or hospital to be treated for malaria than a child from the better-off community (27% v. 42%). During the follow-up period two children died, one from each community. Treatment of malaria in young children is likely to be less effective in the poorer community, where a lack of economic access to health services was demonstrated.

Sexual behaviour and contraception among unmarried adolescents and young adults in Greater Accra and Eastern regions of Ghana

A fertility survey of unmarried adolescents and young adults (953 males and 829 females) in Greater Accra and Eastern regions of Ghana revealed that a substantial proportion of the respondents were sexually experienced. Overall, 66.8% of the males and 78.4% of the females were sexually experienced. The mean ages (+/- SD) of the males and females were 15.5 +/- 2.5 and 16.2 +/- 2.0 years, respectively. Most respondents claimed to have received adequate information on reproductive health and sexually transmitted diseases (STDs), including AIDS. However, 20% and 30% of the respondents in peri-urban and rural areas, respectively, did not know that a girl could get pregnant the first time she has sexual intercourse. The incidence of pregnancy among the unmarried female respondents was relatively high (37%), and was higher in urban than in rural areas. Approximately 47% of those who had ever been pregnant reported that they had had an abortion. Levels of contraceptive awareness were high (98.2% among males and 95.5% among females) but many still engaged in unprotected sexual relations. The most commonly used methods were the condom and the pill. The main reasons given for non-use were that they did not think about contraception, were concerned about the safety of contraceptives, and partner objection. These findings point to the need for targeting of unmarried adolescents and young adults with information on reproductive health and family planning to increase their awareness of the risks of pregnancy, STDs and HIV infection.

Osteometric analysis of sexual dimorphism in the sternal end of the rib in a west African population

This study, and others, are being carried out in order to establish a Forensic Anthropology databank on age estimation and sex determination of skeletonized remains in Ghana. An osteometric study of sexual dimorphism in the sternal end of the right fourth rib on 346 consecutive coroner's autopsy cases (221 males, 125 females) of known age, sex, and race was conducted. The height and width of the sternal end of the rib were measured in each case. The sample was analyzed in three groups: young (< 30 years), old (> or = 30 years), and total sample (total group). Stepwise discriminant function analysis showed that the accuracy of sex determination varied from 80% in the young and 74% in the old groups to 78% for the total group. Statistical analysis of the results obtained when the functions derived from the study were tested using another batch of ribs showed the functions to be effective and reliable in determining sex. When functions derived from a previous study of American Whites were used to determine sex in our study sample, the vast majority of males were misclassified as females. This is the first time, to our knowledge, that a Black African population has been studied osteometrically to evaluate sexual dimorphism in the sternal end of the fourth rib.

Epilepsy: knowledge, attitude and practice in literate urban population, Accra, Ghana

A cross sectional survey was conducted among Government workers and the general public in Accra, Ghana. A total of 380 persons were interviewed. Almost everybody could describe accurately, an epileptic person. However, 172 (45.3%) out of the 380 respondents did not know the cause of epilepsy, and 37.6% did not know how it could be treated. Out of the 358 responses to the cause of epilepsy, 114 (31.8%) said it was inherited disease, 100 (27.9%) said it was due to witchcraft/juju or spiritual. With respect to treatment, 150 out of 333 responses mentioned sending the individual to the medical doctor, 95 (28.5%) said the use of herbs/visits to fetish priest, 59 (17.7%) suggested prayers, 20 (6.0%) said to do nothing. For prevention, 77 (29.1%) out of 319 responses indicated prayers, 49 (15.45%) cautioned marrying into epileptic family, and 13 (4.1%) responses indicated not to touch patient fitting. Those who answered "don't know" regarding knowledge about epilepsy were mostly the young, the lower educational status and the single respondents. However, the most important characteristic of the respondent that was associated with the appropriateness of the responses was the educational status. Although a lot of misconceptions about epilepsy existed in the study population, e.g. epilepsy can be spread by contact and that epileptics must be isolated or avoided, several respondents would share a room, eat or employ persons with epilepsy. The study has shown that the traditional beliefs and attitudes about epilepsy are still held firmly by the adult working population and that the educational level of the respondent was positively related to the appropriateness of the responses. It is therefore suggested that additional efforts must be made to increase the knowledge of the general population through the use of social marketing strategies in order to improve the management of persons with epilepsy.

Evaluation of invermectin distribution in Benin, Côte d'Ivoire, Ghana and Togo: estimation of coverage of treatment and operational aspects of the distribution system

Invermectin distribution by the Onchocerciasis Control Programme (OCP) was assessed in Benin, Côte d'Ivoire, Ghana and Togo, in terms of the proportion of villages which had been treated and the proportion of villagers in each village treated in the last round who had actually received treatment. These proportions were evaluated both for treatment in the last round of ivermectin distribution and for treatment since the beginning of the drug's distribution in each country. During the last treatment round, 97 (74.6%) of the 130 selected villages investigated in the four countries had received ivermectin treatment, and 67.2% of the members of these 97 treated communities had taken ivermectin. In general, higher percentages of the members of treated villages in Côte d'Ivoire and Ghana had been treated [with mean (S.D.) percentage values of 72.0 (5.2) and 71.6 (4.6), respectively] than in those of Togo [61.8 (5.6)] or Benin [64.2 (4.6)]. Overall, 893 (26.1%) of those interviewed had never received treatment since the beginning of ivermectin distribution but 29.4% had received all the annual treatments. The main reason for non-treatment during the last treatment round was absence from village (54.5% of those not treated), followed by non-eligibility (i.e. pregnant women and young children; 12.2%), refusal to take treatment (2.6%), and shortage of drugs (1.9%). Community approval for the programme was demonstrated when all treated individuals, including those who were absent at the last treatment round, said they would take the ivermectin during the next treatment. During the last treatment round, members of the community assisted in the distribution of the ivermectin tablets in 69 (71.1%) of the 97 treated villages which were investigated. Although only 26 (26.8%) of these 97 villages preferred community-based distribution of ivermectin to the 'mobile' method, it is believed that, with good education and efficient organization, the communities could be encouraged to undertake community distribution.

Monitoring progress towards health for all by the year 2000: indicators from Iganga District, Uganda

A sample of 5018 inhabitants in three counties of Iganga district, Uganda was selected by means of a multi-stage cluster sampling procedure and interviewed in 1984. A sub sample was re-interviewed, the following year to study population dynamics. 50.2% of the population were under 15 years of age and 4.2% were aged one year or less. About 80% of both sexes aged 6-15 years were in school or had primary education. Male adult literacy rate was 62% and female adult literacy rate was 38%. The average number of people per sleeping room was 2.4. 82.9% of households used well or unprotected spring as main source of water and 30% of households did not have pit latrine. Infant mortality rate was estimated to be 126 per 1000 livebirths and measles was the major cause of mortality (38%) in the under fives. The crude birth rate estimate was 51 per 1000. The estimate of lameness due to polio was 6.6 per 1000 children aged 15 years or below. The mean weight and the mean height of the children were both below 50th percentile of the NCHS standards. In the re-survey, the crude birth rate and infant mortality rate estimates corresponded well to the initial values for the total sample obtained in the previous survey. 5% of the population had moved out of the village and 1.8% had moved to settle in the village. The growth rate in both weight and height of the under five children was satisfactory compared to the rate of the standard. From the result of the study, only six years after adoption of PHC in Uganda, the relatively high educational level of the younger population should be taken as a positive indicator of better health indices in the future.

Application of Markov process modelling to health status switching behaviour of infants

BACKGROUND

This study is an attempt to apply Markov process modelling to health status switching behaviour of infants. The data for the study consist of monthly records of diagnosed illnesses for 1152 children, each observed from the month of first contact with Kasangati Health Centre, Kampala, Uganda, until age 18 months.

METHODS

Only two states of health are considered in the study, a 'Health' state, denoted by W: (for Well), and an 'Illness' state denoted by S: (for Sick). The data are thus reduced to monthly records (W or S) of the states of health of the study sample. The simplest model of dependence of current health state on the past is one that links the current state to the immediately preceding month only; that is a Markov model. The starting point of this study was therefore to determine the proportions of children making the transitions W-->W, W-->S, S-->W, S-->S, from one month to the next, for each month from birth (month 0) to 18 months of age (month 18). These were used as estimates of the probabilities of making these transitions for each month from birth. This paper discusses the main features emerging from the study of these transition probabilities.

RESULTS

In the first 5 months after birth, the probabilities of making the transitions W-->W, W-->S, S-->W, S-->S from one month to the next, showed some dependence on the age of the child. From the sixth month on, however, the dependence on age seemed to wear off. The transition probabilities remained the same from then on, suggesting that the switching pattern between health states behaves, eventually, like a time-homogeneous Markov Chain. This time-homogeneous chain attained a steady state distribution at about 12 months from birth.

CONCLUSIONS

The study has shown that the transitions between Health and Illness for infants, from month to month, can be modelled by a Markov Chain for which the (single-step) transition probabilities are generally time-dependent or age-dependent. After the first few months of life the dependence on age may wear off, as in this study, leading to a time-homogeneous Markov Chain, which eventually attains a steady state distribution in about 12 months. Interpretations of the transition probabilities as measures of disease prevalence are discussed.

Current trends in the incidence of cerebrovascular accidents in Accra

The incidence of cerebrovascular accidents (CVA) in Accra during three periods--1960-1968, 1976-1983, and 1990-1993, was compared. There was dramatic increase in the incidence between 1990-1993. Uncontrolled hypertension due to non-compliance with drug therapy seems to be the main cause. The economic plight of the people may explain the non compliance. The case fatality was between 41.9% to 50.3% for the years 1990-1993. Cardiovascular diseases, notably hypertension and CVA, have become the major causes of morbidity and mortality in Accra.

The cost of sustaining the Ghana's "Cash and Carry" system of health care financing at a rural health centre

This paper investigates the sudden fall in clinic attendance at a rural health centre. The pressure to sustain the cash and carry system of procuring drugs is being blamed for over prescription, inconsistent pricing of prescriptions and subsequent fall in clinic attendance. The clinic attendance which was dropping since the introduction of fee-for-service (1985) has now dropped sharply to about 25% after the implementation of the Cash and Carry system (1990). Yet, the average revenue generated per patient has jumped from 201 cedis in 1990 to 348 cedis in 1992. Analysis of the prescription pattern for malaria infection showed that 56% and 89% of patients received injections or were given three or more drugs in the free health service period and in the fee-for-service period respectively. Prescriptions which contained injections or more than three items yielded between 120% and 200% profit to the Health Centre compared to a profit of 60% if only chloroquine and analgesics were prescribed. Consumptions of drugs by staff and non paying patients amounted to about 10% of the revenue generated from the paying patients. It is suggested that, at the health centre level, mechanism for pricing of prescriptions to patients must be reviewed, since motivation for profit could influence the management of diseases and also the use of health facilities. Secondly, refund for drugs consumed by staff and non-paying patients must be recovered in order to remove undue pressure to make profit.

Record keeping on early childhood diseases in two decades, at the health centre level in Uganda

This study provides the age specific prevalence rates of diseases using data from 1152 infants by reviewing clinic records, which have been maintained from 1963 till 1984 (grouped according to households) at Kasangati Health Centre near Kampala, Uganda. On the average, each child reported 3 disease episodes per year. The conditions that brought a child to clinic for the first time were: respiratory infection 46.2%; clinical malaria 14.4%; skin infections 9.8%; diarrhoeal diseases 8.5% and, others 21.1%. The prevalence of diseases in infants at the age of less than one month old were, respiratory tract infection 78/1000, skin conditions 29/1000, clinical malaria/fever 18/1000, eye infection 15/1000, diarrhoea 5/1000 and others 67/1000. At the age of one month till the age of 18 months, four conditions consistently topped the disease prevalence list: respiratory tract infection with a range of 175/1000 to 29/1000, being higher in early childhood; clinical malaria/fever with a range of 79/1000 to 23/1000; diarrhoeal diseases with a range of 55/1000 to 10/1000 and skin conditions with a range of 42/1000 to 10/1000. Other disease conditions including urinary tract infection, burns/accidents, eye infections, ear infections, measles and tetanus had age specific prevalence of less than 10/1000 at each age. Most of the diseases showed decreasing level of prevalence as the age increased. Relatively more people used the clinic and at a higher rate in the 1970s compared to the 1960s, mirroring the general economic and political situation of the two periods. There were no sex specific differences in either the frequency of utilization of the clinic or in the prevalence of disease over time.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum polio antibodies in unimmunized preschool children in a rural village in Ghana: before active immunization programme

The finding of the neutralizing antibodies against poliovirus in unimmunized preschool children confirms the endemicity of the disease in the rural community. The predominant polio antibody types were types 1 and 2. In children under 4 months of age, 82% were seropositive to type 1, 91% to polio type 2 and 55% to polio type 3; evidence of maternal transplacental antibodies. There were fewer seropositives in the age group 4-9 months, 28%, 44% and 12% to the types 1, 2 and 3, respectively. However, the percentages of seropositives to all three types increased for the rest of the age groups, indicating possible contact with the wild poliovirus in early infancy. Community spread of the virus is also supported by the intrafamilial clustering of the seropositives.

Growth and diarrhoeal disease surveillance in a rural Ghanaian pre-school child population

This paper is a report of the first year of follow-up on 250 pre-school children in a village in Ghana. The mean weight for age and the mean height for age at the start of the study, ranged between 81 and 97% and 91 and 101.4% of the median WHO reference standards respectively. Classified according to Waterlow (1973) 59.6% of the children were normal, 27.2% were thin, 8.9% were stunted, 3.4% were wasted and 0.9% were stunted and wasted. The mean velocity of height gain was 26.8 cm/year at birth; 9.6 cm/year at age of six months and thereafter the rate decreased almost linearly to a rate of 5 cm/year at the age of 60 months. The curve for weight velocity had a similar shape to that of the height. The rate was on the average 5 kg/year at birth, and 1.7 kg/year at age of six months. Children over 30 months of age gained approximately, 0.5 kg/year compared to an expected gain of about 2 kg/year. The mean incidence of diarrhoeal diseases was 1.9 episodes per child per year. 34.4% of the cohort did not report on any episode of diarrhoea over the one year period. Highest incidence occurred in children between the ages of 7 and 12 months. Children who were less than 80% of the standard weight for age at the start of the study had significantly more diarrhoeal episodes than the rest. The mean incidence of diarrhoeal diseases per year increased as both height for age and weight for height decreased. It is suggested that primary intervention against diarrhoeal morbidity might be better aimed at improving childhood nutrition.

Seroepidemiological study of rotavirus infection in rural Ghana

Children in a village in rural Ghana were found to have acquired antibody to rotavirus by the age of two years. The results of our study suggest that primary infection takes place early in infancy. Fifty-six per cent of the three to 20-months-old had a four-fold rise in antibody levels during the six months follow-up period and 72.2% of them had one or more episodes of diarrhoea compared with 42.8% of those whose antibody levels stayed the same or decreased. The major epidemic season is considered to be the dry season.