Publications by authors named "Irene A Agyepong"

17 Publications

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Systematic review of prediction models for gestational hypertension and preeclampsia.

PLoS One 2020 21;15(4):e0230955. Epub 2020 Apr 21.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.

Introduction: Prediction models for gestational hypertension and preeclampsia have been developed with data and assumptions from developed countries. Their suitability and application for low resource settings have not been tested. This review aimed to identify and assess the methodological quality of prediction models for gestational hypertension and pre-eclampsia with reference to their application in low resource settings.

Methods: Using combinations of keywords for gestational hypertension, preeclampsia and prediction models seven databases were searched to identify prediction models developed with maternal data obtained before 20 weeks of pregnancy and including at least three predictors (Prospero registration CRD 42017078786). Prediction model characteristics and performance measures were extracted using the CHARMS, STROBE and TRIPOD checklists. The National Institute of Health quality assessment tools for observational cohort and cross-sectional studies were used for study quality appraisal.

Results: We retrieved 8,309 articles out of which 40 articles were eligible for review. Seventy-seven percent of all the prediction models combined biomarkers with maternal clinical characteristics. Biomarkers used as predictors in most models were pregnancy associated plasma protein-A (PAPP-A) and placental growth factor (PlGF). Only five studies were conducted in a low-and middle income country.

Conclusions: Most of the studies evaluated did not completely follow the CHARMS, TRIPOD and STROBE guidelines in prediction model development and reporting. Adherence to these guidelines will improve prediction modelling studies and subsequent application of prediction models in clinical practice. Prediction models using maternal characteristics, with good discrimination and calibration, should be externally validated for use in low and middle income countries where biomarker assays are not routinely available.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230955PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173928PMC
July 2020

Improvisation and harm avoidance: An ethnographic study of adherence to postnatal care protocols in two hospitals in Southern Ghana.

Midwifery 2020 Mar 13;82:102576. Epub 2019 Dec 13.

Sociology of Development and Change Group, Wageningen University, 6700 EW, Hollandsweg 1, P. O. Box 8130 Wageningen, the Netherlands.

Providers' adherence to case management protocols can affect quality of care. However, how and why protocols are adhered to by frontline health workers in low- and middle-income countries is not always clear. This study explored midwives' adherence to national postnatal care protocols in two public hospitals in Southern Ghana using an ethnographic study design. Ninety participant observations and 88 conversations were conducted over a 20-months period, and two group interviews held with the midwives in the two hospitals. Data was analysed using a grounded theory approach. Findings: Midwives collectively decided when to adhere, modify or totally ignore postnatal care protocols. Adherence often occurred if required resources (equipment, tools, supplies) were available. Modification occurred when midwives felt that strict adherence could have negative implications for patients and they could be seen as acting 'unprofessionally'. Ignoring or modifying protocols also occurred when midwives were uncertain of the patient's health condition; basic supplies, logistics and infrastructure needed for adherence were unavailable or inappropriate; or midwives felt they might expose themselves or their clients to physical, psychological, emotional, financial or social harm. Regardless of the reasons that midwives felt justified to ignore or modify postnatal care protocols, it appeared in many instances to lead to the provision of care of suboptimal quality. Conclusion and recommendations: Providing clinical decision-making protocols is not enough to improve mother and new born care quality and outcomes. Faced with constraining conditions of work, providers are likely to modify guidelines as part of coping behaviour. Addressing constraining conditions of work must accompany guidelines. This includes adequate risks protection for health workers and clients; and resolution of deficits in essential equipment, infrastructure, supplies and staffing.
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http://dx.doi.org/10.1016/j.midw.2019.102576DOI Listing
March 2020

The G20 and development assistance for health: historical trends and crucial questions to inform a new era.

Lancet 2019 Jul 27;394(10193):173-183. Epub 2019 Jun 27.

Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.

One of the most important gatherings of the world's economic leaders, the G20 Summit and ministerial meetings, takes place in June, 2019. The Summit presents a valuable opportunity to reflect on the provision and receipt of development assistance for health (DAH) and the role the G20 can have in shaping the future of health financing. The participants at the G20 Summit (ie, the world's largest providers of DAH, emerging donors, and DAH recipients) and this Summit's particular focus on global health and the Sustainable Development Goals offers a unique forum to consider the changing DAH context and its pressing questions. In this Health Policy perspective, we examined trends in DAH and its evolution over time, with a particular focus on G20 countries; pointed to persistent and emerging challenges for discussion at the G20 Summit; and highlighted key questions for G20 leaders to address to put the future of DAH on course to meet the expansive Sustainable Development Goals. Key questions include how to best focus DAH for equitable health gains, how to deliver DAH to strengthen health systems, and how to support domestic resource mobilisation and transformative partnerships for sustainable impact. These issues are discussed in the context of the growing effects of climate change, demographic and epidemiological transitions, and a global political shift towards increasing prioritisation of national interests. Although not all these questions are new, novel approaches to allocating DAH that prioritise equity, efficiency, and sustainability, particularly through domestic resource use and mobilisation are needed. Wrestling with difficult questions in a changing landscape is essential to develop a DAH financing system capable of supporting and sustaining crucial global health goals.
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http://dx.doi.org/10.1016/S0140-6736(19)31333-9DOI Listing
July 2019

Universal health coverage: breakthrough or great white elephant?

Authors:
Irene A Agyepong

Lancet 2018 11 8;392(10160):2229-2236. Epub 2018 Oct 8.

Dodowa Health Research Centre, Research and Development Division, Ghana Health Service, Dodowa, Ghana; Public Health Faculty, Ghana College of Physicians and Surgeons, Accra, Ghana. Electronic address:

Will the Sustainable Development Goal 3 sub-goal "Achieve universal health coverage, including financial risk protection, access to quality essential health care services and…safe, effective, quality and affordable essential medicines and vaccines for all" be judged a breakthrough or a great white elephant in implementation, when we look back with the clear eyes of hindsight in 2030? What are the ways in which this agenda might play out in implementation and why might it do so? Drawing on a desk review, this Essay explores dominant ideas, ideology, institutions, and interests in relation to global versus Ghana national health priorities since the WHO constitution came into effect in 1948, to reflect on these questions.
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http://dx.doi.org/10.1016/S0140-6736(18)32402-4DOI Listing
November 2018

Mothers' reproductive and medical history misinformation practices as strategies against healthcare providers' domination and humiliation in maternal care decision-making interactions: an ethnographic study in Southern Ghana.

BMC Pregnancy Childbirth 2018 Jul 3;18(1):274. Epub 2018 Jul 3.

Sociology of Development and Change Group, Wageningen University, P. O. Box 8130, Hollandsweg 1, 6700 EW, Wageningen, Netherlands.

Background: Pregnant women can misinform or withhold their reproductive and medical information from providers when they interact with them during care decision-making interactions, although, the information clients reveal or withhold while seeking care plays a critical role in the quality of care provided. This study explored 'how' and 'why' pregnant women in Ghana control their past obstetric and reproductive information as they interact with providers at their first antenatal visit, and how this influences providers' decision-making at the time and in subsequent care encounters.

Methods: This research was a case-study of two public hospitals in southern Ghana, using participant observation, conversations, interviews and focus group discussions with antenatal, delivery, and post-natal clients and providers over a 22-month period. The Ghana Health Service Ethical Review Committee gave ethical approval for the study (Ethical approval number: GHS-ERC: 03/01/12). Data analysis was conducted according to grounded theory.

Results: Many of the women in this study selectively controlled the reproductive, obstetric and social history information they shared with their provider at their first visit. They believed that telling a complete history might cause providers to verbally abuse them and they would be regarded in a negative light. Examples of the information controlled included concealing the actual number of children or self-induced abortions. The women adopted this behaviour as a resistance strategy to mitigate providers' disrespectful treatment through verbal abuses and questioning women's practices that contradicted providers' biomedical ideologies. Secondly, they utilised this strategy to evade public humiliation because of inadequate privacy in the hospitals. The withheld information affected quality of care decision-making and care provision processes and outcomes, since misinformed providers were unaware of particular women's risk profile.

Conclusion: Many mothers in this study withhold or misinform providers about their obstetric, reproductive and social information as a way to avoid receiving disrespectful maternal care and protect their privacy. Improving provider client relationship skills, empowering clients and providing adequate infrastructure to ensure privacy and confidentiality in hospitals, are critical to the provision of respectful maternal care.
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http://dx.doi.org/10.1186/s12884-018-1916-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6029400PMC
July 2018

Improved prediction of gestational hypertension by inclusion of placental growth factor and pregnancy associated plasma protein-a in a sample of Ghanaian women.

Reprod Health 2018 Mar 27;15(1):56. Epub 2018 Mar 27.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.

Background: We assessed whether adding the biomarkers Pregnancy Associated Plasma Protein-A (PAPP-A) and Placental Growth Factor (PlGF) to maternal clinical characteristics improved the prediction of a previously developed model for gestational hypertension in a cohort of Ghanaian pregnant women.

Methods: This study was nested in a prospective cohort of 1010 pregnant women attending antenatal clinics in two public hospitals in Accra, Ghana. Pregnant women who were normotensive, at a gestational age at recruitment of between 8 and 13 weeks and provided a blood sample for biomarker analysis were eligible for inclusion. From serum, biomarkers PAPP-A and PlGF concentrations were measured by the AutoDELFIA immunoassay method and multiple of the median (MoM) values corrected for gestational age (PAPP-A and PlGF) and maternal weight (PAPP-A) were calculated. To obtain prediction models, these biomarkers were included with clinical predictors maternal weight, height, diastolic blood pressure, a previous history of gestational hypertension, history of hypertension in parents and parity in a logistic regression to obtain prediction models. The Area Under the Receiver Operating Characteristic Curve (AUC) was used to assess the predictive ability of the models.

Results: Three hundred and seventy three women participated in this study. The area under the curve (AUC) of the model with only maternal clinical characteristics was 0.75 (0.64-0.86) and 0.89(0.73-1.00) for multiparous and primigravid women respectively. The AUCs after inclusion of both PAPP-A and PlGF were 0.82 (0.74-0.89) and 0.95 (0.87-1.00) for multiparous and primigravid women respectively.

Conclusion: Adding the biomarkers PAPP-A and PlGF to maternal characteristics to a prediction model for gestational hypertension in a cohort of Ghanaian pregnant women improved predictive ability. Further research using larger sample sizes in similar settings to validate these findings is recommended.
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http://dx.doi.org/10.1186/s12978-018-0492-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5870183PMC
March 2018

Development and validation of a prediction model for gestational hypertension in a Ghanaian cohort.

BMJ Open 2017 01 16;7(1):e012670. Epub 2017 Jan 16.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.

Objective: To develop and validate a prediction model for identifying women at increased risk of developing gestational hypertension (GH) in Ghana.

Design: A prospective study. We used frequencies for descriptive analysis, χ test for associations and logistic regression to derive the prediction model. Discrimination was estimated by the c-statistic. Calibration was assessed by calibration plot of actual versus predicted probability.

Setting: Primary care antenatal clinics in Ghana.

Participants: 2529 pregnant women in the development cohort and 647 pregnant women in the validation cohort. Inclusion criterion was women without chronic hypertension.

Primary Outcome: Gestational hypertension.

Results: Predictors of GH were diastolic blood pressure, family history of hypertension in parents, history of GH in a previous pregnancy, parity, height and weight. The c-statistic of the original model was 0.70 (95% CI 0.67-0.74) and 0.68 (0.60 to 0.77) in the validation cohort. Calibration was good in both cohorts. The negative predictive value of women in the development cohort at high risk of GH was 92.0% compared to 94.0% in the validation cohort.

Conclusions: The prediction model showed adequate performance after validation in an independent cohort and can be used to classify women into high, moderate or low risk of developing GH. It contributes to efforts to provide clinical decision-making support to improve maternal health and birth outcomes.
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http://dx.doi.org/10.1136/bmjopen-2016-012670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253568PMC
January 2017

Perinatal mortality among infants born during health user-fees (Cash & Carry) and the national health insurance scheme (NHIS) eras in Ghana: a cross-sectional study.

BMC Pregnancy Childbirth 2016 12 8;16(1):385. Epub 2016 Dec 8.

School of Public Health, University of Ghana, Accra, Ghana.

Background: This research determined the rates of perinatal mortality among infants delivered under Ghana's national health insurance scheme (NHIS) compared to infants delivered under the previous "Cash and Carry" system in Northern Region, especially as the country takes stock of its progress toward meeting the Millennium Development Goals (MDG) 4 and 5.

Methods: The labor and maternity wards delivery records of infants delivered before and after the implementation of the NHIS in Northern Region were examined. Records of available daily deliveries during the two health systems were extracted. Fisher's exact tests of non-random association were used to examine the bivariate association between categorical independent variables and perinatal mortality.

Results: On average, 8% of infants delivered during the health user-fee (Cash & Carry) died compared to about 4% infant deaths during the NHIS delivery fee exemption period in Northern Region, Ghana. There were no remarkable difference in the rate of infant deaths among mothers in almost all age categories in both the Cash and Carry and the NHIS periods except in mothers age 35 years and older. Infants born to multiparous mothers were significantly more likely to die than those born to first time mothers. There were more twin deaths during the Cash and Carry system (p = 0.001) compared to the NHIS system. Deliveries by caesarean section increased from an average of 14% in the "Cash and Carry" era to an average of 20% in the NHIS era.

Conclusion: The overall rate of perinatal mortality declined by half (50%) in infants born during the NHIS era compared to the Cash and Carry era. However, caesarean deliveries increased during the NHIS era. These findings suggest that pregnant women in the Northern Region of Ghana were able to access the opportunity to utilize the NHIS for antenatal visits and possibly utilized skilled care at delivery at no cost or very minimal cost to them, which therefore improved Ghana's progress towards meeting the MDG 4, (reducing under-five deaths by two-thirds).
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http://dx.doi.org/10.1186/s12884-016-1179-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5146850PMC
December 2016

Erratum to: Pathways to psychiatric care for mental disorders: a retrospective study of patients seeking mental health services at a public psychiatric facility in Ghana.

Int J Ment Health Syst 2016 18;10:70. Epub 2016 Oct 18.

School of Public Health, University of Ghana, P.O. Box LG13, Accra, Ghana ; Ghana Health Service, Private Mail Bag, Ministries, Accra, Ghana.

[This corrects the article DOI: 10.1186/s13033-016-0095-1.].
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http://dx.doi.org/10.1186/s13033-016-0103-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070368PMC
October 2016

Temporal trends in childhood mortality in Ghana: impacts and challenges of health policies and programs.

Glob Health Action 2016;9:31907. Epub 2016 Aug 23.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.

Background: Following the adoption of the Millennium Development Goal 4 (MDG 4) in Ghana to reduce under-five mortality by two-thirds between 1990 and 2015, efforts were made towards its attainment. However, impacts and challenges of implemented intervention programs have not been examined to inform implementation of Sustainable Development Goal 3.2 (SDG 3.2) that seeks to end preventable deaths of newborns and children aged under-five. Thus, this study aimed to compare trends in neonatal, infant, and under-five mortality over two decades and to highlight the impacts and challenges of health policies and intervention programs implemented.

Design: Ghana Demographic and Health Survey data (1988-2008) were analyzed using trend analysis. Poisson regression analysis was applied to quantify the incidence rate ratio of the trends. Implemented health policies and intervention programs to reduce childhood mortality in Ghana were reviewed to identify their impact and challenges.

Results: Since 1988, the annual average rate of decline in neonatal, infant, and under-five mortality in Ghana was 0.6, 1.0, and 1.2%, respectively. From 1988 to 1989, neonatal, infant, and under-five mortality declined from 48 to 33 per 1,000, 72 to 58 per 1,000, and 108 to 83 per 1,000, respectively, whereas from 1989 to 2008, neonatal mortality increased by 2 per 1,000 while infant and under-five mortality further declined by 6 per 1,000 and 17 per 1,000, respectively. However, the observed declines were not statistically significant except for under-five mortality; thus, the proportion of infant and under-five mortality attributed to neonatal death has increased. Most intervention programs implemented to address childhood mortality seem not to have been implemented comprehensively.

Conclusion: Progress towards attaining MDG 4 in Ghana was below the targeted rate, particularly for neonatal mortality as most health policies and programs targeted infant and under-five mortality. Implementing neonatal-specific interventions and improving existing programs will be essential to attain SDG 3.2 in Ghana and beyond.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4996861PMC
http://dx.doi.org/10.3402/gha.v9.31907DOI Listing
August 2016

Facilitators and barriers to antiretroviral therapy adherence among adolescents in Ghana.

Patient Prefer Adherence 2016 15;10:329-37. Epub 2016 Mar 15.

Department of Medicine, University of Ghana Medical School, Accra, Ghana; Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra, Ghana.

Introduction: Adherence to antiretroviral therapy (ART) is known to be challenging among adolescents living with HIV/AIDS, notwithstanding the life-saving importance of this therapy. Of the global total number of adolescents living with HIV in 2013, 83% reside in sub-Saharan Africa. The study aimed to identify facilitators of and barriers to antiretroviral treatment adherence among adolescents in Ghana.

Methods: A cross-sectional qualitative study using semi-structured interviews for data collection was carried out among adolescents (aged 12-19 years) at the adolescents HIV clinic at the Korle-Bu Teaching Hospital in Ghana. Predominantly open-ended questions relating to ART were used. Interviews were done until saturation. In total, 19 interviews were conducted. Analysis was done manually to maintain proximity with the text.

Findings: The main facilitators were support from health care providers, parental support, patient's knowledge of disease and self-motivation, patient's perceived positive outcomes, and dispensed formulation. The identified barriers were patient's forgetfulness to take medicines, perceived stigmatization due to disclosure, financial barriers, and adverse effects of ART. Support from health care workers was the most frequently mentioned facilitator, and patient's forgetfulness and perceived stigmatization after disclosure were the most frequently mentioned barriers. Self-motivation (knowledge induced) to adhere to treatment was a specific facilitator among older adolescents.

Conclusion: Continuous information provision in addition to unflinching support from health care workers and parents or guardians may improve adherence among adolescents. Also, interventions to reduce patient forgetfulness may be beneficial. A multi-sectorial approach would be needed to address adolescent disclosure of HIV/AIDS status.
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http://dx.doi.org/10.2147/PPA.S96691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4801129PMC
April 2016

Incorporating research evidence into decision-making processes: researcher and decision-maker perceptions from five low- and middle-income countries.

Health Res Policy Syst 2015 Nov 30;13:70. Epub 2015 Nov 30.

Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland.

Background: The 'Sponsoring National Processes for Evidence-Informed Policy Making in the Health Sector of Developing Countries' program was launched by the Alliance for Health Policy and Systems Research, WHO, in July 2008. The program aimed to catalyse the use of evidence generated through health policy and systems research in policymaking processes through (1) promoting researchers and policy advocates to present their evidence in a manner that is easy for policymakers to understand and use, (2) creating mechanisms to spur the demand for and application of research evidence in policymaking, and (3) increased interaction between researchers, policy advocates, and policymakers. Grants ran for three years and five projects were supported in Argentina, Bangladesh, Cameroon, Nigeria and Zambia. This paper seeks to understand why projects in some settings were perceived by the key stakeholders involved to have made progress towards their goals, whereas others were perceived to have not done so well. Additionally, by comparing experiences across five countries, we seek to illustrate general learnings to inform future evidence-to-policy efforts in low- and middle-income countries.

Methods: We adopted the theory of knowledge translation developed by Jacobson et al. (J Health Serv Res Policy 8(2):94-9, 2003) as a framing device to reflect on project experiences across the five cases. Using data from the projects' external evaluation reports, which included information from semi-structured interviews and quantitative evaluation surveys of those involved in projects, and supplemented by information from the projects' individual technical reports, we applied the theoretical framework with a partially grounded approach to analyse each of the cases and make comparisons.

Results And Conclusion: There was wide variation across projects in the type of activities carried out as well as their intensity. Based on our findings, we can conclude that projects perceived as having made progress towards their goals were characterized by the coming together of a number of domains identified by the theory. The domains of Jacobson's theoretical framework, initially developed for high-income settings, are of relevance to the low- and middle-income country context, but may need modification to be fully applicable to these settings. Specifically, the relative fragility of institutions and the concomitantly more significant role of individual leaders point to the need to look at leadership as an additional domain influencing the evidence-to-policy process.
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http://dx.doi.org/10.1186/s12961-015-0059-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4666035PMC
November 2015

Maternal body mass index and adverse pregnancy outcomes: A ghanaian cohort study.

Obesity (Silver Spring) 2016 Jan 17;24(1):215-22. Epub 2015 Nov 17.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.

Objective: To examine the association between maternal weight at <17 weeks gestation and maternal and infant outcomes of pregnancy, delivery, and the postpartum period in pregnant Ghanaian women.

Methods: A prospective cohort study of 1,000 women in Accra, Ghana (2012-2014), was conducted. Women were classified as having overweight (BMI 25-30) and obesity (BMI ≥ 30), and their obstetric and infant outcomes were analyzed using multivariate logistic regression.

Results: The analysis included 824 women, average 28 years (SD 5.1); 313 (31.3%) had overweight and 169 (16.9%) obesity. Women with obesity had a two-fold increased risk for cesarean sections (RR 2.20, 95% CI 1.21-4.02) and more than a six-fold higher risk for pregnancy-induced hypertension (RR 6.17, 95% CI 2.90-13.13) and chronic hypertension (RR 6.00, 95% CI 1.40-25.76). Infants of women with overweight or obesity were more likely to be macrosomic (RR 2.37, 95% CI 1.13-4.97).

Conclusions: The global obesity epidemic has reached women in low- and middle-income countries (LMIC) with important adverse consequences for maternal and infant health. Antenatal care in LMIC will need to anticipate this potential expansion of complications, including the development of guidelines for optimal maternity care for pregnant women with overweight and obesity.
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http://dx.doi.org/10.1002/oby.21210DOI Listing
January 2016

Measuring regional and district variations in the incidence of pregnancy-induced hypertension in Ghana: challenges, opportunities and implications for maternal and newborn health policy and programmes.

Trop Med Int Health 2016 Jan 16;21(1):93-100. Epub 2015 Nov 16.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands.

Objectives: The objectives were to assess the quality of health management information system (HMIS) data needed for assessment of local area variation in pregnancy-induced hypertension (PIH) incidence and to describe district and regional variations in PIH incidence.

Methods: A retrospective review of antenatal and delivery records of 2682 pregnant women in 10 district hospitals in the Greater Accra and Upper West regions of Ghana was conducted in 2013. Quality of HMIS data was assessed by completeness of reporting. The incidence of PIH was estimated for each district.

Results: Key variables for routine assessment of PIH such as blood pressure (BP) at antenatal visits, weight and height were 95-100% complete. Fundal height, gestational age and BP at delivery were not consistently reported. The incidence of PIH differed significantly between Greater Accra region (6.1%) and Upper West region (3.2%). Prevalence of obesity among pregnant women in Greater Accra region (13.9%) was significantly higher than that of women in Upper West region (2.2%).

Conclusions: More attention needs to be given to understanding local area variations in PIH and possible relationships with urbanisation and lifestyle changes that promote obesity, to inform maternal and newborn health policy. This can be done with good quality routine HMIS data.
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http://dx.doi.org/10.1111/tmi.12626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737319PMC
January 2016

Advancing the application of systems thinking in health: provider payment and service supply behaviour and incentives in the Ghana National Health Insurance Scheme--a systems approach.

Health Res Policy Syst 2014 Aug 5;12:35. Epub 2014 Aug 5.

Department of Health Policy Planning and Management (HPPM), University of Ghana School of Public Health, P,O, Box LG 13, Legon, Accra, Ghana.

Background: Assuring equitable universal access to essential health services without exposure to undue financial hardship requires adequate resource mobilization, efficient use of resources, and attention to quality and responsiveness of services. The way providers are paid is a critical part of this process because it can create incentives and patterns of behaviour related to supply. The objective of this work was to describe provider behaviour related to supply of health services to insured clients in Ghana and the influence of provider payment methods on incentives and behaviour.

Methods: A mixed methods study involving grey and published literature reviews, as well as health management information system and primary data collection and analysis was used. Primary data collection involved in-depth interviews, observations of time spent obtaining service, prescription analysis, and exit interviews with clients. Qualitative data was analysed manually to draw out themes, commonalities, and contrasts. Quantitative data was analysed in Excel and Stata. Causal loop and cause tree diagrams were used to develop a qualitative explanatory model of provider supply incentives and behaviour related to payment method in context.

Results: There are multiple provider payment methods in the Ghanaian health system. National Health Insurance provider payment methods are the most recent additions. At the time of the study, the methods used nationwide were the Ghana Diagnostic Related Groupings payment for services and an itemized and standardized fee schedule for medicines. The influence of provider payment method on supply behaviour was sometimes intuitive and sometimes counter intuitive. It appeared to be related to context and the interaction of the methods with context and each other rather than linearly to any given method.

Conclusions: As countries work towards Universal Health Coverage, there is a need to holistically design, implement, and manage provider payment methods reforms from systems rather than linear perspectives, since the latter fail to recognize the effects of context and the between-methods and context interactions in producing net effects.
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http://dx.doi.org/10.1186/1478-4505-12-35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142471PMC
August 2014

Profile: the Dodowa HDSS.

Int J Epidemiol 2013 Dec;42(6):1686-96

Dodowa Health Research Centre (DHRC), Ghana Health Service (GHS), Dodowa, University of Ghana, Legon, Accra, Ghana, Navrongo Health Research Centre (NHRC), Navrongo, Ghana and University of Health and Allied Sciences (UHAS), Ho, Ghana.

The Dodowa Health and Demographic Surveillance System (DHDSS) operates in the south-eastern part of Ghana. It was established in 2005 after an initial attempt in 2003 by the Dodowa Health Research Centre (DHRC) to have an accurate population base for piloting a community health insurance scheme. As at 2010, the DHDSS had registered 111 976 residents in 22 767 households. The district is fairly rural, with scattered settlements. Information on pregnancies, births, deaths, migration and marriages using household registration books administered by trained fieldworkers is obtained biannually. Education, immunization status and household socioeconomic measures are obtained annually and verbal autopsies (VA) are conducted on all deaths. Community key informants (CKI) complement the work of field staff by notifying the field office of events that occur after a fieldworker has left a community. The centre has very close working relationships with the district health directorate and the local government authority. The DHDSS subscribes to the INDEPTH data-sharing policy and in addition, contractual arrangements are made with various institutions on specific data-sharing issues.
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http://dx.doi.org/10.1093/ije/dyt197DOI Listing
December 2013

Community concepts of poverty: an application to premium exemptions in Ghana's National Health Insurance Scheme.

Global Health 2013 Mar 14;9:12. Epub 2013 Mar 14.

School of Public Health, University of Ghana, P. O. Box LG 13, Legon, Ghana.

Background: Poverty is multi dimensional. Beyond the quantitative and tangible issues related to inadequate income it also has equally important social, more intangible and difficult if not impossible to quantify dimensions. In 2009, we explored these social and relativist dimension of poverty in five communities in the South of Ghana with differing socio economic characteristics to inform the development and implementation of policies and programs to identify and target the poor for premium exemptions under Ghana's National Health Insurance Scheme.

Methods: We employed participatory wealth ranking (PWR) a qualitative tool for the exploration of community concepts, identification and ranking of households into socioeconomic groups. Key informants within the community ranked households into wealth categories after discussing in detail concepts and indicators of poverty.

Results: Community defined indicators of poverty covered themes related to type of employment, educational attainment of children, food availability, physical appearance, housing conditions, asset ownership, health seeking behavior, social exclusion and marginalization. The poverty indicators discussed shared commonalities but contrasted in the patterns of ranking per community.

Conclusion: The in-depth nature of the PWR process precludes it from being used for identification of the poor on a large national scale in a program such as the NHIS. However, PWR can provide valuable qualitative input to enrich discussions, development and implementation of policies, programs and tools for large scale interventions and targeting of the poor for social welfare programs such as premium exemption for health care.
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http://dx.doi.org/10.1186/1744-8603-9-12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3600679PMC
March 2013