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In low-and-middle income countries, maternal mental health needs remain neglected, and common mental disorders during pregnancy and after birth are routinely associated with hormonal changes. The psycho-social, and spiritual components of childbirth are often downplayed. A qualitative study was conducted as part of a wider realist evaluation on health systems responsiveness to examine the interrelationships between pregnant and postnatal women, their families, and their environment, and how these influence women's interactions with healthcare providers in Ghana. Data collection methods combined six qualitative interviews (n= 6) and 18 focus group discussions (n= 121) with pregnant and postnatal women, their relatives and health care providers (midwives, community mental health nurses) at the primary healthcare level. Data analysis was based on the Context-Mechanism-Outcome heuristic of realist evaluation methodology. A programme theory was developed and iteratively refined, drawing on Crowther's ecology of birth theory to unpack how context shapes women's interactions with public and alternative health care providers. We found that context interacts dynamically with embodiment, relationality, temporality, spatiality, and mystery of childbirth experiences, which in turn influence women's wellbeing in three primary areas. There is an intricate intersection of pregnancy with mental health impacting women's expectations of temporality, which does not always coincide with the timings provided by formal healthcare services. Societal deficiencies in social support structures for women facing economic challenges become particularly evident during the pregnancy and postnatal period, where women need heightened assistance. Socio-cultural beliefs associated with the mystery of childbirth, support the role of private providers in offering women a feeling of protection from uncertainty. Co-production of context specific interventions, including the integration of maternal and mental health policies, with relevant stakeholders can help formal healthcare providers accommodate women's perspectives on spirituality and mental health, which can subsequently help to make health system responsive to maternal mental health conditions., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Introduction: In sub-Saharan Africa, pregnant and postpartum women with mental health problems are often missed in healthcare systems. To address this, a practical and simple screening tool for maternal mental health should be available to primary healthcare workers. An important step toward having such a tool is to assess the existing tools and their effectiveness in primary care settings., Methods: We systematically searched PubMed, LILAC, CINAHL, Google Scholar, African Index Medicus, HINARI, and African Journals Online from inception to 31 January 2023, without language restriction. Reference lists of retrieved articles were reviewed and experts in the field were contacted for studies not captured by our searches. All retrieved records were collated in Endnote, de-duplicated, and exported to Rayyan for screening. Study selection and data extraction were done by at least two reviewers using a pre-tested flow chart and data extraction form. Disagreements between reviewers were resolved through discussion. We contacted primary authors for missing or insufficient information and conducted a content analysis of the psychometric properties of the tools., Results: In total, 1,181 studies were retrieved by our searches, of which 119 studies were included in this review. A total of 74 out of 119 studies (62%) were screened for depression during pregnancy and or the postpartum period. The Edinburg Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ-9) were the most commonly used tools. In total, 12 studies reported specificity and sensitivity for tools for measuring depression (EPDS, PHQ-9, and Whooley) and psychological distress [Self Report Questionnaire (SRQ) and Kessler Psychological Distress Scale (KPDS)]. The average sensitivity and specificity of the EPDS reported were 75.5 and 76.5%, respectively, at a cut-off of ≥13. The EPDS appears to be the most acceptable, adaptable, user-friendly, and effective in screening for maternal mental health conditions during pregnancy and postpartum. However, the methodological approach varied for a particular tool, and documentation on the attributes was scanty., Conclusion: The EPDS was the most commonly used tool and considered as most acceptable, adaptable, user-friendly, and effective. Information on the performance and psychometric properties of the vast majority of screening tools was limited., Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022323558, identifier CRD42022323558 (PROSPERO)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Gyimah, Agyepong, Owiredu, Awini, Yevoo, Ashinyo, Aye, Abbas, Cronin de Chavez, Mirzoev and Danso-Appiah.)

Background: Instruments to assess the knowledge about the rights of persons with mental health conditions and psychosocial disabilities, the attitudes toward their role as rights holders, and mental health professionals' practices related to substitute decision-making and coercion are either missing or lack evaluation of their validity and reliability., Aim: The aim of this study is to evaluate the validity and reliability of three instruments developed to fill this gap in the literature, the World Health Organization's QualityRights (WHO QR) Knowledge questionnaire, the WHO QR Attitudes questionnaire, and the WHO QR Practices questionnaire., Methods: A sample of participants was recruited and completed an online survey. Content validity and face validity were assessed for the three questionnaires. Based on the characteristics of the questionnaires, different approaches were used to assess their construct validity (confirmatory factor analysis, known group validity, and convergent and divergent validity). Internal consistency was evaluated using Cronbach's alpha and test re-test reliability using Pearson's and Spearman's r coefficients., Results: The analyses conducted indicate that the three questionnaires are valid and reliable instruments to evaluate the knowledge about the rights of persons with mental health conditions and psychosocial disabilities, the attitudes toward their role as rights holders, and mental health professionals' practices related to substitute decision-making and coercion., Conclusion: This finding lends support to the use of these instruments both within mental health services and in the general population for a better understanding of current knowledge, attitudes, and practices related to a human rights-based approach to mental health in mental health services and the community., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer FS declared a shared affiliation with authors MA, SD’O, and MC to the handling editor at the time of review. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Moro, Gyimah, Susser, Ansong, Kane, Amissah, Gureje, Osei, Norcini Pala, Taylor, Drew, Kofie, Baingana, Ohene, Addico, Fatawu, Atzeni, D’Oca, Carta and Funk.)

Background: Globally, human rights violations experienced by persons with psychosocial, intellectual or cognitive disabilities continue to be a concern. The World Health Organization's (WHO) QualityRights initiative presents practical remedies to address these abuses. This paper presents an overview of the implementation of the initiative in Ghana., Aims: The main objective of the QualityRights initiative in Ghana was to train and change attitudes among a wide range of stakeholders to promote recovery and respect for human rights for people with psychosocial, intellectual and cognitive disabilities., Method: Reports of in-person and online training, minutes of meetings and correspondence among stakeholders of the QualityRights initiative in Ghana, including activities of international collaborators, were analysed to shed light on the implementation of the project in Ghana., Results: In-person and online e-training on mental health were conducted. At the time of writing, 40 443 people had registered for the training, 25 416 had started the training and 20 865 people had completed the training and obtained a certificate. The team conducted 27 in-person training sessions with 910 people. The successful implementation of the project is underpinned by a committed partnership among stakeholders, strong leadership from the coordinating agency, the acceptance of the initiative and the outcome. A few challenges, both in implementation and acceptance, are discussed., Conclusions: The exposure of the WHO QualityRights initiative to a substantial number of key stakeholders involved in mental healthcare in Ghana is critical to reducing human rights abuses for people with psychosocial, intellectual and cognitive disabilities.

Background: Diagnosing a life-threatening disease like the human immunodeficiency virus (HIV) can be unbearable to the individual, which has implications for their subsequent care-seeking decision-making. However, an essential element of HIV testing is identifying infected individuals and linking them with adequate care services, thus contributing to the UNAIDS 95-95-95 targets. The attainment of these targets has been particularly challenging for lower and middle-income countries (LMIC). This study explored the psychological reactions to a positive HIV status in a hospital treatment centre to provide insight into mental health interventions' role in improving HIV screening and early antiretroviral therapy (ART) initiation to enhance the quality of life., Methods: An exploratory qualitative study was investigated among adults who were diagnosed as HIV positive. Participants were purposively recruited from an HIV Treatment Centre. Data were collected with semi-structured interviews that explored the interpretations and psychological reactions to their positive HIV status. Overall, 18 participants were interviewed to reach saturation. Data were transcribed verbatim and analysed thematically to produce findings that address the study's objective., Results: Following analysis of participants' interpretations, understanding and implications of their HIV-positive diagnosis, two major themes emerged: (1) anxiety regarding the impact of the disease on self, family and society was overwhelming. Participants were anxious because of the stigma, fear, worry, shock, and shame they faced. (2) Participants expressed hopelessness and could not see meaning or purpose in life. Suicidal ideation, suicide plans and self-harm characterised hopelessness., Conclusions: The initial reaction to the diagnosis of HIV in this LMIC context has the potential to impact linkage to care negatively and, thus, the attainment of the global 95-95-95 targets. It is, therefore, essential that mental health and psychological support services are integrated with testing services to manage the initial reactions and support individuals to improve early linkage to care and thus improve overall outcomes for the infected individual and society., (© 2023. The Author(s).)

Background: Despite growing recognition of essential human rights, people with mental health conditions and psychosocial, intellectual, or cognitive disabilities' rights are known to be frequently violated in mental healthcare worldwide, with common use of coercive practices and limited recognition of people's right to exercise their legal capacity and make decisions for themselves on treatment and other issues affecting them. To tackle this issue, Ghana adopted the WHO QualityRights Initiative in 2019. This aims to introduce a right-based, person-centred recovery approach within the mental health care system, protecting and promoting the rights of people with mental health conditions, psychosocial, cognitive, and intellectual disabilities in the healthcare context and community., Methods: E-training (capacity-building) was provided in Ghana across a broad array of stakeholder groups including healthcare professionals, carers, and people with lived experience. The training covered legal capacity, coercion, community inclusion, recovery approach, service environment, and the negative attitudes commonly held by stakeholder groups; it was completed by 17,000 people in Ghana as of December 2021. We assessed the impact of the e-training on attitudes through comparing trainees' pre- and post-questionnaire responses on 17 items, each measured on a 5-point Likert scale (strongly disagree to strongly agree), such that higher scores indicated negative attitudes towards persons with mental health conditions and psychosocial disabilities as rights holders. Analyses were conducted on two main groups: matched pairs (417 pairs of baseline and follow-up questionnaire responses matched to a high degree of certainty), and the unmatched group (4299 individual completed questionnaire responses)., Results: We assessed the impact of the WHO QualityRights e-training on attitudes: training resulted in highly significant attitude changes towards alignment with human rights, with scores changing by approximately 40% between baseline and follow-up. In particular, attitude changes were seen in items representing treatment choice, legal capacity, and coercion. This change was not affected by age, gender, or background experience., Conclusions: The QualityRights e-training programme is effective in changing people's (especially healthcare professionals') attitudes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities: this is a step towards mental healthcare being more with human rights-based worldwide., (© 2023. The Author(s).)

Xylia evansii is widely used in traditional medicine to stop bleeding gums and treat wounds. This study was undertaken to assess the wound healing activity and toxicity profile of the stem bark methanol extract of X. evansii (XES). Wound healing activity was determined by the dermal excision model in rats. The free radical scavenging capacity, antioxidant activity, total phenolic and flavonoid contents were evaluated by the 1, 1-diphenyl-2-picrylhydrazyl (DPPH) free radical scavenging, total antioxidant capacity (TAC), aluminum chloride colorimetric and Folin Ciocalteu methods respectively. Acute and sub-acute oral toxicity assessment was performed following the Organization for Economic Co-operation and Development guidelines. Significant ( p < 0.05 ) dose-dependent wound healing effect, similar to that of 1 % silver sulphadiazine was elicit by the 10, 15 and 20 % w / w XES ointments. The highest effect was demonstrated by XES 20 % w / w which resulted in 98.3 % wound surface closure by day 9 of treatment ( p < 0.0001 ). The total phenolic and flavonoid contents were determined to be 381.2 ± 12.57 mg/g gallic acid equivalent (GAE) and 460 ± 29.07 mg/g quercetin equivalent respectively. XES exhibited remarkable free radical scavenging effect (IC 50  = 68.13 ± 1.87 μg/mL) and had a total antioxidant capacity of 279.2 ± 32.08 mg/g GAE. The LD 50 of XES was estimated to be > 5000 mg/kg. In sub-acute toxicity, 28 days treatment with XES (250, 500, 1000 mg/kg body weight) did not result in any significant ( p > 0.05 ) change in the body weight or weight of the heart, lung, spleen, liver and kidneys. The haematological and biochemical profiles of XES-treated rats were not significantly ( p > 0.05 ) affected after 4-weeks treatment with XES, except for platelet count which increased significantly ( p < 0.0001 ) in a non-dose-dependent manner. Histopathological examination did not reveal any toxic effect to liver cells, however at 1000 mg/kg XES, slight abnormalities were identified in the glomeruli. Microscopy of the powdered stem bark displayed calcium oxalate crystals, pitted vessels and lignified fibres. Tannins, flavonoids, coumarins, saponins, triterpenes and alkaloids were identified in the bark. This is the first report on the wound healing potential and safety profile of X. evansii , giving scientific credence to its use in traditional medicine., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

This study focused on documenting and evaluating the cercaricidal activity of medicinal plants used for schistosomiasis treatment in an endemic area in Ghana. Through semistructured questionnaires, personal interviews with herbalists in communities surrounding the Barekese dam in the Atwima-Nwabiagya district, where the disease is endemic, were carried out. Thirty medicinal plants distributed in 19 families were reported to be used for schistosomiasis treatment in the survey. Information on the plants, including scientific names, common names, families, and the used plant part were recorded. The families Apocynaceae and Euphorbiaceae recorded the highest number of plants (14% each), followed by Asteraceae (10%), Loranthaceae (7%), and Rubiaceae (7%). In vitro cercaricidal activity of methanol extracts of nine out of the thirty plants was performed by exposing human Schistosoma mansoni cercariae obtained from Biomphalaria pfeifferi to various concentrations of extracts over a duration of 240 minutes. All the plants tested demonstrated time- and concentration-dependent cercaricidal activity. With lethality being set at <1000  μ g/mL, the cercaricidal activity in order of decreasing potency was as follows: Withania somnifera (LC 50  = 1.29) >  Balanites aegyptiaca (LC 50  = 7.1) >  Xylia evansii (LC 50  = 11.14) > Jathropha multifida (LC 50  = 12.9) > Justicia flava (LC 50  = 22.9) > Anopyxis klaineana (LC 50  = 182.81) >  Ximenia americana (LC 50  = 194.98) > Loranthus lecardii (LC 50  = 223.87) > Bridelia tenufolia (LC 50  = 309.03) >  Zanthoxylium zanthoxyloides (LC 50  = 851.94). Phytochemicals, including alkaloids, tannins, triterpenes, saponins, phytosterols, and flavonoids were identified in the plants. The result of this study gives scientific credence to the traditional use of these plants in the treatment of schistosomiasis and proves that the rich botanical knowledge of medicinal plants provides an incredible starting point for the discovery of new anti-schistosomal drugs for the local population., Competing Interests: The author(s) declare(s) that they have no conflicts of interest., (Copyright © 2023 Evelyn Asante-Kwatia et al.)

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: Challenges such as stigma and loneliness may increase vulnerability to Human Immunodeficiency Virus (HIV) infection and negatively affect the quality of life of people living with HIV (PLHIV) despite the massive investment in access to antiretroviral therapy. This study aims to determine the level of loneliness and stigma and explore the coping resources employed by PLHIV in a resource-constrained setting., Methods: This was a sequential mixed methods study conducted at the Cape Coast Teaching Hospital (CCTH) in Ghana between May and December 2021. A total of 395 adults were selected using a simple random sampling technique. HIV Stigma Scale and UCLA Loneliness Scale were used to collect quantitative data. A purposive sampling technique was applied to recruit 18 participants to saturation using a semi-structured interview guide. SPSS version 21 was used for the statistical analysis of the quantitative data. HIV-related loneliness and stigma levels were estimated, and bivariate and multivariable logistic regression were used to evaluate associated factors using a statistical significance of p-value (p < .05). In general, the thematic analysis approach by Braun and Clark was employed to analyse the qualitative data. Findings were then triangulated., Results: The mean age was 46.79 years (± 12.53), 75.4% of the participants were female, with a prevalence of stigma of 99.0% (95%CI = 97.4-99.7) and loneliness of 30.1% (95%CI = 25.6-34.9). Tertiary-level education and instrumental support were associated with lower levels of loneliness. In contrast, comorbidity, personalised stigma, negative self-image, and self-blame were positively related to loneliness. Thematic analyses of the qualitative data produced a range of themes that showed that people living with HIV rely on personal resources, social support networks, and behaviour modification strategies to manage their condition. In particular, some of these strategies include; religiosity and spirituality, family and friends, medication and professional support systems., Conclusion: The results suggest that PLHIV in the developing world face enormous challenges, socially, psychologically and financially. Although there have been global efforts to make HIV services accessible, the findings suggest a need for integrating mental health services contextually to reduce loneliness and HIV-related stigma to improve quality of life., (© 2023. The Author(s).)

Background: There are currently major efforts underway in Ghana to address stigma and discrimination, and promote the human rights of those with mental health conditions, within mental health services and the community, working with the World Health Organization's QualityRights initiative. The present study aims to investigate attitudes towards people with lived experience of mental health conditions and psychosocial disabilities as rights holders., Methods: Stakeholders within the Ghanaian mental health system and community, including health professionals, policy makers, and persons with lived experience, completed the QualityRights pre-training questionnaire. The items examined attitudes towards coercion, legal capacity, service environment, and community inclusion. Additional analyses explored how far participant factors may link to attitudes., Results: Overall, attitudes towards the rights of persons with lived experience were not well aligned with a human rights approach to mental health. Most people supported the use of coercive practices and often thought that health practitioners and family members were in the best position to make treatment decisions. Health/mental health professionals were less likely to endorse coercive measures compared to other groups., Conclusion: This was the first in-depth study assessing attitudes towards persons with lived experience as rights holders in Ghana, and frequently attitudes did not comply with human rights standards, demonstrating a need for training initiatives to combat stigma and discrimination and promote human rights., (© 2023. The Author(s).)

Background and Aims: An important but much less researched burden of human immunodeficiency virus (HIV) in Sub-Saharan Africa includes the associated mental health outcomes of living with the virus. This study aimed to estimate the prevalence of depression, anxiety, and stress, and describe some of the socio-demographic associations among people living with HIV (PLHIV) in Ghana., Methods: A cross-sectional study was conducted at the Cape Coast Teaching Hospital, Ghana. Simple random sampling was used to recruit 395 PLHIV who access HIV-related services at the antiretroviral therapy clinic. The Depression, Anxiety, and Stress Scale-21 was used to assess prevalence of depression, anxiety, and stress. Frequencies and percentages were used to estimate the prevalence and multivariable logistic regression was used to evaluate sociodemographic factors associated with depression, anxiety, and stress., Results: The prevalence estimates of depression, anxiety, and stress among PLHIV were 28.6% (95% confidence interval [CI] 24.4-33.3), 40.8% (95% CI = 36.0-45.8), and 10.6% (95% CI = 7.9-14.1), respectively. Females reported higher prevalence of depression (32.2%; 95% CI = 27.2-37.7), anxiety (44.0%; 95% CI = 38.4-49.6), and stress (12.6%; 95% CI = 9.4-17.0) compared to depression (17.5%; 95% CI = 11.1-26.4), anxiety (30.9%; 95% CI = 22.5-40.7), and stress (4.1%; 95% CI = 1.2-10.4) among males. PLHIV without a regular partner were about 0.63 increased odds of experiencing anxiety compared to those with a regular partner (AOR = 0.63, 95% CI = 0.40-1.00: p  = 0.049). PLHIV without formal education were about 0.49 and 0.44 increased odds to experience anxiety and stress, respectively compared to those with tertiary education., Conclusions: Generally, the levels of stress, anxiety, and depression are high among PLHIV, but disproportionately higher among females. Mental health assessment and management should be integrated into the HIV care services. There should be capacity building for health care workers to offer differentiated service delivery based on mental health care needs of PLHIV., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background: In 2012, Ghana ratified the United Nations Convention on the Rights of Persons with Disabilities and enacted a Mental Health Act to improve the quality of mental health care and stop human rights violations against people with mental health conditions. In line with these objectives, Ghanaian stakeholders collected data on the quality of mental health services and respect for human rights in psychiatric facilities to identify challenges and gather useful information for the development of plans aimed to improve the quality of the services offered. This study aimed to assess psychiatric facilities from different Ghanaian regions and provide evidence on the quality of care and respect of human rights in mental health services., Methods: Assessments were conducted by independent visiting committees that collected data through observation, review of documentation, and interviews with service users, staff, and carers, and provided scores using the World Health Organization QualityRights Toolkit methodology., Results: This study revealed significant key challenges in the implementation of the United Nations Convention on the Rights of Persons with Disabilities principles in Ghanaian psychiatric services. The rights to an adequate standard of living and enjoyment of the highest attainable standard of health were not fully promoted. Only initial steps had been taken to guarantee the right to exercise legal capacity and the right to personal liberty and security. Significant gaps in the promotion of the right to live independently and be included in the community were identified., Conclusions: This study identifies shortcomings and critical areas that the Ghanaian government and facilities need to target for implementing a human rights-based approach in mental health and improve the quality of mental health care throughout the country., (© 2022. The Author(s).)

The present study evaluated the wound healing, anthelmintic and antioxidant potentials of crude methanol extracts and fractions (petroleum ether, ethyl acetate and methanol) of the leaves and stem bark of Amphimas pterocarpoides . Wound healing activity was determined by the dermal excision model in rats; anthelmintic activity was evaluated by the adult worm motility test using the adult Indian worm, Pheretima postuma . Total flavonoid, phenolic content and antioxidant activity were assessed by the aluminum chloride colorimetric, Folin Ciocalteu, 1, 1-diphenyl-2-picrylhydrazyl (DPPH) free radical scavenging and total antioxidant capacity (TAC) assays respectively. HPLC/UV fingerprints were developed for quality control. The maximum amount of phenolics and flavonoids were detected in the methanol fractions of the stem bark (225.0 ± 20.0 mg/g gallic acid equivalent (GAE) and 201.0 ± 1.41 mg/g quercetin equivalent (QCE) respectively) and leaves (84.54 ± 1.36 mg/g GAE and 130.7 ± 1.71 mg/g QCE, respectively). Both leaf and bark displayed remarkable free radical scavenging and TAC with the highest effect given by the methanol fractions. Significant ( p < 0.05) wound contraction was achieved by topical application of the leaf (APL) and stem bark (APS) ointments (5-15%) with >90 % wound surface closure for 1% silver sulphadiazine, APS 15% and APL 10% treated groups by day 15. APL and APS demonstrated a concentration- and time-dependent paralysis and mortality of the P. posthuma with APL (6.25 mg/mL) causing worm paralysis at 82.60 min and death at 93 min, better than 10 mg/mL albendazole (paralysis at 76.30 min; death at 117 min). Tannins, triterpenoids, phytosterols, flavonoids, saponins and coumarins were detected in the leaves and bark. The results have proven the potential of A. pterocarpoides as a wound healing and anthelmintic agent, giving scientific credence to its use in traditional medicine., Competing Interests: The authors declare no conflict of interest., (© 2021 The Author(s).)

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.)

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., Competing Interests: The authors have declared that no competing interests exist.