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Abstract Background Effect of indoor air pollution (IAP) on birth weight remains largely unexplored but yet purported as the most important environmental exposure for pregnant women in developing countries due to the effects of second-hand smoke. We investigated the associations between the determinants of indoor air quality in households and birth weight. Methods A cross-sectional study of 592 mothers and their newborns using postnatal services at the Korle Bu Teaching Hospital located in Accra, Ghana was conducted in 2010 to collect information on characteristics of indoor environment and other potential determinants of fetal growth. Birth weight was recorded from hospital records. Results Household cooking fuel choices and garbage burning practices were determinants of birth weight. Multivariate linear regression analysis adjusting for age, social class, marital status and gravidity of mothers, and sex of neonate resulted in a 243g (95% CI: 496, 11) and 178g (95% CI: 421, 65) reduction in birth weight for use of charcoal, and garbage burning respectively compared with use of LPG only. The estimated reductions in birth weight was not statistically significant. Applying the ordinal scale exposure parameter nonetheless revealed a significant exposure-response relationship between maternal exposures from charcoal use and garbage burning, and birth weight. Generalized linear models adjusting for confounders resulted in a 41% (risk ratio [RR] = 1.41; 95% CI: 0.62, 3.23) and 195% (RR=2.95; 95% CI: 1.10, 7.92) increase in the risk of low birth weight (LBW) for use of charcoal, and garbage burning respectively compared with use of LPG only. A combination of charcoal use and household garbage burning during pregnancy on fetal growth resulted in a 429g (95% CI: 259, 599) reduction in birth weight and 316% (RR=4.16; 95% CI: 2.02, 8.59) excess risk of LBW. Sensitivity analysis performed by restricting the analysis to term births produced similar results. Conclusions Maternal use of charcoal as a cooking fuel during pregnancy and burning of garbage at home are strong determinants of average fetal growth and risk of LBW. Efforts to reduce maternal exposures to IAP are thus important to improve birth outcomes.

Abstract Background In Plasmodium falciparum, resistance to chloroquine (CQ) is conferred by a K to T mutation at amino acid position 76 (K76T) in the P. falciparum CQ transporter (PfCRT). To date, at least 15 pfcrt genotypes, which are represented by combinations of five amino acids at positions 72-76, have been described in field isolates from various endemic regions. To identify novel mutant pfcrt genotypes and to reveal the genetic relatedness of pfcrt genotypes, a large-scale survey over a wide geographic area was performed. Methods Sequences for exon 2 in pfcrt, including known polymorphic sites at amino acid positions 72, 74, 75 and 76, were obtained from 256 P. falciparum isolates collected from eight endemic countries in Asia (Bangladesh, Cambodia, Lao P.D.R., the Philippines and Thailand), Melanesia (Papua New Guinea and Vanuatu) and Africa (Ghana). A haplotype network was constructed based on six microsatellite markers located -29 kb to 24 kb from pfcrt in order to examine the genetic relatedness among mutant pfcrt genotypes. Results In addition to wild type (CVMNK at positions 72-76), four mutant pfcrt were identified; CVIET, CVIDT, SVMNT and CVMNT (mutated amino acids underlined). Haplotype network revealed that there were only three mutant pfcrt lineages, originating in Indochina, Philippines and Melanesia. Importantly, the Indochina lineage contained two mutant pfcrt genotypes, CVIET (n = 95) and CVIDT (n = 14), indicating that CVIDT shares a common origin with CVIET. Similarly, one major haplotype in the Melanesian lineage contained two pfcrt genotypes; SVMNT (n = 71) and CVMNT (n = 3). In Africa, all mutant pfcrt genotypes were the CVIET of the Indochina lineage, probably resulting from the intercontinental migration of CQ resistance from Southeast Asia. Conclusions The number of CQ-mutant lineages observed in this study was identical to that found in previous studies. This supports the hypothesis that the emergence of novel CQ resistance is rare. However, in the mutant pfcrt genotypes, amino acid changes at positions 72, 74 and 75 appear to have recently been generated at least several times, producing distinct pfcrt mutant genotypes. The occurrence of new mutations flanking K76T may yield stronger resistance to CQ and/or a higher fitness than the original pfcrt mutant.

Abstract Background Health worker shortage and maldistribution are among the biggest threats to health systems in Africa. New medical graduates are prime targets for recruitment to deprived rural areas. However, little research has been done to determine the influence of workers' background and future plans on their preference for rural practice incentives and characteristics. The purpose of this study was to identify determinants of preference for rural job characteristics among fourth year medical students in Ghana. Methods We asked fourth-year Ghanaian medical students to rank the importance of rural practice attributes including salary, infrastructure, management style, and contract length in considering future jobs. We used bivariate and multivariate ordinal logistic regression to estimate the association between attribute valuation and students' socio-demographic background, educational experience, and future career plans. Results Of 310 eligible fourth year medical students, complete data was available for 302 students (97%). Students considering emigration ranked salary as more important than students not considering emigration, while students with rural living experience ranked salary as less important than those with no rural experience. Students willing to work in a rural area ranked infrastructure as more important than students who were unwilling, while female students ranked infrastructure as less important than male students. Students who were willing to work in a rural area ranked management style as a more important rural practice attribute than those who were unwilling to work in a rural area. Students studying in Kumasi ranked contract length as more important than those in Accra, while international students ranked contract length as less important than Ghanaian students. Conclusions Interventions to improve rural practice conditions are likely to be more persuasive than salary incentives to Ghanaian medical students who are willing to work in rural environments a priori. Policy experiments should test the impact of these interventions on actual uptake by students upon graduation.

Abstract Background Retaining health workers in rural areas is challenging for a number of reasons, ranging from personal preferences to difficult work conditions and low remuneration. This paper assesses the influence of intrinsic and extrinsic motivation on willingness to accept postings to deprived areas among medical students in Ghana. Methods A computer-based survey involving 302 fourth year medical students was conducted from May-August 2009. Logistic regression was used to assess the association between students' willingness to accept rural postings and their professional motivations, rural exposure and family parental professional and educational status (PPES). Results Over 85% of students were born in urban areas and 57% came from affluent backgrounds. Nearly two-thirds of students reported strong intrinsic motivation to study medicine. After controlling for demographic characteristics and rural exposure, motivational factors did not influence willingness to practice in rural areas. High family PPES was consistently associated with lower willingness to work in rural areas. Conclusions Although most Ghanaian medical students are motivated to study medicine by the desire to help others, this does not translate into willingness to work in rural areas. Efforts should be made to build on intrinsic motivation during medical training and in designing rural postings, as well as favour lower PPES students for admission.

Abstract Background The ability of many countries to achieve national health goals such as the Millennium Development Goals remains hindered by inadequate and poorly distributed health personnel, including doctors. The distribution of doctors in Ghana is highly skewed, with a majority serving in two major metropolitan areas (Accra and Kumasi), and inadequate numbers in remote and rural districts. Recent policies increasing health worker salaries have reduced migration of doctors out of Ghana, but made little difference to distribution within the country. This qualitative study was undertaken to understand how practicing doctors and medical leaders in Ghana describe the key factors reducing recruitment and retention of health professionals into remote areas, and to document their proposed policy solutions. Methods In-depth interviews were carried out with 84 doctors and medical leaders, including 17 regional medical directors and deputy directors from across Ghana, and 67 doctors currently practicing in 3 regions (Greater Accra, Brong Ahafo, and Upper West); these 3 regions were chosen to represent progressively more remote distances from the capital of Accra. Results and discussion All participants felt that rural postings must have special career or monetary incentives given the loss of locum (i.e. moonlighting income), the higher workload, and professional isolation of remote assignments. Career 'death' and prolonged rural appointments were a common fear, and proposed policy solutions focused considerably on career incentives, such as guaranteed promotion or a study opportunity after some fixed term of service in a remote or hardship area. There was considerable stress placed on the need for rural doctors to have periodic contact with mentors through rural rotation of specialists, or remote learning centers, and reliable terms of appointment with fixed end-points. Also raised, but given less emphasis, were concerns about the adequacy of clinical equipment in remote facilities, and remote accommodations. Conclusions In-depth discussions with doctors suggest that while salary is important, it is career development priorities that are keeping doctors in urban centers. Short-term service in rural areas would be more appealing if it were linked to special mentoring and/or training, and led to career advancement.

Studies have reported widespread disposable diaper (DD) consumption in parts of urban Africa, increasing municipal waste generation and with mismanaged DD waste impacting water quality. However, the DD manufacturing and distribution systems behind this trend are little studied, yet understanding these underlying systems is critical in informing efforts to promote extended producer responsibility. This study therefore aims to assess DD brand preferences and trends in international trade in absorbent hygiene products in two case study Sub-Saharan countries. A cross-sectional survey was undertaken of 440 carers of children aged 0–36 months attending health facilities in Greater Accra, Ghana and Kisumu, Kenya. Survey analysis was supplemented by analysis of international trade in absorbent hygiene products for both countries from 2000–2021. Trade data showed DD imports to Ghana and Kenya increased from 2000–17 particularly from China, but declined thereafter. This coincided with Chinese foreign direct investment establishing DD production facilities within both countries in 2018–19, and increased DD exports from Kenya and Ghana to surrounding countries. Meanwhile, 93.0% and 94.2% of survey respondents in Greater Accra and Kisumu respectively reported using DD. In Greater Accra and Kisumu respectively, 62.4% and 45.3% of survey participants reported using the brand produced by these new domestic manufacturing facilities, with 29.8% and 40.9% using imported brands. In Greater Accra, approximately half of reported imported brands were unregistered with the regulator. Given its market dominance, we therefore recommend engagement with the leading manufacturer to identify product or waste management innovations to address water pollution from DD waste. We also recommend similar engagement with imported brand manufacturers and greater DD import regulation in Ghana, given lack of imported brand registration. [ABSTRACT FROM AUTHOR]

Background: Dams provide water for industrial, agricultural, and domestic use, particularly in arid regions. However, controlled dam releases due to heavy rainfall may affect downstream communities' livelihoods and life courses such long-term impacts may be omitted from damage and loss assessments. This study aims to assess the lived experiences and long-term consequences of dam release flooding for downstream populations, comparing these with the typical scope of a damage and loss assessment (DaLA). Methods: This research was conducted in two flood-prone districts in the White Volta basin, Ghana, subject to dam spillage. Four Focus Group Discussions (FGDs) with community opinion headers, household heads, chiefs, local politicians, and institutional staff were conducted and analysed, alongside semi-structured interviews with twelve opinion leaders and disaster-related institutions. Results: Flood-affected communities struggled to attract partners for marriage due to stigmatisation from flooding impacts. Women outside flooded areas rejected male members' marriage proposals, while communities offered young girls for marriage to wealthy men for greater financial security. Out-migration of female members to seek better livelihoods frequently led to divorce, subsequently affecting children's education and well-being. Participants reported long-term trauma from flood-related contact with dangerous wildlife, travel disruption, disease risk, livelihood loss, and accidents. Such life course events and long-term trauma would be omitted from a DaLA exercise. Conclusion: Beyond its immediate impacts, flooding undermines family relationships and marriage, impairing children's education and traumatises affected communities. We recommend livelihood diversification programmes, psychological support and family counselling to address these long-term impacts, with expansion of DaLA's scope to underpin such support. [ABSTRACT FROM AUTHOR]

There is accumulating evidence that the emerging burden of global climate change threatens the fidelity of routine indicators for disease detection and management of risks to public health. The threat partially reflects the conservative character of the health sector and the reluctance to adopt new indicators, despite the growing awareness that existing environmental health indicators were developed to respond to risks that may no longer be relevant, and are too simplistic to also act as indicators for newer global-scale risk factors. This study sought to understand the scope of existing health indicators, while aiming to discover new indicators for building resilience against three climate sensitive diseases (cerebro spinal meningitis, malaria and diarrhea). Therefore, new potential indicators derived from human and biophysical origins were developed to complement existing health indicators, thereby creating climate-sensitive battery of robust composite indices of resilience in health planning. Using Ghana's health sector as a case study systematic international literature review, national expert consultation, and focus group outcomes yielded insights into the relevance, sensitivity and impacts of 45 indicators in 11 categories in responding to climate change. In total, 65% of the indicators were sensitive to health impacts of climate change; 24% acted directly; 31% synergistically; and 45% indirectly, with indicator relevance strongly associated with type of health response. Epidemiological indicators (e.g. morbidity) and health demographic indicators (e.g. population structure) require adjustments with external indicators (e.g. biophysical, policy) to be resilient to climate change. Therefore, selective integration of social and ecological indicators with existing public health indicators improves the fidelity of the health sector to adopt more robust planning of interdependent systems to build resilience. The study highlights growing uncertainties in translating research into protective policies when new indicators associated with non-health sources are needed to complement existing health indicators that are expected to respond to climate change.

Introduction In many low-income countries, health worker shortages hamper progress towards meeting the health-related Millennium Development Goals. (1) Africa is the region of the World Health Organization (WHO) with the [...], Objective To determine how specific job attributes influenced fourth year medical students' stated preference for hypothetical rural job postings in Ghana. Methods Based on discussions with medical student focus groups and physicians in practice and in the Ministry of Health, we created a discrete choice experiment (DCE) that assessed how students' stated preference for certain rural postings was influenced by various job attributes: a higher salary, free superior housing, an educational allowance for children, improved equipment, supportive management, shorter contracts before study leave and a car. We conducted the DCE among all fourth year medical students in Ghana using a brief structured questionnaire and used mixed legit models to estimate the utility of each job attribute. Findings Complete data for DCE analysis were available for 302 of 310 (97%) students. All attribute parameter estimates differed significantly from zero and had the expected signs. In the main effects mixed logit model, improved equipment and supportive management were most strongly associated with job preference (/3 = 1.42; 95% confidence interval, Ch 1.17 to 1.66, and [beta] = 1.17; 95% CI: 0.96 to 1.39, respectively), although shorter contracts and salary bonuses were also associated. Discontinuing the provision of basic housing had a large negative influence ([beta]= -1.59; 95% Ch-1.88 to -1.31). In models including gender interaction terms, women's preferences were more influenced by supportive management and men's preferences by superior housing. Conclusion Better working conditions were strongly associated with the stated choice of hypothetical rural postings among fourth year Ghanaian medical students. Studies are needed to find out whether job attributes determine the actual uptake of rural jobs by graduating physicians. Objectif Determiner comment les preferences d'etudiants en quatrieme annee de medecine pour des postes de travail hypothetiques en milieu rural au Ghana ont ete influencees par les caracteristiques specifiques de ces postes. Methodes A partir de discussions avec des groupes thematiques d'etudiants en medecine, des medecins en exercice et des employes du Ministere de la sante, nous avons mis sur pied une experience a choix discrets (DCE), qui a permis d'evaluer comment les preferences exprimees par les etudiants pour certains postes en milieu rural etaient influencees par les diverses caracteristiques de ces postes : salaire plus eleve, logement confortable gratuit et indemnite pour l'education des enfants, equipement perfectionne, encadrement cooperatif, contrats plus courts avant la fin des etudes et vehicule de fonction. Nous avons applique cette DCE a l'ensemble des etudiants ghaneens en quatrieme annee de medecine a l'aide d'un bref questionnaire structure, puis employe des modeles logit a effets mixtes pour estimer l'utilite de chaque caracteristique des postes. Resultats Nous disposions de donnees completes se pretant a une analyse de la DCE pour 302 etudiants sur 310 (97%). Toutes les estimations des parametres lies aux caracteristiques differaient significativement de zero et presentaient les signes attendus. La modelisation logit des effets mixtes principaux faisait apparaitre une forte association entre la presence d'un equipement perfectionne ou d'un encadrement cooperatif et la preference pour le poste ([beta] = 1,42; intervalle de confiance a 95%, IC: 1,17a 1,66, et [beta] = 1,17; IC a 95% : 0,96 a 1,39, respectivement), meme si la possibilite de contrats plus courts et l'existence de primes salariales etaient aussi associees a cette preference. Ne pas mettre a disposition un logement de base avait une forte influence negative (p = -1,59; IC a 95%: -1,88 a -1,31). Les modeles integrant les termes d'interaction entre les sexes indiquaient que les preferences des femmes etaient plus influencees par la presence d'un encadrement cooperatif et celles des hommes par la mise a disposition d'un logement confortable. Conclusion II existait une forte association entre de meilleures conditions de travail et le choix declare par les etudiants ghaneens en quatrieme annee de medecine d'un poste rural hypothetique. Des etudes sont necessaires pour determiner si les caracteristiques des postes conditionnent l'acceptation reelle des postes en milieu rural par des medecins ayant obtenu leur diplome. Objetivo Determinar que condiciones especificas de empleo influyen en la preferencia declarada de alumnos de cuarto ano de medicina por puestos de trabajo hipoteticos en zonas rurales en Ghana. Metodos Basandonos en conversaciones mantenidas con grupos de discusion de estudiantes de medicina y medicos en ejercicio en el Ministerio de Salud, creamos un modelo de eleccion discreta (MED) para evaluar el efecto de diversas condiciones de empleo en la preferencia declarada de los estudiantes por determinados destinos rurales; a saber: sueldos mas altos, alojamiento gratuito de mayor calidad, subsidios de educacion para los ninos, mejores equipos, gestion de apoyo, contratos mas cortos antes de la licencia de estudios, y entrega de un coche. Ensayamos sobre el terreno el MED y un breve cuestionario estructurado entre todos los estudiantes de cuarto ano de medicina en Ghana, y usamos modelos logit mixtos para estimar la utilidad de cada caracteristica del trabajo. Resultados Se consiguio usar en el analisis MED los datos completos de 302 de un total de 310 estudiantes (97%). Todas las estimaciones de los parametros de las condiciones estudiadas fueron significativamente distintas de cero y tuvieron el signo previsto. En el modelo logit mixto de efectos principales, un mejor equipo y la gestion de apoyo fueron los factores mas estrechamente relacionados con la preferencia por el trabajo ([beta] = 1,42, intervalo de confianza del 95%: 1,1 7-1,66, [beta] = 1,1 7, IC95%: 0,96-1,39, respectivamente), si bien se observo tambien una asociacion con los contratos mas cortos y las bonificaciones salariales. La interrupcion de la prestacion de alojamiento basico tuvo una enorme influencia negativa (6 = 1,59, IC95%: 1,88-1,31). En los modelos que incluian la interaccion del factor genero, las preferencias de las mujeres respondian en mayor medida a la gestion de apoyo y las de los hombres, a una vivienda mejor. Conclusion Se observo una solida relacion entre unas condiciones de empleo mejores y la eleccion declarada de puestos de trabajo rurales hipoteticos entre estudiantes de cuarto ano de medicina de Ghana. Es necesario realizar nuevos estudios para averiguar si las condiciones de empleo determinan la ocupacion real de puestos de trabajo rurales por los medicos que acaban la carrera.

Introduction Arsenic contamination of drinking water, air, food, and beverages is one of the major global health problems (Essumang 2009; Essumang et al. 2007; Hughes 2006; Navas-Acien and Nachman 2013; [...], Background: Exposure to arsenic is one of the major global health problems, affecting > 300 million people worldwide, but arsenic's effects on human reproduction are uncertain. OBJECTIVES: We conducted a systematic review and meta-analysis to examine the association between arsenic and adverse pregnancy outcomes/infant mortality. METHODS: We searched PubMed and Ovid MEDLINE (from 1946 through July 2013) and EMBASE (from 1988 through July 2013) databases and the reference lists of reviews and relevant articles. Studies satisfying our a priori eligibility criteria were evaluated independently by two authors. RESULTS: Our systematic search yielded 888 articles; of these, 23 were included in the systematic review. Sixteen provided sufficient data for our quantitative analysis. Arsenic in groundwater (≥ 50 µg/L) was associated with increased risk of spontaneous abortion (6 studies: OR = 1.98; 95% CI: 1.27, 3.10), stillbirth (9 studies: OR = 1.77; 95% CI: 1.32, 2.36), moderate risk of neonatal mortality (5 studies: OR = 1.51; 95% CI: 1.28, 1.78), and infant mortality (7 studies: OR = 1.35; 95% CI: 1.12, 1.62). Exposure to environmental arsenic was associated with a significant reduction in birth weight (4 studies: β = -53.2 g; 95% CI: -94.9, -11.4). There was paucity of evidence for low-to-moderate arsenic dose. CONCLUSIONS: Arsenic is associated with adverse pregnancy outcomes and infant mortality. The interpretation of the causal association is hampered by methodological challenges and limited number of studies on dose response. Exposure to arsenic continues to be a major global health issue, and we therefore advocate for high-quality prospective studies that include individual-level data to quantify the impact of arsenic on adverse pregnancy outcomes/infant mortality. http://dx.doi.org/10.1289/ehp.1307894