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Background: Despite the availability of a safe and effective vaccine coupled with the awareness of the potential risk of Healthcare Workers acquiring Hepatitis B Virus infection, some HCWs never get vaccinated. Generally, hepatitis B vaccination coverage globally is below the expected level as adherence has remained poor in various healthcare settings, especially in developing countries. The objective of this study was to assess the completion of a three-dose Hepatitis B virus vaccination cycle and associated factors among healthcare workers in the Greater Accra Region of Ghana. Methods and materials: An analytical cross-sectional study was conducted and included 363 healthcare workers selected using probability sampling procedures. The participants were recruited from five facilities within the Greater Accra Region in the first half of 2018. A pretested questionnaire was used to collect data which was analyzed using SPSS version 21. The proportion of healthcare workers receiving the recommended 3 doses of the hepatitis vaccine was computed. The multivariable analysis procedure identified the factors associated with adherence to the receipt of three doses of the hepatitis B vaccine. Odds ratios were estimated with corresponding confidence intervals with the level of significance set at 0.05. Results: A total of 340 sample units were included in the analysis. Most of the participants (252/340, 74.1%) were females, mainly nurses/midwives (162/340, 47.6%) with a mean age of 34.5 (SD ±7.7). A high proportion of the participants (82.7%) have tertiary/post-tertiary level education and ever participated in at least one training workshop on the prevention of blood-borne infections (80.6%). Overall vaccination uptake was 60.9% (207/340) (95% CI = 55.7%-66.1%). Complete vaccination coverage (three doses) was 46.8% (159/340). High-risk perception (AOR = 4.0; 95% CI = 1.3–12.5), and previous training in infection prevention (AOR = 2.8; 95% CI = 1.1–7.5) were significantly associated with adherence to receipt of three doses of hepatitis B vaccine. Conclusion: Adherence to three-dose hepatitis B vaccination cycles is not universal among the healthcare workers in the Greater Accra Region. Receipt of the three-dose regimen is significantly associated with high-risk perception and attendance of training in infectious disease prevention. Interventions to increase risk perception and training in the prevention of blood-borne infections could improve adherence to complete/full vaccination protocol among healthcare workers who are at constant risk of exposure to the hepatitis B virus. [ABSTRACT FROM AUTHOR]

Background: Clinicians in areas where malaria and typhoid fever are co-endemic often treat infected patients irrationally, which may lead to the emergence of drug resistance and extra cost to patients. This study determined the proportion of febrile conditions attributable to either malaria and/or typhoid fever and the susceptibility patterns of Salmonella spp. isolates to commonly used antimicrobial agents in Ghana. Methods: One hundred and fifty-seven (157) febrile patients attending the Ga West Municipal Hospital, Ghana, from February to May 2017 were sampled. Blood samples were collected for cultivation of pathogenic bacteria and the susceptibility of the Salmonella isolates to antimicrobial agents was performed using the Kirby-Bauer disk diffusion method with antibiotic discs on Müller Hinton agar plates. For each sample, conventional Widal test for the detection of Salmonella spp was done as well as blood film preparation for detection of Plasmodium spp. Data on the socio-demographic and clinical characteristics of the study participants were collected using an android technology software kobo-collect by interview. Results: Of the total number of patients aged 2–37 years (median age = 6 years, IQR 3–11), 82 (52.2%) were females. The proportion of febrile patients with falciparum malaria was 57/157 (36.3%), while Salmonella typhi O and H antigens were detected in 23/157 (14.6%) of the samples. The detection rate of Salmonella spp in febrile patients was 10/157 (6.4%). Malaria and typhoid fever coinfection using Widal test and blood culture was 9 (5.7%) and 3 (1.9%), respectively. The isolates were highly susceptible to cefotaxime, ceftriaxone, ciprofloxacin, and amikacin but resistant to ampicillin, tetracycline, co-trimoxazole, gentamicin, cefuroxime, chloramphenicol, and meropenem. Conclusion: Plasmodium falciparum and Salmonella spp coinfections were only up to 1.9%, while malaria and typhoid fever, individually, were responsible for 36.3% and 6.4%, respectively. Treatment of febrile conditions must be based on laboratory findings in order not to expose patients to unnecessary side effects of antibiotics and reduce the emergence and spread of drug resistance against antibiotics. [ABSTRACT FROM AUTHOR]

Background: Despite several efforts at addressing the barriers to adherence to the WHO-supported test, treat and track (T3) malaria case management guideline in Ghana, adherence remains a challenge. This study explored the challenges of prescribers regarding adherence to the T3 guideline. Methods: This was an explorative study using key informant interviews amongst prescribers comprising medical doctors, physician assistants, nurses and a health extension worker from 16 health facilities in six districts in Ghana. The data was analysed using Nvivo 10 and organized into thematic areas. Results: Prescribers lauded the guideline on testing and treatment as it ensures the quality of malaria case management, but irregular supply of malaria rapid diagnostic test kits (RDT), mistrust of laboratory tests, and the reluctance of prescribers to change from presumptive treatment were key barriers to testing. Patients with malaria test negative results if not treated, revisiting the facility with severe malaria, the experience of prescribers, lack of regular training and supervision for old and new staff and the inability of prescribers to investigate non-malaria fever hindered adherence to results-based treatment. Conclusion: As malaria remains a significant cause of morbidity and mortality in Ghana, this study provides insights on gaps in adherence to the testing and treatment of malaria. While the diagnostic capacity for malaria case management is a challenge, the lack of training resulting in the inability of some prescribers to investigate non-malaria fever hinders adherence to the malaria case management guideline. Therefore, there is a need to train new prescribers, laboratory personnel, and other staff involved in malaria diagnosis and treatment on the malaria case management guideline before they assume duty. Equipping laboratory personnel and prescribers with the knowledge to investigate non-malaria fevers could improve adherence to the guideline for improved patient care. [ABSTRACT FROM AUTHOR]

Background: Increased coverage of interventions have been advocated to reduce under-five mortality. However, Ghana failed to achieve the Millennium Development Goal on child survival in 2015 despite improved coverage levels of some child health interventions. Therefore, there is the need to determine which interventions contributed the most to mortality reduction and those that can further rapidly reduce mortality to inform the prioritization of the scale-up of interventions. Materials and methods: Deterministic mathematical modeling was done using Lives Saved and Missed Opportunity Tools. Secondary data was used, and the period of the evaluation was between 2008 and 2014. Some of the interventions assessed were complementary feeding, skilled delivery, and rotavirus vaccine. Results: A total of 48,084 lives were saved from changes in coverage of interventions and a reduction in the prevalence of stunting and wasting. Reduction in wasting prevalence saved 10,372(21.6%) lives, insecticide-treated net/indoor residual spraying 6,437(13.4%) lives saved, reduction in stunting 4,315(9%) lives saved and artemisinin-based combination therapy (ACTs) 4,325(9.0%) lives saved. If coverage levels of interventions in 2014 were scaled up to 90% in 2015, among neonates, full supportive care for prematurity (5,435 lives saved), full supportive care for neonatal sepsis/pneumonia (3,002 lives saved), and assisted vaginal delivery (2,163 lives saved), would have saved the most lives among neonates, while ACTs (4,925 lives saved), oral rehydration salts (ORS) (2,056 lives saved), and antibiotics for the treatment of pneumonia (1,805 lives saved) would have made the most impact on lives saved among children 1–59 months. Lastly, if all the interventions were at 100% coverage in 2014, the under-five mortality rate would have been 40.1 deaths per 1,000 live births in 2014. Discussion: The state of the package of interventions will likely not lead to rapid mortality reduction. Coverage and quality of childbirth-related interventions should be increased. Additionally, avenues to further reduce stunting and wasting, including increased breastfeeding and complementary feeding, will be beneficial. [ABSTRACT FROM AUTHOR]

Empirical antimicrobial therapy is linked to a surge in antimicrobial resistant infections. However, an insight on the bacteria etiology of ocular infections is essential in the appropriation of choice of antimicrobial among clinicians, yet there remains a dearth of data from Ghana. We investigated the bacteria etiology of external ocular and periocular infections and antimicrobial treatment patterns among a Ghanaian ophthalmic population. A multicenter study design with purposive sampling approach was employed. Patients demographics and clinical data were collated using a pretested structure questionnaire. Cornea specimens and conjunctival swabs were obtained for bacterial isolation following standard protocols. About 95% (98/103) of ocular samples were positive for bacteria culture. The proportion of Gram-negative bacteria was 58.2%, and the predominant bacteria species were Pseudomonas aeruginosa 38.8% and Staphylococcus aureus 27.6%. Conjunctivitis 40.0% and keratitis 75.0% were mostly caused by Pseudomonas aeruginosa. The routinely administered antimicrobial therapy were polymyxin B 41.2%, neomycin 35.1% and ciprofloxacin 31.6%. Participants demographic and clinical characteristics were unrelated with positive bacteria culture (p > 0.05). Our results showed a markedly high burden of ocular bacterial infections and variations in etiology. Bacterial infection-control and antimicrobial agent management programs should be urgently institutionalized to prevent the emergence of resistant infections. [ABSTRACT FROM AUTHOR]

Background: Spontaneous reporting of adverse drug reactions (ADR) is an effective means of ensuring postmarketing surveillance of drugs, and health professionals play a cardinal role through voluntary reporting of ADR. However, the pharmacovigilance system in Ghana is plagued with under-reporting issues, which is of public health concern.Method: A questionnaire-based cross-sectional study involving 268 health professionals at Kpone-Katamanso District was carried out. Data on spontaneous reporting of ADR, demographics of participants, knowledge, and attitudes of professionals towards reporting and factors that may influence ADR reporting were collected. Logistic regression models were used to examine the association of the independent variables with spontaneous reporting of ADR.Result: Overall, 77.6% (208) of the 268 respondents had observed ADR; however, only 17.3% of the respondents had ever reported an ADR to the Ghana FDA. Health professionals who had average knowledge on spontaneous reporting of ADR were 51.9%, while 30.3% had good knowledge of spontaneous reporting of ADR. After adjustment on potential confounding variables (Knowledge, Feedback from FDA, Uncertainty about cause of ADR, Severity of ADR), Age (AOR = 2.26, 95%CI = 1.25-4.10), Fear of Legal Consequences (AOR = 0.15, 95%CI = 0.41-0.51), Time Constraint (AOR = 0.3, 95%CI = 0.10-0.91), Pharmacovigilance training (AOR = 18.78, 95%CI = 5.46-64.59) and Unavailability of Reporting form (AOR = 0.28, 95%CI = 0.09-0.88) were found to be significantly associated spontaneous reporting of ADR.Conclusion: The proportion of health professionals in the Kpone- Katamanso District who spontaneously reported observed ADR was low though they had average knowledge about ADR reporting. This underscores the need for a policy to be implemented that makes spontaneous reporting of adverse drug reaction mandatory for health professionals. [ABSTRACT FROM AUTHOR]

Aims: To assess the determinants of glycaemic control among patients with Type 2 diabetes mellitus (T2DM) presenting at the Greater Accra Regional Hospital, Ghana. Methods: The study employed semi-structured questionnaires and review of clinical records of patients 16 years and above with Type 2 Diabetes. Results: The mean age of participants was 56.6 ± 13.8 years, with majority (71.6%) being females. A total of 161 (59.4%) of patients had poor glycaemic control (HbA1c ≥8.1%; 95% CI: 53.6 to 65.3%). Poor glycaemic control was significantly associated with high body mass index of the patient (AOR 13.22; 95% CI: 1.95 to 89.80), having only elementary education (AOR 5.22, 95% CI 2.12–12.86, p<0.0001) and being on insulin therapy (AOR 2.88; 95% CI: 1.05 to 7.88). On the other hand, seldom coffee intake (AOR: 0.27; 95% CI: 0.11 to 0.64), high physical activity (AOR 1.57, 95% CI 1.06–2.35, p = 0.025) and having a cardiovascular disease (AOR: 0.15; 95% CI: 0.05 to 0.46) appeared to positively influence glycaemic control. Self-monitoring of blood glucose and diet interventions did not appear to influence glycaemic control. Conclusions: The study results showing that a high proportion of patients attending the Diabetes Clinic with uncontrolled diabetes has serious implications for the management of T2DM diabetes as it suggests that current hospital-based treatment measures are less effective. Comprehensive management of T2DM targeting all the key factors identified in this study and incorporating a multispectral collaborative effort based on holistic approach, combined with non-pharmacological components are strongly warranted. [ABSTRACT FROM AUTHOR]

Background: Despite a 53 % decline in under-five mortality (U5M) worldwide during the period of the Millennium Development Goals (MDGs), U5M remains a challenge. Under-five mortality decline in Ghana is slow and not parallel with the level of coverage of child health interventions. The interventions promoted to improve child survival include early initiation of breastfeeding, clean postnatal care, and skilled delivery. This study sought to assess the effectiveness of these interventions on U5M in Ghana.Methods: A quasi-experimental study was conducted using secondary data of the 2008 and 2014 Ghana Demographic and Health Surveys. Coarsened Exact Matching and logistic regression were done. The interventions assessed were iron intake, early initiation of breastfeeding, clean postnatal care, hygienic disposal of stool, antenatal care visits, skilled delivery, intermittent preventive treatment of malaria in pregnancy, and tetanus toxoid vaccine.Results: There were 2,045 children under-five years and 40 (1.9 %) deaths in 2008. In 2014, the total number of children under-five years was 4,053, while deaths were 53(1.2 %). In 2014, children less than one month old formed 1.6 % of all children under-five years, but 47.8 % of those who died. Mothers who attended four or more antenatal care visits were 78.2 % in 2008 and 87.0 % in 2014. Coverage levels of improved sanitation and water connection in the home were among the lowest, with 11.6 % for improved sanitation and 7.3 % for water connection in the home in 2014. Fifty-eight (58), 1.4 %, of children received all the eight (8) interventions in 2014, and none of those who received all these interventions died. After controlling for potential confounders, clean postnatal care was associated with a 66% reduction in the average odds of death (aOR = 0.34, 95 %CI:0.14-0.82), while early initiation of breastfeeding was associated with a 62 % reduction in the average odds of death (aOR = 0.38, 95 % CI: 0.21-0.69).Conclusions: Two (clean postnatal care and early initiation of breastfeeding) out of eight interventions were associated with a reduction in the average odds of death. Thus, a further decline in under-five mortality in Ghana will require an increase in the coverage levels of these two high-impact interventions. [ABSTRACT FROM AUTHOR]

Background: Artisanal mining creates enabling breeding ground for the vector of malaria parasites. There is paucity of data on the effects of artisanal mining on malaria. This study assessed burden of malaria and caregivers' health-seeking behaviour for children under five in artisanal mining communities in East Akim District in Ghana. Methods: A cross-sectional study involving caregivers and their children under five was conducted in three artisanal mining communities in the East Akim District in Ghana. Caregivers were interviewed using a structured questionnaire. Finger prick blood samples were collected and analysed for haemoglobin concentration using a rapid diagnostic test, and thick and thin blood smears were analysed to confirm the presence of malaria parasites. Results: Of the 372 children under 5 years included in the study, 197 (53.1%) were male, with a mean age (± SD) of 23.0 ± 12.7 months. The proportion of children with malaria (Plasmodium falciparum and P. malariae) was 98.1% and 1.9%, respectively, whilst the proportion with anaemia (Hb < 11.0 g/dl) was 39.5% (n = 147). Almost all caregivers were female (98.9%), and 28.6% (n = 106) did not have access to any malaria control information. Caregivers associated malaria infection with mosquito bites (68.3%, n = 254) and poor sanitation (21.2%, n = 79). Malaria in children under five was significantly associated with anaemia (OR 11.07, 95% CI 6.59–18.68, n = 111/160, 69.4%; P < 0.0001), residing close to stagnant water (≤ 25 m) from an artisanal mining site (AOR 2.91, 95% CI 1.47–5.76, P = 0.002) and caregiver age younger than 30 years (OR 0.44, 95% CI 0.208–0.917, n = 162, 43.55%, P = 0.001). Conclusions: There is a high burden of malaria and anaemia among children under five in artisanal mining communities of the East Akim District, and far higher than in non-artisanal mining sites. Interventions are needed to effectively regulate mining activities in these communities, and strengthen malaria control and health education campaigns to curtail the high malaria burden and improve health-seeking behaviour. [ABSTRACT FROM AUTHOR]

Background: Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam. Methods: We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors' expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions' actual performance. Discussion: The study's key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities. [ABSTRACT FROM AUTHOR]

Background: Job satisfaction describes an employee's motivation and/or feeling of satisfaction towards his/her work. Globally, healthcare professionals' turnover and retention play a critical role in the delivery of essential health services. In Ghana, however, little has been done to ascertain job satisfaction levels among human resources for eye-health. The objective of this study therefore was to assess job satisfaction and its associated factors among optometrists in Ghana.Methods: A cross-sectional survey was conducted among 304 registered and licensed optometrists of the Ghana Optometric Association between September 2018 and June 2019. A validated, well-structured questionnaire was used to elicit information on socio-demographic characteristics of participants and measures on job satisfaction. Scores from a five-point Likert scale was employed to examine job satisfaction and its associated factors. Linear regression analyses were used to evaluate the association between overall job satisfaction and its associated factors using Rasch logit scores.Results: A total of 214 optometrists gave valid responses to the questionnaires used for the final analysis. The mean (± SD) score of the overall perception of job satisfaction among optometrists was 3.36 (± 1.00), with 74.3% of them being satisfied with their jobs. After statistical adjustment, Good work-life balance (Unstandardized co-efficient (β) = 0.288, p = 0.001), Salary (β = 0.222, p < 0.0005), Supervision (β = 0.117, p = 0.044), and Continuing Education Opportunities (β = 0.138, p = 0.017) were all significantly associated with higher levels of overall job satisfaction.Conclusions: Most optometrists were satisfied with their jobs. Effective strategic planning and management of human resources for eye-health in Ghana are essential in the development of quality eye-health systems and the provision of high-quality eyecare services. [ABSTRACT FROM AUTHOR]

Background: Typically, raw meat can be contaminated with antibiotic resistant pathogens at unhygienic slaughter and sale points. Consumption of meat contaminated with antibiotic resistant E. coli is associated with grave health care consequences. The aim of this study was to determine the microbial quality of raw meat, the antimicrobial susceptibility and Extended Spectrum Beta Lactamase (ESBL) production in E. coli isolates from raw meat. Results: Total Plate Counts exceeded the acceptable limit of 5.0 log CFU/cm2 in 60.5% (124/205) of raw meat samples. Total Coliform Counts in 70.7% (145/205) of samples were in excess of the acceptable limit of 2.5 log CFU/cm2. E. coli was detected in about half of raw meat samples (48%), ranging from 9.5-79.0% among the slaughter sites. Isolates were susceptible to meropenem (100%), ceftriaxone (99%), cefotaxime (98%), chloramphenicol (97%), gentamycin (97%), ciprofloxacin (92%) and amikacin (92%), but resistant to ampicillin (57%), tetracycline (45%), sulfamethoxazole-trimethoprim (21%) and cefuroxime (17%). Multi-drug resistance (MDR) was identified in 22% of the isolates. The blaTEM gene was detected in 4% (4/98) of E. coli isolates in this study. Conclusion: The levels of microbial contamination of raw meat in this study were unacceptable. Meat handlers and consumers are at risk of foodborne infections from E. coli including ESBL producing E. coli that are resistant to most antibiotics in use. We recommend an enhanced surveillance for antibiotic resistance in food products for the early detection of emerging resistant bacteria species in the food chain. [ABSTRACT FROM AUTHOR]

Background: Over the past decade there has been growing interest in the use of herbal medicine both in developed and developing countries. Given the high proportion of patients using herbal medicine in Ghana, some health facilities have initiated implementation of herbal medicine as a component of their healthcare delivery. However, the extent to which herbal medicine has been integrated in Ghanaian health facilities, how integration is implemented and perceived by different stakeholders has not been documented. The study sought to explore these critical issues at the Kumasi South Hospital (KSH) and outline the challenges and motivations of the integration process. Methods: Qualitative phenomenological exploratory study design involving fieldwork observations, focus group discussion, in-depth interviews and key informants' interviews was employed to collect data. Results: Policies and protocols outlining the definition, process and goals of integration were lacking, with respondents sharing different views about the purpose and value of integration of herbal medicine within public health facilities. Key informants were supportive of the initiative. Whilst biomedical health workers perceived the system to be parallel than integrated, health personnel providing herbal medicine perceived the system as integrated. Most patients were not aware of the herbal clinic in the hospital but those who had utilized services of the herbal clinic viewed the clinic as part of the hospital. Conclusions: The lack of a regulatory policy and protocol for the integration seemed to have led to the different perception of the integration. Policy and protocol to guide the integration are key recommendations. [ABSTRACT FROM AUTHOR]

Background: Schistosomiasis causes long-term illness and significant economic burden. Morbidity control through integration within existing health care delivery systems is considered a potentially sustainable and cost-effective approach, but there is paucity of information about health-seeking behaviour. Methods: A questionnaire-based study involving 2,002 subjects was conducted in three regions of Ghana to investigate health-seeking behaviour and utilization of health facilities for symptoms related to urinary (blood in urine and painful urination) and intestinal schistosomiasis (diarrhea, blood in stool, swollen abdomen and abdominal pain). Fever (for malaria) was included for comparison. Results: Only 40% of patients with urinary symptoms sought care compared to >70% with intestinal symptoms and >90% with fever. Overall, about 20% of schistosomiasis-related symptoms were reported to a health facility (hospital or clinic), compared to about 30% for fever. Allopathic self-medication was commonly practiced as alternative action. Health-care seeking was relatively lower for patients with chronic symptoms, but if they took action, they were more likely to visit a health facility. In a multivariate logistic regression analysis, perceived severity was the main predictor for seeking health care or visiting a health facility. Age, socio-economic status, somebody else paying for health care, and time for hospital visit occasionally showed a significant impact, but no clear trend. The effect of geographic location was less marked, although people in the central region, and to a lesser extent the north, were usually less inclined to seek health care than people in the south. Perceived quality of health facility did not demonstrate impact. Conclusion: Perceived severity of the disease is the most important determinant of seeking health care or visiting a health facility in Ghana. Schistosomiasis control by passive case-finding within the regular health care delivery looks promising, but the number not visiting a health facility is large and calls for supplementary control options. Author Summary: The World Health Organization recommends that long-term benefit of schistosomiasis control should include treatment in local health facilities. This means that patients should visit a hospital or clinic with their complaints. However, little is known about whether they do so. We conducted a study in three regions of Ghana and interviewed two thousand people about whether they recently had schistosomiasis-related symptoms such as blood in urine or blood in faeces, and what they had done about it. We included fever (mostly caused by malaria) for comparison. We found that 40% of patients with urinary symptoms sought care compared to 70% of those with intestinal symptoms and 90% with fever. Overall, only 20% of all schistosomiasis-related symptoms were reported to a hospital or clinic, compared to 30% for fever. Self-medication with allopathic (i.e., orthodox) medicines was the main alternative. Our study showed that the most important determinant for seeking health care or visiting a health facility is perceived severity of the symptom. Factors such as age, sex, socio-economic status and geographic region showed no impact or a clear pattern. We conclude that many schistosomiasis patients do not visit a health facility, the only place with effective drugs, necessitating additional control measures. [ABSTRACT FROM AUTHOR]

Passive case finding based on adequate diagnosis and treatment of symptomatic individuals with praziquantel by the health care facilities is a minimum requirement for integrated schistosomiasis control. Two field studies were conducted in Ghana to obtain quantifications about the steps in this process: (1) a study of health-seeking behaviour through interview of individuals with reported schistosomiasis-related symptoms; (2) a study of the performance of the Ghanaian health system with regard to schistosomiasis case management by presenting clinical scenarios to health workers and collecting information about availability of praziquantel. It appeared that cases of blood in urine (the most typical symptom of Schistosoma haematobium) and blood in stool (the most typical symptom of S. mansoni) have a very small probability of receiving praziquantel (4.4% and 1.4%, respectively) from health facilities. Programmes aimed at making the drug available at all levels of the health care delivery system and encouraging health-seeking behaviour through health education are not likely to increase these probabilities beyond 30%. This is because many cases with blood in urine do not consider it serious enough to seek health care, and blood in stool usually requires (imperfect) diagnostic testing and referral. We therefore conclude that additional control activities, especially for high-risk groups, will remain necessary. [ABSTRACT FROM AUTHOR]

Introduction: Pregnancy and postpartum-related mental health problems pose serious public health threat to the society, but worryingly, neglected in sub-Saharan Africa (SSA). This review will assess the burden and distribution of maternal mental health (MMH) problems in SSA, with the aim to inform the implementation of context sensitive interventions and policies., Methods and Analysis: All relevant databases, grey literature and non-database sources will be searched. PubMed, LILAC, CINAHL, SCOPUS and PsycINFO, Google Scholar, African Index Medicus, HINARI, African Journals Online and IMSEAR will be searched from inception to 31 May 2023, without language restriction. The reference lists of articles will be reviewed, and experts contacted for additional studies missed by our searches. Study selection, data extraction and risk of bias assessment will be done independently by at least two reviewers and any discrepancies will be resolved through discussion between the reviewers. Binary outcomes (prevalence and incidence) of MMH problems will be assessed using pooled proportions, OR or risk ratio and mean difference for continuous outcomes; all will be presented with their 95% CIs. Heterogeneity will be investigated graphically for overlapping CIs and statistically using the I 2 statistic and where necessary subgroup analyses will be performed. Random-effects model meta-analysis will be conducted when heterogeneity is appreciable, otherwise fixed-effect model will be used. The overall level of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation., Ethics and Dissemination: Although no ethical clearance or exemption is needed for a systematic review, this review is part of a larger study on maternal mental health which has received ethical clearance from the Ethics Review Committee of the Ghana Health Service (GHS-ERC 012/03/20). Findings of this study will be disseminated through stakeholder forums, conferences and peer review publications., Prospero Registration Number: CRD42021269528., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: Implementing medicines pricing policy effectively is important for ensuring equitable access to essential medicines and ultimately achieving universal health coverage. However, published analyses of policy implementations are scarce from low- and middleincome countries. This paper contributes to bridging this knowledge gap by reporting analysis of implementation of two medicines pricing policies in Ghana: value-added tax (VAT) exemptions and framework contracting (FC) for selected medicines. We analysed implications of actor involvements, contexts, and contents on the implementation of these policies, and the interplay between these. This paper should be of interest, and relevance, to policy designers, implementers, the private sector and policy analysts., Methods: Data were collected through document reviews (n=18), in-depth interviews (n=30), focus groups (n=2) and consultative meetings (n=6) with purposefully identified policy actors. Data were analysed thematically, guided by the four components of the health policy triangle framework., Results: The nature and complexity of policy contents determined duration and degree of formality of implementation processes. For instance, in the FC policy, negotiating medicines prices and standardizing the tendering processes lengthened implementation. Highly varied stakeholder participation created avenues for decision-making and promoted inclusiveness, but also raised the need to manage different agendas and interests. Key contextual enablers and constraints to implementation included high political support and currency depreciation, respectively. The interrelatedness of policy content, actors, and context influenced the timeliness of policy implementations and achievement of intended outcomes, and suggest five attributes of effective policy implementation: (1) policy nature and complexity, (2) inclusiveness, (3) organizational feasibility, (4) economic feasibility, and (5) political will and leadership., Conclusion: Varied contextual factors, active participation of stakeholders, nature, and complexity of policy content, and structures have all influenced the implementation of medicines pricing policies in Ghana., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Introduction: Universal availability and affordability of essential medicines are determined by effective design and implementation of relevant policies, typically involving multiple stakeholders. This paper examined stakeholder engagements, powers and resultant influences over design and implementation of four medicines pricing policies in Ghana: Health Commodity Supply Chain Master Plan, framework contracting for high demand medicines, Value Added Tax (VAT) exemptions for selected essential medicines, and ring-fencing medicines for local manufacturing., Methods: Data were collected using reviews of policy documentation (n=16), consultative meetings with key policy actors (n=5) and in-depth interviews (n=29) with purposefully identified national-level policymakers, public and private health professionals including members of the National Medicine Pricing Committee, pharmaceutical wholesalers and importers. Data were analysed using thematic framework., Results: A total of 46 stakeholders were identified, including representatives from the Ministry of Health, other government agencies, development partners, pharmaceutical industry and professional bodies. The Ministry of Health coordinated policy processes, utilising its bureaucratic mandate and exerted high influences over each policy. Most stakeholders were highly engaged in policy processes. Whereas some led or coproduced the policies in the design stage and participated in policy implementation, others were consulted for their inputs, views and opinions. Stakeholder powers reflected their expertise, bureaucratic mandates and through participation in national level consultation meetings, influences policy contents and implementation. A wider range of stakeholders were involved in the VAT exemption policies, reflecting their multisectoral nature. A minority of stakeholders, such as service providers were not engaged despite their interest in medicines pricing, and consequently did not influence policies., Conclusions: Stakeholder powers were central to their engagements in, and resultant influences over medicine pricing policy processes. Effective leadership is important for inclusive and participatory policymaking, and one should be cognisant of the nature of policy issues and approaches to policy design and implementation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Health systems responsiveness is a key objective of any health system, yet it is the least studied of all objectives particularly in low-income and middle-income countries. Research on health systems responsiveness highlights its multiple elements, for example, dignity and confidentiality. Little is known, however, about underlying theories of health systems responsiveness, and the mechanisms through which responsiveness works. This realist synthesis contributes to bridging these two knowledge gaps., Methods and Analysis: In this realist synthesis, we will use a four-step process, comprising: mapping of theoretical bases, formulation of programme theories, theory refinement and testing of programme theories using literature and empirical data from Ghana and Vietnam. We will include theoretical and conceptual pieces, reviews, empirical studies and grey literature, alongside the primary data. We will explore responsiveness as entailing external and internal interactions within health systems. The search strategy will be purposive and iterative, with continuous screening and refinement of theories. Data extraction will be combined with quality appraisal, using appropriate tools. Each fragment of evidence will be appraised as it is being extracted, for its relevance to the emerging programme theories and methodological rigour. The extracted data pertaining to contexts, mechanisms and outcomes will be synthesised to identify patterns and contradictions. Results will be reported using narrative explanations, following established guidance on realist syntheses., Ethics and Dissemination: Ethics approvals for the wider RESPONSE (Improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam) study, of which this review is one part, were obtained from the ethics committees of the following institutions: London School of Hygiene and Tropical Medicine (ref: 22981), University of Leeds, School of Medicine (ref: MREC19-051), Ghana Health Service (ref: GHS-ERC 012/03/20) and Hanoi University of Public Health (ref: 020-149/DD-YTCC).We will disseminate results through academic papers, conference presentations and stakeholder workshops in Ghana and Vietnam., Prospero Registration Number: CRD42020200353. Full record: https://www.crd.york.ac.uk/prospero/display&#95;record.php?ID=CRD42020200353., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Ensuring universal availability and accessibility of medicines and supplies is critical for national health systems to equitably address population health needs. In sub-Saharan Africa (SSA), this is a recognised priority with multiple medicines pricing policies enacted. However, medicine prices have remained high, continue to rise and constrain their accessibility. In this systematic review, we aim to identify and analyse experiences of implementation of medicines pricing policies in SSA. Our ambition is for this evidence to contribute to improved implementation of medicines pricing policies in SSA., Methods and Analysis: We will search: Medline, Web of Science, Scopus, Global Health, Embase, Cairn.Info International Edition, Erudit and African Index Medicus, the grey literature and reference from related publications. The searches will be limited to literature published from the year 2000 onwards that is, since the start of the Millennium Development Goals.Published peer-reviewed studies of implementation of medicines pricing policies in SSA will be eligible for inclusion. Broader policy analyses and documented experiences of implementation of other health policies will be excluded. The team will collaboratively screen titles and abstracts, then two reviewers will independently screen full texts, extract data and assess quality of the included studies. Disagreements will be resolved by discussion or a third reviewer. Data will be extracted on approaches used for policy implementation, actors involved, evidence used in decision making and key contextual influences on policy implementation. A narrative approach will be used to synthesise the data. Reporting will be informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guideline., Ethics and Dissemination: No ethics approvals are required for systematic reviews.Results will be disseminated through academic publications, policy briefs and presentations to national policymakers in Ghana and mode widely across countries in SSA., Prospero Registration Number: CRD42020178166., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Typically, raw meat can be contaminated with antibiotic resistant pathogens at unhygienic slaughter and sale points. Consumption of meat contaminated with antibiotic resistant E. coli is associated with grave health care consequences. The aim of this study was to determine the microbial quality of raw meat, the antimicrobial susceptibility and Extended Spectrum Beta Lactamase (ESBL) production in E. coli isolates from raw meat., Results: Total Plate Counts exceeded the acceptable limit of 5.0 log CFU/ cm 2 in 60.5% (124/205) of raw meat samples. Total Coliform Counts in 70.7% (145/205) of samples were in excess of the acceptable limit of 2.5 log CFU/cm 2 . E. coli was detected in about half of raw meat samples (48%), ranging from 9.5-79.0% among the slaughter sites. Isolates were susceptible to meropenem (100%), ceftriaxone (99%), cefotaxime (98%), chloramphenicol (97%), gentamycin (97%), ciprofloxacin (92%) and amikacin (92%), but resistant to ampicillin (57%), tetracycline (45%), sulfamethoxazole-trimethoprim (21%) and cefuroxime (17%). Multi-drug resistance (MDR) was identified in 22% of the isolates. The bla TEM gene was detected in 4% (4/98) of E. coli isolates in this study., Conclusion: The levels of microbial contamination of raw meat in this study were unacceptable. Meat handlers and consumers are at risk of foodborne infections from E. coli including ESBL producing E. coli that are resistant to most antibiotics in use. We recommend an enhanced surveillance for antibiotic resistance in food products for the early detection of emerging resistant bacteria species in the food chain.