Publications by authors named "John Kuumuori Ganle"

31 Publications

Sexual and reproductive health education and its association with ever use of contraception: a cross-sectional study among women in urban slums, Accra.

Reprod Health 2022 Jan 15;19(1). Epub 2022 Jan 15.

Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, P. O. Box LG 13, Accra, Ghana.

Background: Sexual and reproductive health education among girls and women has several reproductive health benefits, including improved contraceptive knowledge, contraception use at first intercourse, increased chance of contraceptive use in a lifetime, and effective usage of contraceptives. It is however not clear whether women/girls in urban slums who have had sexual and reproductive health education would likely utilize contraception. This study sets out to test the hypothesis that Accra slum women who have had sex education have higher chances of ever using contraception.

Methods: A cross-sectional survey was conducted among reproductive aged women in two slums (i.e. Agbogbloshie and Old Fadama) in Accra, Ghana. A sample size of 691, made up of respondents who provided responses to the question on ever used contraception, sex education as well as those with complete information on all the other variables of interest was considered in this study. Binary logistic regression models were fitted to examine association between sexual and reproductive health education and ever use of contraception. Crude odds ratios (cOR) and adjusted odds ratios (aOR) at p-value less than 0.05 were used to assess the strength of the association between the outcome and independent variables.

Results: More than half (56.73%) of the women have never received sexual and reproductive health education. Most of the respondents (77.28%) had ever used contraceptives. Women who had no form of sexual and reproductive health education had lower odds of ever using contraception (OR = 0.641, 95% CI 0.443, 0.928) and this persisted after controlling for the effect of demographic factors (AOR = 0.652, 95% CI 0.436, 0.975] compared to those who have ever received any form of sex education. Non-married women as well as women who were exposed to media (newspapers/radio/television) were also more likely to use contraceptives in slums in Accra, Ghana.

Conclusion: The study revealed a relatively low prevalence of sex education among women in urban slums in Accra. However, sex education was found to increase the odds of ever use of contraception. These findings call for intensified sexual and reproductive health education among reproductive aged girls and women in urban slums in Accra using existing informal social networks and local media platforms.
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http://dx.doi.org/10.1186/s12978-021-01322-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8760577PMC
January 2022

Ghanaian women's knowledge on whether malaria treatment is covered by the national health insurance: A multilevel regression analysis of national data.

BMC Public Health 2021 Dec 11;21(1):2263. Epub 2021 Dec 11.

Department of Population, Family and Reproductive Health; School of Public Health, University of Ghana, Accra, Ghana.

Background: To obviate malaria and other healthcare costs and enhance healthcare utilization, the government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2005. Nonetheless, there is dearth of empirical evidence on Ghanaian women's knowledge about whether malaria treatment is covered by the NHIS or not. The current study, therefore, investigated factors associated with knowledge of malaria treatment with the NHIS among women aged 15-49 in Ghana.

Methods: The study is a secondary analysis of data from women respondents in the 2014 Ghana Demographic and Health Survey. A total of 2,560 women participated in this study. Descriptive computation of the weighted proportion of women who knew that malaria is covered by NHIS was conducted at 95% confidence interval (CI). A multilevel logistic regression analyses was carried out with Stata's MLwinN package version 3.05. We declared significance at 5% alpha. Findings from the models were reported as adjusted odds ratios (aOR) and credible intervals (CrIs).

Results: In all, 81.0% of Ghanaian women included in the study knew that NHIS covers malaria treatment. Women aged 45-49 had higher odds of knowing that NHIS covers malaria relative to those aged 15-19 age category [aOR=1.5;95%crl=1.2-2.1]. Women with higher education (post-secondary) had higher odds of knowing that NHIS covers malaria treatment compared with women who had no formal education [aOR=1.6;95%Crl=1.2-2.0]. Richest women were more likely to know that NHIS covers malaria treatment compared to the poorest women [aOR=1.3;95%Crl=1.2-1.7]. Women who had subscribed to the NHIS were more likely to report that NHIS covers malaria treatment [aOR=1.5;95%Crl=1.2-1.8]. The study revealed that the variance in the tendency for a woman to be aware that NHIS covers malaria treatment is attributable to 10.8% community level factors.

Conclusion: This study has shown that individual, community and regional level factors affect women's knowledge on whether NHIS covers malaria treatment or not. As knowledge that malaria treatment is covered by NHIS may increase use of malaria prevention and treatment services in health facilities, we recommend that the Ghana Health Service intensifies community level education and awareness creation efforts, targeted at women among whom awareness levels are currently low.
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http://dx.doi.org/10.1186/s12889-021-12290-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8666054PMC
December 2021

What Support Systems do Women Caring for Preterm Infants at Home Require in Urban Ghana? A Qualitative Study.

Matern Child Health J 2021 Nov 27. Epub 2021 Nov 27.

Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, P.O. Box LG 13, Accra, Ghana.

Introduction: Caring for preterm infants and ensuring their survival beyond neonatal intensive care units remain a challenge in many low-income settings. While studies highlight the difficulties of caring for preterm infants at home, few have focused on the forms, sources, and accessibility to support systems. This study explored the forms of support systems women caring for preterm infants at home in urban Ghana require, and their accessibility to such support systems.

Methods: An explorative cross-sectional qualitative study was conducted. A total of 19 women who were caring for preterm infants aged 2-6 months at home were purposively sampled. In-depth interviews were conducted and thematic content analysis used to analyse the data.

Results: Women reported four main forms of support which they require: psychosocial support, practical support, material support and spiritual support. However, accessibility to these support systems was highly unequal, often depended on one's social status and the quality of one's family and interpersonal relationships prior to giving birth to a preterm infant.

Conclusion: Women caring for preterm infants at home require a variety of support systems; but effective accessibility remains a challenge for many in urban settings. Interventions to strengthen community and home-based support for women caring for preterm infants at home, including use of social media-based peer support groups, are urgently needed.
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http://dx.doi.org/10.1007/s10995-021-03288-zDOI Listing
November 2021

Is improvement in indicators of women's empowerment associated with uptake of WHO recommended IPTp-SP levels in sub-Saharan Africa? A multilevel approach.

BMJ Open 2021 10 29;11(10):e047606. Epub 2021 Oct 29.

School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada

Objectives: The global burden of malaria has reduced considerably; however, malaria in pregnancy remains a major public health problem in sub-Saharan Africa (SSA), where about 32 million pregnant women are at risk of acquiring malaria. The WHO has recommended that pregnant women in high malaria transmission locations, including SSA, have intermittent preventive treatment of malaria during pregnancy with at least three doses of sulphadoxine-pyrimethamine (IPTp-SP). Therefore, we investigated the prevalence of IPTp-SP uptake and associated individual-level, community-level and country-level predictors in SSA.

Design: A cross-sectional survey was conducted using recent Demographic and Health Surveys datasets of 20 SSA countries. A total of 96 765 women were included. Optimum uptake of IPTp-SP at most recent pregnancy was the outcome variable. We fitted three-level multilevel models: individual, community and country parameters at 95% credible interval.

Results: In all, 29.2% of the women had optimal IPTp-SP uptake ranging from 55.1% (in Zambia) to 6.9% (in Gambia). The study revealed a high likelihood of optimum IPTp-SP uptake among women with high knowledge (aOR=1.298, Crl 1.206 to 1.398) relative to women with low knowledge. Women in upper-middle-income countries were more than three times likely to have at least three IPTp-SP doses compared with those in low-income countries (aOR=3.268, Crl 2.392 to 4.098). We found that community (σ=1.999, Crl 1.088 to 2.231) and country (σ=1.853, Crl 1.213 to 2.831) level variations exist in optimal uptake of IPTp-SP. According to the intracluster correlation, 53.9% and 25.9% of the variation in optimum IPTp-SP uptake are correspondingly attributable to community-level and country-level factors.

Conclusions: The outcome of our study suggests that low-income SSA countries should increase budgetary allocation to maternal health, particularly for IPTp-SP interventions. IPTp-SP advocacy behavioural change communication strategies must focus on women with low knowledge, rural dwellers, married women and those who do not meet the minimum of eight antenatal care visits.
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http://dx.doi.org/10.1136/bmjopen-2020-047606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8559097PMC
October 2021

Testing the effect of an integrated-intervention to promote access to sexual and reproductive healthcare and rights among women with disabilities in Ghana: a quasi-experimental study protocol.

Reprod Health 2021 Oct 15;18(1):206. Epub 2021 Oct 15.

Department of Biostatistics, School of Public Health, University of Ghana, Legon, Accra, Ghana.

Background: There is evidence that women with disabilities (WWDs) experience the most difficulty accessing and using sexual and reproductive health and rights (SRHRs) services and information worldwide. However, there are currently no workable interventions to reach WWDs with essential SRHR services. This study aims to test the effect of an integrated health facility and individual-level intervention on access to SRHRs information and services among sexually active WWDs aged 15-49 years in Ghana.

Methods: A quasi-experimental study design with four arms will be implemented in four districts in the Northern region of Ghana to test the effect of three inter-related interventions. The inventions are (1) capacity building in disability-centred SRHRs information and service delivery for healthcare providers, (2) support for WWDs to access disability-unfriendly healthcare infrastructure, and (3) one-on-one regular SRHRs education, information provision, and referral. The first two interventions are at the health-facility level while the third one is at the individual/family level. The first arm of the experiment will expose eligible WWDs to all three interventions. In the second arm, WWDs will be exposed to only the two-health facility-level interventions. The third arm will expose WWDs to only the individual level intervention. The forth arm will constitute the control group. A total of 680 (170 in each arm) sexually active women with physical disability and visual impairments will take part in the study over a period of 12 months. To assess the effect of the interventions on key study outcomes (i.e. awareness about, and use of modern contraceptive, ANC attendance, and skilled delivery among parous women), pre- and post-intervention surveys will be conducted. Difference-in-Difference analysis will be used to examine the effect of each intervention in comparison to the control group, while controlling for confounders. Cost-effectiveness analyses will also be conducted on the three-intervention arms vis a vis changes in key outcome measures to identify which of the three interventions is likely to yield greater impact with lower costs.

Discussion: Lack of access to SRHRs information and services for WWDs is not only a violation of their right to appropriate and quality SRH care but could also undermine efforts to achieve equitable healthcare access as envisaged under SDG 3. This research is expected to generate evidence to inform local health programmes to increase access to SRHRs among WWDs by strengthening local health system capacity to provide disability-sensitive SRHRs services. Trial registration Name of the registry: Pan African Clinical Trials Registry (PACTR). Trial ID: 14591. Date of registration: 02/01/2020. URL of trial registry record: https://pactr.samrc.ac.za/Researcher/TrialRegister.aspx?TrialID=14591.
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http://dx.doi.org/10.1186/s12978-021-01253-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8520222PMC
October 2021

Family planning for urban slums in low- and middle-income countries: a scoping review of interventions/service delivery models and their impact.

Int J Equity Health 2021 08 19;20(1):186. Epub 2021 Aug 19.

Population Council, Accra, Ghana.

Background: Although evidence suggest that many slum dwellers in low- and middle-income countries have the most difficulty accessing family planning (FP) services, there are limited workable interventions/models for reaching slum communities with FP services. This review aimed to identify existing interventions and service delivery models for providing FP services in slums, and as well examine potential impact of such interventions and service delivery models in low- and middle-income settings.

Methods: We searched and retrieved relevant published studies on the topic from 2000 to 2020 from e-journals, health sources and six electronic databases (MEDLINE, Global Health, EMBASE, CINAHL, PsycINFO and Web of Science). Grey and relevant unpublished literature (e.g., technical reports) were also included. For inclusion, studies should have been published in a low- and middle-income country between 2000 and 2020. All study designs were included. Review articles, protocols or opinion pieces were excluded. Search results were screened for eligible articles and reports using a pre-defined criterion. Descriptive statistics and narrative syntheses were produced to summarize and report findings.

Results: The search of the e-journals, health sources and six electronic databases including grey literature and other unpublished materials produced 1,260 results. Following screening for title relevance, abstract and full text, nine eligible studies/reports remained. Six different types of FP service delivery models were identified: voucher schemes; married adolescent girls' club interventions; Willows home-based counselling and referral programme; static clinic and satellite clinics; franchised family planning clinics; and urban reproductive health initiatives. The urban reproductive health initiatives were the most dominant FP service delivery model targeting urban slums. As regards the impact of the service delivery models identified, the review showed that the identified interventions led to improved targeting of poor urban populations, improved efficiency in delivery of family planning service, high uptake or utilization of services, and improved quality of family planning services.

Conclusions: This review provides important insights into existing family planning service delivery models and their potential impact in improving access to FP services in poor urban slums. Further studies exploring the quality of care and associated sexual and reproductive health outcomes as a result of the uptake of these service delivery models are essential. Given that the studies were reported from only 9 countries, further studies are needed to advance knowledge on this topic in other low-middle income countries where slum populations continue to rise.
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http://dx.doi.org/10.1186/s12939-021-01518-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375135PMC
August 2021

An ecological approach to understanding stroke experience and access to rehabilitation services in Ghana: A cross-sectional study.

Health Soc Care Community 2021 09 5;29(5):e67-e78. Epub 2020 Dec 5.

Center for Health Policy, University of Witwatersrand, Johannesburg, South Africa.

Despite a growing burden of stroke in low-middle-income countries, research on patient's experiences and access to rehabilitation services remains limited. This study explores the experiences of stroke patients in relation to access and use of stroke rehabilitation services, coping strategies and strategies to improve care in Ghana. A cross-sectional study was conducted. A total of 136 adult stroke patients hospitalised and subsequently discharged in three major referral hospitals in Ghana participated in the study. A paper-based questionnaire was used to collect data. Data were inputted into STATA version 12, cleaned and analysed using descriptive statistics and Chi-Square tests. Findings showed that stroke patients experience stroke differently. Early detection (awareness) of stroke symptoms at onset was low (29.4%). Hypertension was the major (58.1%) predisposing risk factor for stroke, followed by diabetes (14.7%). Multiple barriers impede access to outpatient rehabilitation services: high cost of medications (43.4%), transportation constraints (10.3%), long waiting time (6.6%), forgetfulness about appointment (4.4%), limited education on rehabilitation (20.6%), lack of community support (12.5%) and ineffective communication with healthcare providers (5.2%). Recommended strategies to improve access to rehabilitation care included public education on stroke and its associated risk, reduction in the cost of drugs and increased stroke rehabilitation funding by the NHIS, especially for physiotherapy consultation and training support to caregivers on patient care. Given the difference in stroke experience and barriers in accessing rehabilitation care, multi-level health policy and service delivery reforms are needed to improve access to rehabilitation care, including national public awareness campaigns on early signs of stroke and subsidised cost of stroke rehabilitation.
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http://dx.doi.org/10.1111/hsc.13243DOI Listing
September 2021

Barriers facing persons with disability in accessing sexual and reproductive health services in sub-Saharan Africa: A systematic review.

PLoS One 2020 12;15(10):e0238585. Epub 2020 Oct 12.

Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Accra, Ghana.

Background: There is evidence that persons with disabilities often encounter grave barriers when accessing sexual and reproductive health services. To the best of our knowledge, however, no systematic review has been conducted to pull together these pieces of research evidence for us to understand the nature, magnitude and extent of these barriers in different settings in sub-Saharan Africa. We do not yet have a good understanding of the strength/quality of the evidence that exist on the barriers persons with disabilities face when accessing sexual and reproductive health services in sub-Saharan Africa. We therefore conducted a systematic review to examine the barriers persons with disabilities face in accessing sexual and reproductive health services in sub-Saharan Africa.

Methods: A systematic review was conducted using PRISMA guidelines (PROSPEROO protocol registration number: CRD42017074843). An electronic search was conducted in Medline, EMBASE, CINAHL, PsycINFO, and Web of Science from 2001 to 2020. Manual search of reference list was also conducted. Studies were included if they reported on barriers persons with disability face in accessing sexual and reproductive health services. The Critical Appraisal Skills Programme and Centre for Evidence Based Management (CEBMa) appraisal tools were used to assess methodological quality of eligible studies.

Findings: A total of 1061 studies were identified. Only 26 studies covering 12 sub-Saharan African countries were eligible for analysis. A total of 33 specific barriers including inaccessible physical health infrastructure and stigma and discrimination were identified. These barriers were further categorised into five levels: broader national level barriers; healthcare system/institutional barriers; individual level barriers; community level barriers; and economic barriers.

Conclusion: Persons with disabilities face a myriad of demand and supply side barriers to accessing sexual and reproductive healthcare in sub-Saharan Africa. Multilevel interventions are urgently needed to address these barriers.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238585PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549766PMC
November 2020

'They are my future': childbearing desires and motivations among women with disabilities in Ghana - implications for reproductive healthcare.

Reprod Health 2020 Oct 6;17(1):151. Epub 2020 Oct 6.

School of Community Health, Faculty of Science, Charles Sturt University, Bathurst, New South Wales, Australia.

Background: Previous research has highlighted widespread public mis/perceptions that portray women with disabilities (WWDs) as asexual, less likely to marry, and often not interested in childbearing. However, evidence from high-income settings shows that many WWDs are sexually active and do have or want to have children. Notwithstanding this, very few studies have focused on understanding childbearing desires and motivations among WWDs in low-income settings. This qualitative research explored childbearing desires and motivations among WWDs in Ghana.

Methods: A cross-sectional qualitative study was conducted with WWDs aged 18-49 years in Northern Ghana. The distribution of participants by disability types were as follows: physical disability/impairment (n = 37); visual impairment (n = 11); speech and hearing impairment (n = 14); epilepsy (n = ten); and albinism (n = five). A pre-tested open-ended thematic topic guide was designed and used to conduct in-depth interviews. Interviews were tape-recorded and later transcribed for analysis. Transcripts were coded using QSR NVivo 11 software. Thematic content analysis techniques were used to analyse and present the data.

Results: Nearly all the WWDs interviewed were sexually active, desiring to have children, and intended to have as many children as they could support. Strong desire to experience the joy of motherhood; fear of social insecurity; fear of old age economic insecurity; desire to challenge stigma and negative stereotypes about disability, sexuality and motherhood; and desire for self-actualisation, were key motivations for childbearing.

Conclusion: Our findings challenge existing negative public perceptions about the status of WWDs in relation to sexuality, childbearing and motherhood. More importantly, our findings suggest that if the Sustainable Development Goals related to universal access to sexual and reproductive healthcare are to be attained, WWDs must be targeted with quality sexual and reproductive healthcare information and services.
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http://dx.doi.org/10.1186/s12978-020-01000-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539488PMC
October 2020

Childhood obesity in urban Ghana: evidence from a cross-sectional survey of in-school children aged 5-16 years.

BMC Public Health 2019 Nov 26;19(1):1561. Epub 2019 Nov 26.

Regional Institute for Population Studies, University of Ghana, Accra, Ghana.

Background: Childhood obesity is a growing public health concern in many low-income urban settings; but its determinants are not clear. The purpose of this study is to assess the prevalence of childhood obesity and associated factors among in-school children aged 5-16 years in a Metropolitan district of Ghana.

Methods: A cross-sectional quantitative survey was conducted among a sample of 285 in-school children aged 5-16 years. Pre-tested questionnaires and anthropometric data collection methods were used to collect data. Descriptive, bivariate, binary and multivariate logistic regression statistical techniques were used to analyse data.

Results: Some 46.9% (42.2% for males and 51.7% for females) of the children were overweight. Of this, 21.2% were obese (BMI falls above 95th percentile). Childhood obesity was higher in private school (26.8%) than public school (21.4%), and among girls (27.2%) than boys (19%). Factors that increased obesity risks included being aged 11-16 as against 5-10 years (aOR = 6.07; 95%CI = 1.17-31.45; p = 0.025), having a father whose highest education is 'secondary' (aOR =2.97; 95% CI = 1.09-8.08; p = 0.032), or 'tertiary' (aOR = 3.46; 95% CI = 1.27-9.42; p = 0.015), and consumption of fizzy drinks most days of the week (aOR = 2.84; 95% CI = 1.24-6.52; p = 0.014). Factors that lowered obesity risks included engaging in sport at least 3times per week (aOR = 0.56; 95% CI = 0.33-0.96; p = 0.034), and sleeping for more than 8 h per day (aOR = 0.38; 95% CI = 0.19-0.79; p = 0.009).

Conclusion: Higher parental (father) educational attainment and frequent consumption of fizzy drinks per week may increase obesity risks among in-school children aged 5-16 years in the Metropolitan district of Ghana. However, regular exercise (playing sport at least 3 times per week) and having 8 or more hours of sleep per day could lower obesity risks in the same population. Age and sex-appropriate community and school-based interventions are needed to promote healthy diet selection and consumption, physical activity and healthy life styles among in-school children.
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http://dx.doi.org/10.1186/s12889-019-7898-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880588PMC
November 2019

Stocking and over-the-counter sale of misoprostol for medical abortion in Ghana's community pharmacies: comparison of questionnaire and mystery client survey.

Int J Pharm Pract 2020 Jun 20;28(3):267-274. Epub 2019 Nov 20.

Regional Institute for Population Studies, University of Ghana, Accra, Ghana.

Objectives: In many sub-Saharan African countries with restricted safe abortion services, community pharmacies are important sources of abortifacients. However, data on stocking and over-the-counter sale of abortifacients in community pharmacies are often limited. The main objective of this study was to compare stocking and over-the-counter sale of misoprostol at community pharmacies using questionnaire and mystery client surveys in Ghana.

Methods: A cross-sectional questionnaire-based survey, complemented with a mystery client survey, was conducted at 165 randomly selected community pharmacies in Accra, Ghana. Structured questionnaires were administered to pharmacists/pharmacy workers. A mystery client survey to each of these pharmacies was also undertaken. Descriptive statistical techniques (frequencies and proportions) were used to estimate and compare stocking and over-the-counter sale of misoprostol at community pharmacies from the two data collection methods.

Key Findings: Some 50.3% (83) of community pharmacists/pharmacy workers reported stocking misoprostol and selling it over-the-counter for medical abortion in the questionnaire-based survey. However, in the mystery client survey, 122 (74%) pharmacists/pharmacy workers reported stocking misoprostol and actually selling it over-the-counter to the mystery clients. Thus approximately 39 (24%) more pharmacies stocked misoprostol and sold it over-the-counter even though they originally denied stocking the drug in the questionnaire survey. Also, the drug was often sold without a prescription, and many did so without asking for a confirmatory pregnancy test or gestational age.

Conclusions: In contexts where access to safe abortion services is restricted, mystery client surveys, rather than conventional questionnaire-based survey techniques, may better illuminate stocking and over-the-counter sale of abortifacients at community pharmacies.
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http://dx.doi.org/10.1111/ijpp.12593DOI Listing
June 2020

Anaemia at antenatal care initiation and associated factors among pregnant women in West Gonja District, Ghana: a cross-sectional study.

Pan Afr Med J 2019 27;33:325. Epub 2019 Aug 27.

Nadowli Hospital, Ghana Health Service, Nadowli, Upper West Region, Ghana.

Introduction: Anaemia in pregnancy remains a critical public health concern in many African settings; but its determinants are not clear. The purpose of this study was to assess anaemia at antenatal care initiation and associated factors among pregnant women in a local district of Ghana.

Methods: A facility-based cross-sectional survey was conducted. A total of 378 pregnant women attending antenatal care at two health facilities were surveyed. Data on haemoglobin level, helminths and malaria infection status at first antenatal care registration were extracted from antenatal records booklets of each pregnant women. Questionnaires were then used to collect data on socio-demographic and dietary variables. Binary and multivariate logistic regression analyses were done to assess factors associated with anaemia.

Results: The prevalence of anaemia was 56%, with mild anaemia being the highest form (31.0%). Anaemia prevalence was highest (73.2%) among respondents aged 15-19 years. Factors that significantly independently reduced the odds of anaemia in pregnancy after controlling for potential confounders were early (within first trimester) antenatal care initiation (AOR=5.01; 95% CI =1.41-17.76; p=0.013) and consumption of egg three or more times in a week (AOR=0.30; 95% CI=0.15-0.81; P=0.014).

Conclusion: Health facility and community-based preconception and conception care interventions must not only aim to educate women and community members about the importance of early ANC initiation, balanced diet, protein and iron-rich foods sources that may reduce anaemia, but must also engage community leaders and men to address food taboos and cultural prohibitions that negatively affect pregnant woman.
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http://dx.doi.org/10.11604/pamj.2019.33.325.17924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815505PMC
November 2019

Discontinuation of Exclusive Breastfeeding in Ghana: A Longitudinal, One-Group Observational Study of Postnatal Mothers With Children 0-6 Months old.

J Hum Lact 2020 Aug 29;36(3):461-470. Epub 2019 Aug 29.

260088 Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana.

Background: Although exclusive breastfeeding of infants has several benefits, in Ghana only 52% of children under 6 months old are breastfed exclusively. However, researchers have not conducted longitudinal observational studies to examine exclusive breastfeeding discontinuation and determine risk factors.

Research Aims: (1) To determine exclusive breastfeeding discontinuation, and (2) to examine those factors linked to discontinued exclusive breastfeeding.

Methods: A longitudinal, one-group observational study was conducted. A total of 322 mothers who had normal and full-term delivery at a district level referral hospital from January to December 2017 were recruited, followed-up every month, and subsequently interviewed after 6 months postpartum. Data were collected using validated questionnaires. Binary and multivariable Poisson regression analyses were the statistical analytical methods used.

Results: Respondents' mean age was 29.78 years ( = 5.20). Among the 322 mothers who initiated breastfeeding with human milk at birth, 108 (34%) discontinued exclusive breastfeeding before 6 months postpartum. After controlling for possible covariates, attending antenatal care 4 or less times during pregnancy ( = 6.54; 95% [1.77-24.22]; = .005); lack of support from family to breastfeed exclusively ( = 2.41; 95% [1.23-4.71]; = .010), outside pressure to provide other food to the baby < 6 months postpartum ( = 1.87; 95% [1.01-3.46]; = .045), and living in an urban area ( = 2.10; 95% [1.17-3.75]; = .013) significantly increased the risks of discontinuing exclusive breastfeeding.

Conclusion: Universal exclusive breastfeeding may not be achieved without tackling the key determinants of discontinuation of exclusive breastfeeding. Health facility and community-based exclusive breastfeeding promotion interventions are therefore needed.
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http://dx.doi.org/10.1177/0890334419871012DOI Listing
August 2020

Risky sexual behaviour and contraceptive use in contexts of displacement: insights from a cross-sectional survey of female adolescent refugees in Ghana.

Int J Equity Health 2019 08 16;18(1):127. Epub 2019 Aug 16.

Nadowli Hospital, Nadowli, Upper West Region, Ghana.

Background: Difficulty in accessing sexual and reproductive healthcare is one of the challenges young refugee women face worldwide, in addition to sexual exploitation, violence and abuse. Although Ghana hosts several refugees, little is known about their sexual behaviour and contraceptive use. This study assesses sexual behaviour and contraceptive use among female adolescent refugees in Ghana.

Methods: A cross-sectional survey was conducted between June and August 2016. Respondents comprised 242 female adolescent refugees aged 14-19 years. Structured validated questionnaires were used to collect data. Descriptive statistical methods and multivariate logistic regression statistical analyses methods were used to analyze data.

Findings: Over 78% of respondents have had penetrative sex; 43% have had coerced sex; 71% have had transactional sex; 36% have had sex while drunk, 57% have had 4-6 sexual partners in the last 12 months before the study, and 38% have had both coerced and transactional sex. Factors that predicted ever having transactional sex included being aged 14-16 compared to those aged 17-19 (AOR =4·80; 95% CI = 2·55-9·04); being from Liberia compared to being from Ghana (AOR = 3·05; 95% CI = 1.69-13·49); having a mother who had no formal education compared to having a mother with tertiary education (AOR = 5.75; 95CI = 1.94-14.99); and living alone (self) compared to living with parents (AOR = 3.77; 95CI = 1.38-10.33). However, having 1-3 sexual partners in the last 12 months as against having 4-6 partners significantly reduced the odds of ever having transactional sex (AOR = 0·02; 95% CI = 0·01-0·08). Awareness about contraceptives was 65%, while ever use of contraceptives was 12%. However, contraceptive use at last sexual intercourse was 8.2%, and current use was 7.3%. Contraceptive use was relatively higher among those who have never had sex while drunk, as well as among those who have never had transactional sex and coerced sex. Contraceptive use was similarly higher among those who had 1-3 sexual partners in the last 12 months compared to those who had 4-6 during the same time period.

Conclusion: In this time of global migration crises, addressing disparities in knowledge and access to contraception as well as high risk sexual behaviours in refugee situations is important for reducing inequalities in reproductive health outcomes and ensuring both universal health coverage and global health justice. Sex and contraception education and counselling, self-efficacy training, and skills acquisition are needed to help young refugee women negotiate and practice safe sex and resist sexual pressures.
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http://dx.doi.org/10.1186/s12939-019-1031-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697917PMC
August 2019

Factors influencing the use of supervised delivery services in Garu-Tempane District, Ghana.

BMC Pregnancy Childbirth 2019 Apr 27;19(1):141. Epub 2019 Apr 27.

Regional Institute for Population Studies, University of Ghana, Legon, Accra, Ghana.

Background: There is evidence that supervised delivery has the potential to improve birth outcomes for both women and newborns. However, not all women especially in low-income settings like Ghana use supervised delivery services during childbirth. The purpose of this study was to estimate the prevalence of supervised delivery and determine factors that influence use of supervised delivery services in a local district of Ghana.

Methods: A retrospective cross-sectional survey of 322 randomly sampled postpartum women who delivered between January and December 2016 in the Garu-Tempane District was conducted. Structured questionnaires were used to collect data. Descriptive, binary and multivariate logistic regression analysis techniques were used to analyse data.

Results: Although antenatal care attendance among respondents was very high 291(90.4%), prevalence of supervised birth was only 219(68%). More than a quarter 103(32%) of the postpartum women delivered their babies at home without skilled birth attendants. After controlling for possible confounders in multivariable logistic regression analyses, factors that strongly independently predicted supervised delivery were religion (p < 0.01), distance to health facility (p < 0.05), making at least 4 antenatal care visits (p < 0.01), national health insurance scheme registration (p < 0.01), satisfaction with services received during antenatal care (p < 0.01), need partner's approval before delivering in health facility (p < 0.01), woman's thoughts that her religious beliefs prohibited health facility delivery(p < 0.01), and woman's belief that there are norms in her community that did not support health facility delivery (p < 0.01).

Conclusion: There is need for targeted interventions, including community mobilization and health education, and male partner involvement to help generate local demand for, and uptake of, supervised delivery services. Improvement in the quality of services in health facilities, including ensuring respect and dignity for service users, would also be essential.
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http://dx.doi.org/10.1186/s12884-019-2295-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6487062PMC
April 2019

Understanding factors influencing home delivery in the context of user-fee abolition in Northern Ghana: Evidence from 2014 DHS.

Int J Health Plann Manage 2019 Apr 18;34(2):727-743. Epub 2019 Jan 18.

Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana.

User-fee exemption for skilled delivery services has been implemented in Ghana since 2003 as a way to address financial barriers to access. However, many women still deliver at home. Based on data from the 2014 Ghana Demographic and Health Survey, we estimated the prevalence of home delivery and determined the factors contributing to homebirths among a total of 622 women in the Northern region in the context of the user-fee exemption policy in Ghana. Binary and multivariate logistic regression analyses were employed. Results suggest home delivery prevalence of 59% (365/622). Traditional birth attendants attended majority of home deliveries (93.4%). After adjusting for potential confounders, making less than four antenatal care visits (aOR = 2.42; CI = 1.91-6.45; p = 0.001), being a practitioner of traditional African religion (aOR = 16.40; CI = 3.10-25.40; p = 0.000), being a Muslim (aOR 2.10; CI = 1.46-5.30; p = 0.042), not having a health insurance (aOR = 1.85; CI = 1.773-4.72; p = 0.016), living in a male-headed household (aOR = 2.07; CI = 1.02-4.53; p < 0.01), and being unexposed to media (aOR = 3.10; CI = 1.12-5.38; p = 0.021) significantly predicted home delivery. Our results suggest that unless interventions are implemented to address other health system factors like insurance coverage, and socio-cultural and religious beliefs that hinder uptake of skilled care, the full benefits of user-fee exemption may not be realized in Ghana.
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http://dx.doi.org/10.1002/hpm.2731DOI Listing
April 2019

Inclusion of men in maternal and safe motherhood services in inner-city communities in Ghana: evidence from a descriptive cross-sectional survey.

BMC Pregnancy Childbirth 2017 Dec 14;17(1):419. Epub 2017 Dec 14.

Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana.

Background: There has been a growing realisation of the need to enhance men's inclusion in maternal and safe motherhood services, especially in low-income settings. However, empirical studies on the extent to which men are involved in maternal and safe motherhood services especially in poor inner-city communities are lacking. The purpose of this study was to describe the level of men's inclusion in maternal and safe-motherhood services in inner-city communities in Ghana, and to assess the barriers of men's involvement.

Methods: A descriptive cross-sectional quantitative survey was conducted among a total of 256 randomly selected adult men in Chorkor, an inner-city fishing community in Accra, the capital city of Ghana. A multistage sampling strategy was used to select houses, households and respondents. Descriptive statistical techniques were used to analyse the data. Data analysis was done with the aid of SPSS version 20.

Results: Although almost all (96.6%) respondents knew the meaning of family planning, as high as 236(92.2%) have never accompanied their wives/partners to clinics to seek family planning services. Also 242(94.5%) and 251(98%) of men, respectively, knew the importance of antenatal services and supervised delivery. However, only 114(44.5%) of men ever accompanied their wives/partners to seek skilled delivery services. Men's involvement was hindered by barriers such as attitude of health workers, long waiting time and socio-cultural beliefs.

Conclusion: The study revealed a gap between men's awareness of the importance of maternal and safe motherhood services and their actual involvement in accessing these services with their female partners. There is a need to create a supportive environment that encourages men to be involved in maternal health services to help reduce maternal/neonatal morbidity and mortality.
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http://dx.doi.org/10.1186/s12884-017-1590-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5731062PMC
December 2017

Community health workers in Ghana: the need for greater policy attention.

BMJ Glob Health 2016 2;1(4):e000141. Epub 2016 Dec 2.

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

From the 1970s to the 1990s, the WHO, United Nations and other agencies mooted the idea of formally training and recognising community health workers (CHWs) to complement efforts to improve primary healthcare delivery in low and middle income countries. Recently, CHWs have been recognised as important players in the achievement of the health-related Millennium Development Goals (MDGs). Despite this recognition, little understanding exists in Ghana about the activities of CHWs: who they are; how they are recruited; what they do; level of health policy support; contribution to healthcare delivery and the challenges they face. Based on a rapid scoping review of the existing literature, and our experience working in Ghana, this paper reflects on the role of CHWs in healthcare delivery in Ghana. We argue that CHWs have played critical roles in improving health service delivery and outcomes, including guinea worm eradication, expanded immunisation coverage, maternal and child health, and HIV/AIDS treatment and management. However, these achievements notwithstanding, CHWs face challenges which prevent them from being optimally productive, including capacity problems, neglect by the healthcare system, high attrition rates and inadequate supervision. Policymakers in Ghana therefore need to give increased attention to CHWs, provide remuneration for their activities, create career opportunities and other means of motivations to boost their productivity and sustain gains associated with their activities.
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http://dx.doi.org/10.1136/bmjgh-2016-000141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5321387PMC
December 2016

Overweight and obesity prevalence among public servants in Nadowli district, Ghana, and associated risk factors: a cross-sectional study.

BMC Obes 2017 1;4:15. Epub 2017 Jun 1.

Ministry of Health, Accra, Ghana.

Background: Globally, overweight and obesity are becoming a mounting concern, impacting negatively on the health of populations especially in low-income settings. However, there is paucity of epidemiological information available in Ghana to support intervention activities. We conducted a study among public servants to estimate overweight/obesity, hypertension and diabetes prevalence and associated risk factors.

Methods: A descriptive cross sectional survey involving 271 purposively sampled public servants aged 20 to 59 years was conducted. We used a structured questionnaire to collect data on eating patterns, risk factors for overweight and obesity, as well as data on socio-demographics and physical activity. Anthropometric measurements were carried out and body mass index (BMI) calculated. Information on blood pressure and diabetes was also gathered. We used descriptive statistical and logistic regression analyses to, respectively, estimate overweight/obesity prevalence, and examine associations between behavioral factors and overweight/obesity and hypertension/diabetes.

Results: The overall hypertension/diabetes, overweight and obesity prevalence were 20, 29.9 and 4.8% respectively. The study found that marital status ( < 0.001), leisure time with physical activity and level of physical activity during work ( < 0.035) as well as morbidities such as diabetes and hypertension ( < 0.012) were significantly associated with BMI. Findings showed no significant relationship between mealtime, eating habits, education, age and body mass index. Even though prevalence of overweight/obesity was higher among respondents who travelled to work by car compared to respondents who used motor bikes or walked, the association between weight status and means of transport was not statistically significant. Both smoking ( = 0.730) and alcohol consumption ( = 0.109) were not linked to weight status.

Conclusion: Population-based interventions are needed to promote nutritious food selection and consumption, physical activity and healthy life styles. We also recommend that age and gender-specific interventions should be designed and implemented by relevant authorities to promote and support healthy living and healthy-lifestyles at home and in workplaces.
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http://dx.doi.org/10.1186/s40608-017-0153-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5452290PMC
June 2017

ART access-related barriers faced by HIV-positive persons linked to care in southern Ghana: a mixed method study.

BMC Infect Dis 2016 12 7;16(1):738. Epub 2016 Dec 7.

Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana.

Background: Timely and enduring access to antiretroviral therapy (ART) by HIV-infected individuals has been shown to substantially reduce HIV transmission risk, HIV-related morbidity and mortality. However, there is evidence that in addition to limited supply of antiretrovirals (ARVs) and linkage to ART in many low-income countries, HIV+ persons often encounter barriers in accessing ART-related services even in contexts where these services are freely available. In Ghana, limited research evidence exists regarding the barriers HIV+ persons already linked to ART face. This paper explores ART access-related barriers that HIV+ persons linked to care in southern Ghana face.

Methods: A mixed method study design, involving a cross-sectional survey and qualitative in-depth interviews, was conducted to collect data from four healthcare providers and a total of 540 adult HIV+ persons receiving ART at four treatment centres in Ghana. We used univariate analysis to generate descriptive tabulations for key variables from the survey. Data from qualitative in-depth interviews were thematically analysed. Results from the survey and in-depth interviews were brought together to illuminate the challenges of the HIV+ persons.

Results: All (100%) the HIV+ persons interviewed were ARV-exposed and linked to ART. Reasons for taking ARVs ranged from beliefs that they will suppress the HIV virus, desire to maintain good health and prolong life, and desire to prevent infection in unborn children, desire both to avoid death and to become good therapeutic citizens (abide by doctors' advice). Despite this, more than half of the study participants (63.3%) reported seven major factors as barriers hindering access to ART. These were high financial costs associated with accessing and receiving ART (26%), delays associated with receiving care from treatment centres (24%), shortage of drugs and other commodities (23%), stigma (8.8%), fear of side effects of taking ARVs (7.9%), job insecurity arising from regular leave of absence to receive ART (5.3%), and long distance to treatment centres (4.9%).

Conclusions: The results in this study suggest that efforts to provide and scale-up ART to all HIV+ persons must be accompanied by interventions that address structural and individual level access barriers.
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http://dx.doi.org/10.1186/s12879-016-2075-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5142337PMC
December 2016

'If I go with him, I can't talk with other women': Understanding women's resistance to, and acceptance of, men's involvement in maternal and child healthcare in northern Ghana.

Soc Sci Med 2016 10 20;166:195-204. Epub 2016 Aug 20.

Department of Sociology and Social Work, Faculty of Social Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

Men's involvement in maternal and child healthcare especially in patriarchal societies such as Ghana is increasingly being advocated. While a number of studies have been conducted to explore men's views on their involvement, few studies have examined the perspectives of childbearing women. Based on qualitative focus group discussions that were conducted between January and August 2014 with a total of 125 adult women in seven communities in the Upper West Region of Ghana, this paper examines women's perspectives on men's involvement in maternal and child healthcare. Findings suggest that although many women recognised the benefits of men's involvement, few actually supported greater male involvement. The majority of women expressed negative attitudes and opinions on the involvement of men. These negative attitudes and opinions were framed by three broad factors: perceptions that pregnancy and child care should be a female role while men should be bread winners; women's desire to avoid negative stereotyping; and fears that men's involvement may turn hitherto secure social spaces for women into insecure ones. These narrative accounts largely challenge current programmatic efforts that seek to promote men's involvement in maternal and child healthcare, and suggest that such male involvement programmes are less likely to succeed if the views and concerns of childbearing women are not taken into account.
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http://dx.doi.org/10.1016/j.socscimed.2016.08.030DOI Listing
October 2016

Challenges Women with Disability Face in Accessing and Using Maternal Healthcare Services in Ghana: A Qualitative Study.

PLoS One 2016 27;11(6):e0158361. Epub 2016 Jun 27.

Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana.

Background: While a number of studies have examined the factors affecting accessibility to and utilisation of healthcare services by persons with disability in general, there is little evidence about disabled women's access to maternal health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and the challenges they face in accessing skilled maternal health services. The objective of this paper is to explore the challenges women with disabilities encounter in accessing and using institutional maternal healthcare services in Ghana.

Methods And Findings: A qualitative study was conducted in 27 rural and urban communities in the Bosomtwe and Central Gonja districts of Ghana with a total of 72 purposively sampled women with different physical, visual, and hearing impairments who were either lactating or pregnant at the time of this research. Semi-structured in-depth interviews were used to gather data. Attride-Stirling's thematic network framework was used to analyse the data. Findings suggest that although women with disability do want to receive institutional maternal healthcare, their disability often made it difficult for such women to travel to access skilled care, as well as gain access to unfriendly physical health infrastructure. Other related access challenges include: healthcare providers' insensitivity and lack of knowledge about the maternity care needs of women with disability, negative attitudes of service providers, the perception from able-bodied persons that women with disability should be asexual, and health information that lacks specificity in terms of addressing the special maternity care needs of women with disability.

Conclusions: Maternal healthcare services that are designed to address the needs of able-bodied women might lack the flexibility and responsiveness to meet the special maternity care needs of women with disability. More disability-related cultural competence and patient-centred training for healthcare providers as well as the provision of disability-friendly transport and healthcare facilities and services are needed.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0158361PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922658PMC
July 2017

Coliform Contamination of Peri-urban Grown Vegetables and Potential Public Health Risks: Evidence from Kumasi, Ghana.

J Community Health 2016 Apr;41(2):392-7

Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

Peri-urban vegetable farming in Ghana is an important livelihood activity for an increasing number of people. However, increasing quality and public health concerns have been raised, partly because freshwater availability for irrigation purposes is a major constraint. This paper investigated on-farm vegetable contamination and potential health risks using samples of lettuce, spring onions and cabbage randomly selected from 18 vegetable farms in peri-urban Kumasi, Ghana. Vegetable samples were tested for total coliform, fecal coliform, Escherichia coli and Salmonella spp. bacteria contamination using the Most Probable Number method. Results show high contamination levels of total and fecal coliforms, and Escherichia coli bacteria in all 18 vegetable samples. The mean total coliform/100 ml concentration for spring onions, lettuce and cabbage were 9.15 × 10(9), 4.7 × 10(7) and 8.3 × 10(7) respectively. The mean fecal coliform concentration for spring onions, lettuce and cabbage were also 1.5 × 10(8), 4.15 × 10(7) and 2.15 × 10(7) respectively, while the mean Escherichia coli bacteria contamination for spring onions, lettuce and cabbage were 1.4 × 10(8), 2.2 × 10(7) and 3.2 × 10(7) respectively. The level of total coliform, fecal coliform and Escherichia coli bacteria contamination in all the vegetable samples however declined as the distance between the main water source (Wiwi River) and farms increases. Nonetheless, all contamination levels were well above acceptable standards, and could therefore pose serious public health risks to consumers. Increased education and supervision of farmers, as well as public health and food hygiene education of consumers, are critical to reducing on-farm vegetable contamination and the health risks associated with consumption of such vegetables.
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http://dx.doi.org/10.1007/s10900-015-0109-yDOI Listing
April 2016

'What men don't know can hurt women's health': a qualitative study of the barriers to and opportunities for men's involvement in maternal healthcare in Ghana.

Reprod Health 2015 Oct 10;12:93. Epub 2015 Oct 10.

Institute of African and Gender Studies, University of Cape Town, Cape Town, South Africa.

Background: The importance of men's involvement in facilitating women's access to skilled maternal healthcare in patriarchal societies such as Ghana is increasingly being recognised. However, few studies have been conducted to examine men's involvement in issues of maternal healthcare, the barriers to men's involvement, and how best to actively involve men. The purpose of this paper is to explore the barriers to and opportunities for men's involvement in maternal healthcare in the Upper West Region of Ghana.

Methods: Qualitative focus group discussions, in-depth interviews and key informant interviews were conducted with adult men and women aged 20-50 in a total of seven communities in two geographic districts and across urban and rural areas in the Upper West Region of Ghana. Attride-Stirling's thematic network analysis framework was used to analyse and present the qualitative data.

Results: Findings suggest that although many men recognise the importance of skilled care during pregnancy and childbirth, and the benefits of their involvement, most did not actively involve themselves in issues of maternal healthcare unless complications set in during pregnancy or labour. Less than a quarter of male participants had ever accompanied their wives for antenatal care or postnatal care in a health facility. Four main barriers to men's involvement were identified: perceptions that pregnancy care is a female role while men are family providers; negative cultural beliefs such as the belief that men who accompany their wives to receive ANC services are being dominated by their wives; health services factors such as unfavourable opening hours of services, poor attitudes of healthcare providers such as maltreatment of women and their spouses and lack of space to accommodate male partners in health facilities; and the high cost associated with accompanying women to seek maternity care. Suggestions for addressing these barriers include community mobilisation programmes to promote greater male involvement, health education, effective leadership, and respectful and patient-centred care training for healthcare providers.

Conclusions: The findings in this paper highlight the need to address the barriers to men's involvement, engage men and women on issues of maternal health, and improve the healthcare systems - both in terms of facilities and attitudes of health staff - so that couples who wish to be together when accessing care can truly do so.
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http://dx.doi.org/10.1186/s12978-015-0083-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4600282PMC
October 2015

How intra-familial decision-making affects women's access to, and use of maternal healthcare services in Ghana: a qualitative study.

BMC Pregnancy Childbirth 2015 Aug 15;15:173. Epub 2015 Aug 15.

Population, Health and Gender Research Group, Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

Background: There is some evidence to suggest that within the household, family and community settings, women in sub-Saharan Africa often have limited autonomy and control over their reproductive health decisions. However, there are few studies that examine how intra-familial decision-making power may affect women's ability to access and use maternal health services. The purpose of this paper is to examine how intra-familial decision-making affects women's ability to access and use maternal health services.

Methods: We conducted 12 focus group discussions and 81 individual interviews with a total of 185 expectant and lactating mothers in six communities in Ghana. In addition, 20 key informant interviews were completed with healthcare providers. Attride-Stirling's thematic network analysis framework was used to analyse the data.

Results: Findings suggest that decision-making regarding access to and use of skilled maternal healthcare services is strongly influenced by the values and opinions of husbands, mothers-in-law, traditional birth attendants and other family and community members, more than those of individual childbearing women. In 49.2%, 16.2%, and 12.4% of cases in which women said they were unable to access maternal health services during their last pregnancy, husbands, mothers-in-law, and husband plus mothers-in-law, respectively, made the decision. Women themselves were the final decision-makers in only 2.7% of the cases. The findings highlight how the goal of improving access to maternal healthcare services can be undermined by women's lack of decision-making autonomy through complex processes of gender inequality, economic marginalisation, communal decision-making and social power.

Conclusion: Interventions to improve women's use of maternity services should move beyond individual women to target different stakeholders at multiple levels, including husbands and mothers-in-law.
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http://dx.doi.org/10.1186/s12884-015-0590-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4537557PMC
August 2015

Why Muslim women in Northern Ghana do not use skilled maternal healthcare services at health facilities: a qualitative study.

BMC Int Health Hum Rights 2015 Apr 28;15:10. Epub 2015 Apr 28.

Department of Geography and Rural Development, Population, Health and Gender Research Group, Faculty of Social Sciences, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana.

Background: Muslim women are one sub-population in Ghana among whom the rate of skilled maternal health services accessibility and utilisation is very low. However, there are no studies in Ghana that explore the maternity needs and care experiences of Muslim women, and why they do not utilise maternal healthcare services at health facilities. The purpose of this paper is to explore the maternity healthcare needs and care experiences of Muslim women and the barriers to accessing and using maternal health services.

Methods: Qualitative research was conducted with 94 Muslim women in three communities in northern Ghana between November 2011 and May 2012. Data were analysed using the Attride-Stirling's thematic network analysis framework.

Results: Findings suggest that although Muslim women do want to receive skilled care in a health facility, they often experience difficulties with accessing and using such services. These difficulties were often conditioned by a religious obligation to maintain bodily sanctity through modest dressing and the avoidance of unlawful bodily exposure or contact with certain people including male or alien caregivers. Other related access barriers include lack of privacy, healthcare providers' insensitivity and lack of knowledge about Muslim women's religious and cultural practices, and health information that lacked the cultural and religious specificity to meet Muslim women's maternity care needs.

Conclusion: Maternal healthcare services designed to meet the needs of mainstream non-Muslim Ghanaian women might lack the flexibility and responsiveness to meet the unique maternity care needs of Muslim women. Recommendations for change include cultural competence training for healthcare providers and cultural/religious matching to meet Muslim women's care needs and to enhance their care experience.
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http://dx.doi.org/10.1186/s12914-015-0048-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417257PMC
April 2015

Addressing health system barriers to access to and use of skilled delivery services: perspectives from Ghana.

Int J Health Plann Manage 2016 Oct 30;31(4):e235-e253. Epub 2015 Mar 30.

The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.

Poor access to and use of skilled delivery services have been identified as a major contributory factor to poor maternal and newborn health in sub-Saharan African countries, including Ghana. However, many previous studies that examine norms of childbirth and care-seeking behaviours have focused on identifying the norms of non-use of services, rather than factors, that can promote service use. Based on primary qualitative research with a total of 185 expectant and lactating mothers, and 20 healthcare providers in six communities in Ghana, this paper reports on strategies that can be used to overcome health system barriers to the use of skilled delivery services. The strategies identified include expansion and redistribution of existing maternal health resources and infrastructure, training of more skilled maternity caregivers, instituting special programmes to target women most in need, improving the quality of maternity care services provided, improving doctor-patient relationships in maternity wards, promotion of choice, protecting privacy and patient dignity in maternity wards and building partnerships with traditional birth attendants and other non-state actors. The findings suggest the need for structural changes to maternity clinics and routine nursing practices, including an emphasis on those doctor-patient relational practices that positively influence women's healthcare-seeking behaviours. Copyright © 2015 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/hpm.2291DOI Listing
October 2016

Ethnic disparities in utilisation of maternal health care services in Ghana: evidence from the 2007 Ghana Maternal Health Survey.

Ethn Health 2016 2;21(1):85-101. Epub 2015 Mar 2.

a Population, Health and Gender Research Group, Department of Geography & Rural Development, Faculty of Social Sciences , Kwame Nkrumah University of Science & Technology , Kumasi , Ghana.

Objective: Disparities in utilisation of maternal health care remain a challenge to attainment of the maternal health-related Millennium Development Goals. The objective of this descriptive study was to examine disparities in utilisation of maternal health care among ethnic groups in Ghana.

Design: Data from the 2007 Ghana Maternal Health Survey were analysed for disparities in antenatal care (ANC) visit, utilisation of tetanus toxoid immunisation and iron tablets/syrup intake during pregnancy, place of delivery, skilled birth attendance, caesarean section (CS) and post-natal care (PNC) among different ethnic groups.

Results: Findings show that the proportion of women who received any form of skilled antenatal, delivery and PNC in the five years (2003-2007) preceding the survey was 96%, 55% and 55%, respectively. Despite the incremental progress Ghana made in improving access to skilled maternal health care services, large gradients of disparities exist. The ethnic difference in utilisation of institutional prenatal care was small; however, fewer births to women from majority ethnic groups such as the Akan (21%) took place at home compared with births to women from minority ethnic groups such as the Ewe (58.8%), Guan (42.7%), Grusi (53.4%), Mole-Dagbani (74.7%) and Gruma (58.8%). The rate of consultation of a skilled health care provider for delivery among the different ethnic groups also ranged from a low of 27% for births to Mole-Dagbani women to a high of 68.8% among births to Akan women.

Conclusion: Minority ethnic groups reported lower utilisation levels for most of the components of skilled maternity care in Ghana. However, ethnic disparities in utilisation of all the components of ANC in Ghana were less compared to delivery in health facilities, skilled attendance at birth, use of CS and PNC. Therefore, efforts to promote universal access to skilled maternity care not only should target those sub-populations with significantly low utilisation levels but also must focus on those components of maternal health care such as skilled attendance at delivery that demonstrate the greatest disparities. There is also the need to further explore who continues to remain excluded from receiving needed care, and how to encourage such women, especially minority women, to seek skilled care.
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http://dx.doi.org/10.1080/13557858.2015.1015499DOI Listing
July 2016

Hegemonic Masculinity, HIV/AIDS Risk Perception, and Sexual Behavior Change Among Young People in Ghana.

Qual Health Res 2016 May 26;26(6):763-81. Epub 2015 Feb 26.

Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

Among the youth in some parts of sub-Saharan Africa, a paradoxical mix of adequate knowledge of HIV/AIDS and high-risk behavior characterizes their daily lives. Based on original qualitative research in Ghana, I explore in this article the ways in which the social construction of masculinity influences youth's responses to behavior change HIV/AIDS prevention interventions. Findings show that although awareness of the HIV/AIDS epidemic and the risks of infection is very high among the youth, a combination of hegemonic masculinity and perceptions of personal invulnerability acts to undermine the processes of young people's HIV/AIDS risk construction and appropriate behavioral change. I argue that if HIV/AIDS prevention is to be effective and sustained, school- and community-based initiatives should be developed to provide supportive social spaces in which the construction of masculinity, the identity of young men and women as gendered persons, and perceptions of their vulnerability to HIV/AIDS infection are challenged.
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http://dx.doi.org/10.1177/1049732315573204DOI Listing
May 2016

A qualitative study of health system barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana after user-fee abolition.

BMC Pregnancy Childbirth 2014 Dec 21;14:425. Epub 2014 Dec 21.

Department of Community Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

Background: To reduce financial barriers to access, and improve access to and use of skilled maternal and newborn healthcare services, the government of Ghana, in 2003, implemented a new maternal healthcare policy that provided free maternity care services in all public and mission healthcare facilities. Although supervised delivery in Ghana has increased from 47% in 2003 to 55% in 2010, strikingly high maternal mortality ratio and low percentage of skilled attendance are still recorded in many parts of the country. To explore health system factors that inhibit women's access to and use of skilled maternal and newborn healthcare services in Ghana despite these services being provided free.

Methods: We conducted qualitative research with 185 expectant and lactating mothers and 20 healthcare providers in six communities in Ghana between November 2011 and May 2012. We used Attride-Stirling's thematic network analysis framework to analyze and present our data.

Results: We found that in addition to limited and unequal distribution of skilled maternity care services, women's experiences of intimidation in healthcare facilities, unfriendly healthcare providers, cultural insensitivity, long waiting time before care is received, limited birthing choices, poor care quality, lack of privacy at healthcare facilities, and difficulties relating to arranging suitable transportation were important health system barriers to increased and equitable access and use of services in Ghana.

Conclusion: Our findings highlight how a focus on patient-side factors can conceal the fact that many health systems and maternity healthcare facilities in low-income settings such as Ghana are still chronically under-resourced and incapable of effectively providing an acceptable minimum quality of care in the event of serious obstetric complications. Efforts to encourage continued use of maternity care services, especially skilled assistance at delivery, should focus on addressing those negative attributes of the healthcare system that discourage access and use.
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http://dx.doi.org/10.1186/s12884-014-0425-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307897PMC
December 2014
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