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Schools have been identified as important settings for promoting adolescent mental health and well-being. Little is known about counselling practices in Ghanaian senior high schools (SHSs). This study explored counselling practices in 11 SHSs in Ghana's capital, Accra. We used convenience sampling methods to select 15 school counsellors and interviewed them about access to and utilisation of counselling in SHSs. We also explored common presenting concerns and service challenges. Data were analysed thematically and showed that most of the counsellors had a master's or doctoral degree in guidance and counselling. According to our participants, students access counselling to address school (academic and career), home (e.g. parents' problems and livelihood issues) and peer relations concerns. Other students access counselling for emotional (including suicidal ideations and self-harm), drug use and conduct issues. Counsellors provide academic advice, career guidance, financial and emotional support. Findings revealed that counsellors are facing several challenges including role conflict, work overload, deficient resources, as well as negative perceptions of counselling. Findings have implications for the government, policy makers, SHS administrators, school psychologists and counsellors and students.

Abstract Background Vaccination has contributed to the reduction in vaccine preventable diseases. Despite, improved global coverage, vaccination among nomadic populations is still low especially in Africa. This study explored factors influencing vaccination uptake among pastoralist nomads in Ghana. Methods We conducted key informant interviews (KII) in 11 districts across four regions of Ghana, using grounded theory qualitative research approach. One hundred and eighty-two KII were conducted among pastoralist nomads, community opinion leaders, community health volunteers, security services personnel, local government personnel and health workers. Guided by the WHO health systems building blocks, data was coded using Nvivo 12 and analysed thematically. Results were presented as narratives with excerpts to support the findings. Results Community leaders support vaccination among pastoralist nomads as part of their leadership and governance responsibilities. Language barrier between health workers and pastoralist nomads affects service delivery. Also, healthcare providers fear being attacked by pastoralist nomads hence are hesitant to visit their settlements for vaccination. With regards to health workforce, healthcare providers’ perceived use of derogatory words and discrimination against pastoralist nomads influence their vaccination uptake. On medical product, the lack of knowledge about diseases, severity and perceived negative effects about vaccines influence vaccination uptake. Inadequate funds and logistics at the district health directorates affects outreach to nomads during vaccinations. Leveraging existing partnership between the health services and community leaders, information centers, volunteers and butchers to send health information to pastoralist nomads influence vaccination uptake. Conclusion Community leaders support vaccination among pastoralist nomads. Nomadic pastoralist miss vaccination dues to language barrier, feel discriminated against, and lack information about diseases and vaccinations. Strengthening Ghana Health Service collaboration with leaders of pastoralist nomads could build trust, create awareness and overcome language barrier between healthcare providers and pastoralist nomads.

Abstract Background Malaria remains a major public health problem, especially among children in sub-Saharan Africa. Knowledge of malaria parasite prevalence informs targeted interventions and helps to monitor the effectiveness of those interventions. This study aimed to determine prevalence and factors associated with malaria in children aged 6 months to 10 years in the Greater Accra Region of Ghana. Methods A community-based cross-sectional study was conducted among 8,741 children aged 6–59 months and 8,292 children aged 5–10 years in all 29 districts of the Greater Accra Region of Ghana in October 2020. Systematic random sampling was used to select communities, households and study participants. A structured questionnaire was used to collect data from caregivers. Rapid diagnostic test kits were used to determine the presence of malaria parasites in blood samples collected by fingerprick. Factors associated with malaria RDT-positivity were determined using multivariate logistic regression analysis. Results Of 8727 children aged 6–59 months and 8279 aged 5–10 years from whom blood samples were obtained, positive results were obtained for 289 (3.3%; 95% CI 3.0–3.7) and 406 (4.9%; 95% CI 4.5–5.4) respectively. Malaria parasite prevalence in the districts ranged from 0.9 to 10.7% and 1.4–15.0% in children aged 6–59 months and 5–10 years respectively. Factors associated with increased odds of malaria included higher age (AOR = 1.43; 95% CI 1.14–1.71), and living in households without nets on the windows (AOR 1.64; 95% CI 1.10–2.45). On the other hand, living in households located in urban communities was associated with a lower risk of malaria (AOR 0.56; 95% CI 0.40–0.78). Conclusion The average prevalence of malaria in the Greater Accra Region is low compared with other regions. However, there are potential hotspots that need to be targeted with appropriate interventions to accelerate the drive towards malaria elimination.

Introduction: Liquefied petroleum gas (LPG) is a clean cooking fuel that emits less household air pollution (HAP) than polluting cooking fuels (e.g. charcoal, wood). While switching from polluting fuels to LPG can reduce HAP and improve health, the impact of ‘stacking’ (concurrent use of polluting fuels and LPG) on adverse health symptoms (e.g. headaches, eye irritation, cough) among female cooks is uncertain. Methods: Survey data from the CLEAN-Air(Africa) study was collected on cooking patterns and health symptoms over the last 12 months (cough, wheezing, chest tightness, shortness of breath, eye irritation, headaches) from approximately 400 female primary cooks in each of three peri‑urban communities in sub-Saharan Africa: Mbalmayo, Cameroon; Obuasi, Ghana; and Eldoret, Kenya. Random effects Poisson regression, adjusted for socioeconomic and health-related covariates, assessed the relationship between primary and secondary cooking fuel type and self-reported health symptoms. Results: Among 1,147 participants, 10 % (n = 118) exclusively cooked with LPG, 45 % (n = 509) stacked LPG and polluting fuels and 45 % (n = 520) exclusively cooked with polluting fuels. Female cooks stacking LPG and polluting fuels had significantly higher odds of shortness of breath (OR 2.16, 95 %CI:1.04–4.48) compared with those exclusively using LPG. In two communities, headache prevalence was 30 % higher among women stacking LPG with polluting fuels (Mbalmayo:82 %; Eldoret:65 %) compared with those exclusively using LPG (Mbalmayo:53 %; Eldoret:33 %). Women stacking LPG and polluting fuels (OR 2.45, 95 %CI:1.29–4.67) had significantly higher odds of eye irritation than women cooking exclusively with LPG. Second-hand smoke exposure was significantly associated with higher odds of chest tightness (OR 1.92, 95 % CI:1.19–3.11), wheezing (OR 1.76, 95 % CI:1.06–2.91) and cough (OR 1.78, 95 %CI:1.13–2.80). Conclusions: In peri‑urban sub-Saharan Africa, women exclusively cooking with LPG had lower odds of several health symptoms than those stacking LPG and polluting fuels. Promoting a complete transition to LPG in these communities may likely generate short-term health benefits for primary cooks.

Abstract Background RTS,S/AS01 has been recommended by WHO for widespread implementation in medium to high malaria transmission settings. Previous analyses have noted lower vaccine efficacies in higher transmission settings, possibly due to the more rapid development of naturally acquired immunity in the control group. Methods To investigate a reduced immune response to vaccination as a potential mechanism behind lower efficacy in high transmission areas, we examine initial vaccine antibody (anti-CSP IgG) response and vaccine efficacy against the first case of malaria (to exclude the effect of naturally acquired immunity) using data from three study areas (Kintampo, Ghana; Lilongwe, Malawi; Lambaréné, Gabon) from the 2009–2014 phase III trial (NCT00866619). Our key exposures are parasitemia during the vaccination series and background malaria incidence. We calculate vaccine efficacy (one minus hazard ratio) using a cox-proportional hazards model and allowing for the time-varying effect of RTS,S/AS01. Results We find that antibody responses to the primary three-dose vaccination series were higher in Ghana than in Malawi and Gabon, but that neither antibody levels nor vaccine efficacy against the first case of malaria varied by background incidence or parasitemia during the primary vaccination series. Conclusions We find that vaccine efficacy is unrelated to infections during vaccination. Contributing to a conflicting literature, our results suggest that vaccine efficacy is also unrelated to infections before vaccination, meaning that control-group immunity is likely a major reason for lower efficacy in high transmission settings, not reduced immune responses to RTS,S/AS01. This may be reassuring for implementation in high transmission settings, though further studies are needed.

Abstract Invasive non-typhoidal Salmonella (iNTS) disease manifesting as bloodstream infection with high mortality is responsible for a huge public health burden in sub-Saharan Africa. Salmonella enterica serovar Typhimurium (S. Typhimurium) is the main cause of iNTS disease in Africa. By analysing whole genome sequence data from 1303 S. Typhimurium isolates originating from 19 African countries and isolated between 1979 and 2017, here we show a thorough scaled appraisal of the population structure of iNTS disease caused by S. Typhimurium across many of Africa’s most impacted countries. At least six invasive S. Typhimurium clades have already emerged, with ST313 lineage 2 or ST313-L2 driving the current pandemic. ST313-L2 likely emerged in the Democratic Republic of Congo around 1980 and further spread in the mid 1990s. We observed plasmid-borne as well as chromosomally encoded fluoroquinolone resistance underlying emergences of extensive-drug and pan-drug resistance. Our work provides an overview of the evolution of invasive S. Typhimurium disease, and can be exploited to target control measures.

Abstract Background Global evidence indicates that early onset of illicit substance use among adolescents and emerging adults is associated with negative mental-health related-outcomes that can persist into adulthood. However, the lack of quality regional data on adolescent illicit substance use and its determinants remains a common barrier to evidence-based policy-making and the development of school-based interventions in Africa. The purpose of our study was to estimate the prevalence and describe the correlates of cannabis and amphetamine use among school-going adolescents in eight sub-Saharan African countries (SSA) – Benin, Ghana, Liberia, Mauritius, Mozambique, Namibia, Seychelles, and Tanzania. Methods We analysed 15,553 school-going adolescents that participated in the Global School-based Student Health Survey. A two-stage sampling approach was used to generate a nationally representative sample of school children (grades 7–12) in each of these countries. Students responded to a self-administered structured questionnaire that contained information on sociodemographic factors, family involvement factors, mental health factors, school environment factors and past-month cannabis and life-time amphetamine use. Results The overall prevalence estimates of past-month cannabis use and lifetime amphetamine use among school-going adolescents in the eight SSA countries was 4.39% (95% CI = 4.08, 4.72) and 3.05% (95% CI = 2.79, 3.34) respectively. In the multivariable logistic regression analysis, demographic characteristics (age and male gender), mental health factors (suicide ideation and attempt), lifestyle factors (cigarette smoking, past-month alcohol use, lifetime drunkenness and leisure-time sedentary behaviour) and school level factors (truancy and bullying victimisation) showed strong associations with increased odds of both past-month cannabis use and lifetime amphetamine use. Social support at school was associated with increased odds for lifetime amphetamine, while parental monitoring decreases the odds for lifetime amphetamine use. It was also observed that parental tobacco use was associated with increased odds of both past-month cannabis use and lifetime amphetamine use. Conclusion The relatively low overall prevalence estimates of past-month cannabis use and lifetime amphetamine use among school-going adolescents in not surprising. However, the identified risk and protective factors associated with cannabis and amphetamine use underscores the need for these eight countries in SSA to develop contextual and multi-sectoral intervention and school-based prevention programmes that could target school-going adolescents who may be at risk of misusing these illicit drugs.

Objectives: Malaria is still one of the main reasons for hospitalization in children living in sub-Saharan Africa. Rapid risk stratification at admission is essential for optimal medical care and improved prognosis. Whereas coma, deep breathing, and, to a lesser degree, severe anemia are established predictors of malaria-related death, the value of assessing prostration for risk stratification is less certain. Methods: Here we used a retrospective multi-center analysis comprising over 33,000 hospitalized children from four large studies, including two observational studies from the Severe Malaria in African Children network, a randomized controlled treatment study, and the phase-3-clinical RTS,S-malaria vaccine trial, to evaluate known risk factors of mortality and with a specific emphasis on the role of prostration. Results: Despite comparable age profiles of the participants, we found significant inter- and intra-study variation in the incidence of fatal malaria as well as in the derived risk ratios associated with the four risk factors: coma, deep breathing, anemia, and prostration. Despite pronounced variations, prostration was significantly associated with an increased risk of mortality (P

Background: Individuals living with hypertension are at an increased risk of cardiovascular- and cerebrovascular-related outcomes. Interventions implemented at the community level to improve hypertension control are considered useful to prevent cardiovascular and cerebrovascular events; however, systematic evaluation of such community level interventions among patients living in low- and middle-income countries (LMICs) is scarce. Methods: Nine databases were searched for randomized controlled trials (RCTs) and cluster randomized control trials (cRCTs) implementing community level interventions in adults with hypertension in LMICs. Studies were included based on explicit focus on blood pressure control. Quality assessment was done using the Revised Cochrane Risk of Bias tool for randomized trials (ROBS 2). Results were presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Fixed-effect meta-analyses were conducted for studies that reported continuous outcome measures. Results: We identified and screened 7125 articles. Eighteen studies, 7 RCTs and 11 cRCTs were included in the analysis. The overall summary effect of blood pressure control was significant, risk ratio = 1.48 (95%CI = 1.40–1.57, n = 12). Risk ratio for RCTs was 1.68 (95%CI = 1.40–2.01, n = 5), for cRCTs risk ratio = 1.46 (95%CI = 1.32–1.61, n = 7). For studies that reported individual data for the multicomponent interventions, the risk ratio was 1.27 (95% CI = 1.04–1.54, n = 3). Discussion: Community-based strategies are relevant in addressing the burden of hypertension in LMICs. Community-based interventions can help decentralize hypertension care in LMIC and address the access to care gap without diminishing the quality of hypertension control. Prospero: CRD42020194081

Abstract Background The Joint United Nations Programme on HIV/AIDS launched the 90-90-90 initiative. Failure to meet the target reflects the difficulties in successfully implementing HIV treatment policy. There are research gaps in exploring personal and external factors influencing HIV treatment in Ghana. To fill this gap, we explored individual and environmental (interpersonal, community and structural) factors influencing stakeholders' HIV treatment policy implementation in Ghana. Methods Fifteen qualitative semi-structured in-depth interviews were conducted among representatives in different management positions at hospitals, health directorates, the Ghana AIDS Commission, the National AIDS and STI control program, and the National Association of People Living with HIV. Results Using thematic analysis, the findings suggest that individual and environmental factors such as attitude towards policy, awareness of HIV treatment policy, training received on policy implementation, difficulties related to patient factors, alternate sources of HIV care, inefficient policy decision-making, monitoring and evaluation of HIV treatment policy, lack of HIV treatment policy implementation training, poor availability of logistics, policy and guidelines, infrastructure, organization of training, and staff availability may hinder successful HIV treatment policy implementation. Conclusion Several individual and environmental (interpersonal, community and structural) factors seem to influence HIV treatment policy implementation. To ensure successful policy implementation stakeholders need to receive training on new policies, availability of sufficient supplies of material resources, inclusive decision-making, receive supportive monitoring of policy implementation, and oversight.

Abstract Background Globally, the increasing rate of caesarean section (CS) delivery has become a major public health concern due to its cost, maternal, neonatal, and perinatal risks. In Ghana, the Family Health Division of the Ghana Health Service in 2016 opted to initiate a program to prevent the abuse of CS and identify the factors contributing to its increase in the country. This study aimed to determine the prevalence and factors influencing CS deliveries in the Kintampo Districts of Ghana. Methods The current study used secondary data from the Every Newborn–International Network for the Demographic Evaluation of Populations and their Health (EN-INDEPTH) project in Kintampo, Ghana. The outcome variable for this study is CS delivery. The predictor variables were socio-demographic and obstetric factors. Results The prevalence of CS delivery in the study area was 14.6%. Women with secondary education were 2.6 times more likely to give birth by CS than those with primary education. Unmarried women were about 2.5 times more likely to deliver by CS compared to those who were married. There was an increasing order of CS delivery among women in the wealthy quintiles from poorer to richest. The likelihood of women with gestational ages from 37 to 40 weeks to give birth by CS was about 58% less compared to those with less than 37 gestational weeks. Women who had 4–7 and 8 or more antenatal care (ANC) visits were 1.95 and 3.5 times more likely to deliver by CS compared to those who had less than 4 ANC visits. The odds of women who have had pregnancy loss before to deliver by CS was 68% higher compared to women who have not lost pregnancy before. Conclusions Caesarean section delivery prevalence in the study population was within the Ghana Health Service and World Health Organization ranges. In addition to known socio-demographic and obstetric factors, this study observed that a history of pregnancy loss increased the chances of a woman undergoing a CS. Policies should aim at addressing identified modifiable factors to stem the rise in CS deliveries.

Abstract Background Though anecdotal evidence suggests that smoke from HAP has a repellent effect on mosquitoes, very little work has been done to assess the effect of biomass smoke on malaria infection. The study, therefore, sought to investigate the hypothesis that interventions to reduce household biomass smoke may have an unintended consequence of increasing placental malaria or increase malaria infection in the first year of life. Methods This provides evidence from a randomized controlled trial among 1414 maternal-infant pairs in the Kintampo North and Kintampo South administrative areas of Ghana. Logistic regression was used to assess the association between study intervention assignment (LPG, Biolite or control) and placental malaria. Finally, an extended Cox model was used to assess the association between study interventions and all episodes of malaria parasitaemia in the first year of infant’s life. Results The prevalence of placental malaria was 24.6%. Out of this, 20.8% were acute infections, 18.7% chronic infections and 60.5% past infections. The study found no statistical significant association between the study interventions and all types of placental malaria (OR = 0.88; 95% CI 0.59–1.30). Of the 1165 infants, 44.6% experienced at least one episode of malaria parasitaemia in the first year of life. The incidence of first and/or only episode of malaria parasitaemia was however found to be similar among the study arms. Conclusion The findings suggest that cookstove interventions for pregnant women and infants, when combined with additional malaria prevention strategies, do not lead to an increased risk of malaria among pregnant women and infants.

Abstract Background Haemoglobinopathies such as sickle cell disorder and glucose-6-phosphate dehydrogenase (G6PD) deficiency as well as differences in ABO blood groups have been shown to influence the risk of malaria and/or anaemia in malaria-endemic areas. This study assessed the effect of adding MNP containing iron to home-made weaning meals on anaemia and the risk of malaria in Ghanaian pre-school children with haemoglobinopathies and different ABO blood groups. Methods This study was a double-blind, randomly clustered trial conducted within six months among infants and young children aged 6 to 35 months in rural Ghana (775 clusters, n = 860). Participants were randomly selected into clusters to receive daily semiliquid home-prepared meals mixed with either micronutrient powder without iron (noniron group) or with iron (iron group; 12.5 mg of iron daily) for 5 months. Malaria infection was detected by microscopy, blood haemoglobin (Hb) levels were measured with a HemoCue Hb analyzer, the reversed ABO blood grouping microtube assay was performed, and genotyping was performed by PCR–RFLP analysis. Results The prevalence of G6PD deficiency among the study participants was 11.2%. However, the prevalence of G6PD deficiency in hemizygous males (8.5%) was significantly higher than that in homozygous females (2.7%) (p = 0.005). The prevalence rates of sickle cell traits (HbAS and HbSC) and sickle cell disorder (HbSS) were 17.5% and 0.5%, respectively. Blood group O was dominant (41.4%), followed by blood group A (29.6%) and blood group B (23.3%), while blood group AB (5.7%) had the least frequency among the study participants. We observed that children on an iron supplement with HbAS had significantly moderate anaemia at the endline (EL) compared to the baseline level (BL) (p = 0.004). However, subjects with HbAS and HbAC and blood groups A and O in the iron group had a significantly increased number of malaria episodes at EL than at BL (p

Abstract Background While adolescent suicidal behaviour (ideation, planning, and attempt) remains a global public health concern, available county-specific evidence on the phenomenon from African countries is relatively less than enough. The present study was conducted to estimate the 12-month prevalence and describe some of the associated factors of suicide behaviour among school-going adolescents aged 12–17 years old in Namibia. Methods Participants (n = 4531) answered a self-administered anonymous questionnaire developed and validated for the nationally representative Namibia World Health Organization Global School-based Student Health Survey conducted in 2013. We applied univariate, bivariable, and multivariable statistical approaches to the data. Results Of the 3,152 analytical sample, 20.2% (95% confidence interval [CI]: 18.3–22.2%) reported suicidal ideation, 25.2% (95% CI: 22.3–28.4%) engaged in suicide planning, and 24.5% (95% CI: 20.9–28.6%) attempted suicide during the previous 12 months. Of those who attempted suicide, 14.6% (95% CI: 12.5–16.9%) reported one-time suicide attempt, and 9.9% (95% CI: 8.1–12.1%) attempted suicide at least twice in the previous 12 months. The final adjusted multivariable models showed physical attack victimisation, bullying victimisation, loneliness, and parental intrusion of privacy as key factors associated with increased likelihood of suicidal ideation, planning, one-time suicide attempt, and repeated attempted suicide. Cannabis use showed the strongest association with increased relative risk of repeated attempted suicide. Conclusion The evidence highlights the importance of paying more attention to addressing the mental health needs (including those related to psychological and social wellness) of school-going adolescents in Namibia. While the current study suggests that further research is warranted to explicate the pathways to adolescent suicide in Namibia, identifying and understanding the correlates (at the individual-level, family-level, interpersonal-level, school context and the broader community context) of adolescent suicidal ideations and non-fatal suicidal behaviours are useful for intervention and prevention programmes.

Introduction The RTS,S vaccine has been approved for use in children under 5 living in moderate to high malaria transmission areas. However, clinically important adverse events have been reported in countries in sub-Saharan Africa. This systematic review aims to assess the frequency, severity and clinical importance of vaccine-related adverse events.Methods and analysis This systematic review protocol has been prepared following robust methods and reported in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses for protocols guidelines. We will search PubMed, CINAHL, LILACS, Google Scholar, SCOPUS, WEB OF SCIENCE, Cochrane library, HINARI, African Journals Online, Trip Pro and TOXNET from 2000 to 30 September 2023, without language restrictions. We will also search conference proceedings, dissertations, World Bank Open Knowledge Repository, and WHO, PATH, UNICEF, Food and Drugs Authorities and European Medicines Agency databases, preprint repositories and reference lists of relevant studies for additional studies. Experts in the field will be contacted for unpublished or published studies missed by our searches. At least two reviewers will independently select studies and extract data using pretested tools and assess risk of bias in the included studies using the Cochrane risk of bias tool. Any disagreements will be resolved through discussion between the reviewers. Heterogeneity will be explored graphically, and statistically using the I2 statistic. We will conduct random-effects meta-analysis when heterogeneity is appreciable, and express dichotomous outcomes (serious adverse events, cerebral malaria and febrile convulsion) as risk ratio (RR) with their 95% CI. We will perform subgroup analysis to assess the impact of heterogeneity and sensitivity analyses to test the robustness of the effect estimates. The overall level of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation.Ethics and dissemination Ethical approval is not required for a systematic review. The findings of this study will be disseminated through stakeholder forums, conferences and peer-review publications.PROSPERO registration number CRD42021275155.

A major part of Ghana’s current household energy policy is focused on using a branded cylinder recirculation model (BCRM) to promote the safe use of Liquefied Petroleum Gas (LPG) for primary cooking. The implementation of the BCRM is expected to increase LPG adoption by households to the announced policy goal of 50% of the population by 2030. We investigated the impact of the COVID-19 pandemic on the implementation of the BCRM, availability, and household use of cleaner fuels. This was assessed using existing data on clean fuel use prior to the COVID-19 pandemic. Additional data was collected using questionnaire-based household surveys and qualitative interviews. It was found that the expansion of BCRM was significantly impacted by the COVID-19 pandemic. Planning activities such as baseline data collection and stakeholder engagement were delayed due to the COVID-19 restrictions. Changes in household incomes during the pandemic had the biggest percentage effect on household choice of cooking fuel, causing a regression in some cases, to polluting fuel use. This study provides insights that could be valuable in future understanding of the interactions between pandemic control measures and economic disruptions that may affect household energy choices for cooking.

Abstract 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.

IntroductionThe correct and consistent use of hormonal contraceptive (HC) methods by sexually active adolescent girls can prevent pregnancy and avert the health and social consequences of unwanted pregnancy for both the mother and her child. Despite these benefits, research shows that HC use is rather low among adolescent girls globally and especially among those in low and middle-income countries. This study was carried out to assess the social-psychological determinants of HC use intentions among adolescent girls and young women.MethodsA cross-sectional survey was conducted among 1,203 young women aged 15–24 years from 70 communities within the Kintampo North Municipality and Kintampo South District in the Bono-East Region of Ghana from April 2021 to September 2021. Multiple linear regression analysis was used to identify factors associated with the intention to use HC among the entire sample of 1,203 respondents and among two sub-samples of young women based on HC use experience.ResultsAttitude toward personal HC use (β = 0.268; p

Background: Prenatal household air pollution impairs birth weight and increases pneumonia risk however time-varying associations have not been elucidated and may have implications for the timing of public health interventions. Methods: The Ghana Randomized Air Pollution and Health Study (GRAPHS) enrolled 1,414 pregnant women from Kintampo, Ghana and measured personal carbon monoxide (CO) exposure four times over pregnancy. Birth weight was measured within 72-hours of birth. Fieldworkers performed weekly pneumonia surveillance and referred sick children to study physicians. The primary pneumonia outcome was one or more physician-diagnosed severe pneumonia episode in the first year of life. We employed reverse distributed lag models to examine time-varying associations between prenatal CO exposure and birth weight and infant pneumonia risk. Results: Analyses included n = 1,196 mother-infant pairs. In models adjusting for child sex; maternal age, body mass index (BMI), ethnicity and parity at enrollment; household wealth index; number of antenatal visits; and evidence of placental malaria, prenatal CO exposures from 15 to 20 weeks gestation were inversely associated with birth weight. Sex-stratified models identified a similar sensitive window in males and a window at 10-weeks gestation in females. In models adjusting for child sex, maternal age, BMI and ethnicity, household wealth index, gestational age at delivery and average postnatal child CO exposure, CO exposure during 34–39 weeks gestation were positively associated with severe pneumonia risk, especially in females. Conclusions: Household air pollution exposures in mid- and late- gestation are associated with lower birth weight and higher pneumonia risk, respectively. These findings support the urgent need for deployment of clean fuel stove interventions beginning in early pregnancy.

Background: Africa faces diverse and complex population/human health challenges due to climate change. Understanding the health impacts of climate change in Africa in all its complexity is essential for implementing effective strategies and policies to mitigate risks and protect vulnerable populations. This study aimed to outline the major climate change-related health impacts in Africa in the context of economic resilience and to seek solutions and provide strategies to prevent or reduce adverse effects of climate change on human health and well-being in Africa. Methods: For this narrative review, a literature search was conducted in the Web of Science, Scopus, CAB Abstracts, MEDLINE and EMBASE electronic databases. We also searched the reference lists of retrieved articles for additional records as well as reports. We followed a conceptual framework to ensure all aspects of climate change and health impacts in Africa were identified. Results: The average temperatures in all six eco-regions of Africa have risen since the early twentieth century, and heat exposure, extreme events, and sea level rise are projected to disproportionately affect Africa, resulting in a larger burden of health impacts than other continents. Given that climate change already poses substantial challenges to African health and well-being, this will necessitate significant effort, financial investment, and dedication to climate change mitigation and adaptation. This review offers African leaders and decision-makers data-driven and action-oriented strategies that will ensure a more resilient healthcare system and safe, healthy populations—in ways that contribute to economic resiliency. Conclusions: The urgency of climate-health action integrated with sustainable development in Africa cannot be overstated, given the multiple economic gains from reducing current impacts and projected risks of climate change on the continent’s population health and well-being. Climate action must be integrated into Africa’s development plan to meet the Sustainable Development Goals, protect vulnerable populations from the detrimental effects of climate change, and promote economic development.

Abstract Background Malaria infection during pregnancy can cause significant morbidity and mortality to a pregnant woman, her fetus and newborn. In areas of high endemic transmission, gravidity is an important risk factor for infection, but there is a complex relationship with other exposure-related factors, and use of protective measures. This study investigated the association between gravidity and placental malaria (PM), among pregnant women aged 14–49 in Kintampo, a high transmission area of Ghana. Methods Between 2008 and 2011, as part of a study investigating the association between PM and malaria in infancy, pregnant women attending antenatal care (ANC) clinics in the study area were enrolled and followed up until delivery. The outcome of PM was assessed at delivery by placental histopathology. Multivariable logistic regression analyses were used to investigate the association between gravidity and PM, identify other key risk factors, and control for potential confounders. Pre-specified effect modifiers including area of residence, socio-economic score (SES), ITN use and IPTp-SP use were explored. Results The prevalence of PM was 65.9% in primigravidae, and 26.5% in multigravidae. After adjusting for age, SES and relationship status, primigravidae were shown to have over three times the odds of PM compared to multigravidae, defined as women with 2 or more previous pregnancies [adjusted OR = 3.36 (95% CI 2.39–4.71), N = 1808, P

ABSTRACT: Objectives: Inappropriate antibiotic dispensing is one of the key drivers of antibiotic resistance. This review documents the effectiveness of interventions aimed at improving antibiotic dispensing practices at the community level by drug dispensers in low- and middle-income countries (LMIC). Methods: We conducted a systematic search in PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science (11 November 2019). Studies were included if they reported data on the outcome measure: appropriate dispensing of medicine including antibiotics. The effectiveness of studies was assessed based on quantitative results reported in the studies included. Results: A total of 1158 articles were screened. Thirteen studies from Asia (six), Africa (five) and South America (one) and one study from both Africa and Asia were included in this review. Nine (69.2%) studies reported significant effectiveness of interventions on all or more than 50% of antibiotic-related outcomes. Cochrane Effective Practice and Organization of Care interventions frequently applied were educational meetings (9/13), distribution of educational materials (7/13), educational outreach meetings (7/13), reminders (6/13), local consensus processes (6/13), distribution of supplies (6/14) and clinical practice guidelines (4/14), Nine studies reported on stakeholder involvement. Conclusion: This review shows that it is possible to improve antibiotic dispensing practices at the community level in LMIC. Stakeholders’ involvement was key in the design and implementation of interventions.

Abstract Background Unintentional injuries among adolescents constitute a significant public health problem globally. Injured adolescents may face negative outcomes ranging from poor academic performance to short- and long-term physical and psychosocial health struggles, and even death. The aim of this study was to estimate the prevalence and describe the correlates and most frequent causes of injuries among school-going adolescents in three West African countries – Benin, Ghana, and Liberia. Methods We analysed self-reported data provided by 8,912 school-going adolescents who participated in the Global School-based Student Health Survey in Ghana (2012), Benin (2016), and Liberia (2017). Students responded to questions on sociodemographic factors, family involvement factors, mental health factors, school environment factors and injury behaviours. Results The overall 12-month prevalence estimate of serious injuries in adolescents was 40.9% (Benin = 27.3%; Ghana = 46.1%; Liberia = 49.2%). The most frequently reported injury type was a broken bone or dislocated joint (33% in Benin), cuts or stab wounds (31.7% in Ghana), and non-specified injuries (35.2% in Liberia). Prevalence of serious injuries was higher among males and increased with age. In the multivariable logistic regression analysis, interpersonal aggression outside the family context (bullying victimisation, engaging in physical fights, and having been physically attacked) emerged as key correlates of increased odds of serious injuries. Conclusion The relatively higher prevalence estimates of serious injury reported in this study underscore the need for the included countries to develop interventions aimed at reducing and preventing physical injuries among adolescents.

In this genomic epidemiology study from Ghana, the authors sequence ~1,000 SARS-CoV-2 whole genomes from March 2020 to September 2021. They describe changes in the predominant circulating lineages over time and infer how variants of concern were likely introduced into the country.

Abstract Background In 2019, the RTS,S/AS01E malaria vaccine was introduced on a pilot basis in six regions of Ghana by the Ministry of Health/Ghana Health Service as part of the WHO-coordinated Malaria Vaccine Implementation Programme (MVIP). This is the first time a malaria vaccination programme has been implemented in any country. This paper describes the challenges faced, and lessons learned, during the planning and early implementation of the RTS,S/AS01E vaccine in three out of the six regions that implemented the programme in Ghana. Methods Twenty-one in-depth interviews were conducted with regional and district health service managers and frontline health workers three months after the start of MVIP in May 2019. Data were coded using NVivo software version 12 and a coding framework was developed to support thematic analysis to identify the challenges and lessons learned during the RTS,S/AS01E implementation pilot, which were also categorized into the Consolidated Framework for Implementation Research (CFIR). Results Participants reported challenges related to the characteristics of the intervention, such as issues with the vaccine schedule and eligibility criteria, and challenges related to how it was implemented as a pilot programme. Additionally, major challenges were faced due to the spread of rumours leading to vaccine refusals; thus, the outer setting of the CFIR was adapted to accommodate rumours within the community context. Health service managers and frontline health workers also experienced challenges with the process of implementing RTS,S/AS01E, including inadequate sensitization and training, as well as issues with the timeline. They also experienced challenges associated with the features of the systems within which the vaccine was being implemented, including inadequate resources for cold-chain at the health facility level and transportation at the district and health facility levels. This study identified the need for a longer, more intensive and sustained delivery of contextually-appropriate sensitization prior to implementation of a programme such as MVIP. Conclusions This study identified 12 main challenges and lessons learned by health service managers and health workers during the planning and early implementation phases of the RTS,S/AS01E pilot introduction in Ghana. These findings are highly relevant to the likely scale-up of RTS,S/AS01E within Ghana and possible implementation in other African countries, as well as to other future introductions of novel vaccines.

Abstract Background Following a 30-year development process, RTS,S/AS01E (GSK, Belgium) is the first malaria vaccine to reach Phase IV assessments. The World Health Organization-commissioned Malaria Vaccine Implementation Programme (MVIP) is coordinating the delivery of RTS,S/AS01E through routine national immunization programmes in areas of 3 countries in sub-Saharan Africa. The first doses were given in the participating MVIP areas in Malawi on 23 April, Ghana on 30 April, and Kenya on 13 September 2019. The countries participating in the MVIP have little or no baseline incidence data on rare diseases, some of which may be associated with immunization, a deficit that could compromise the interpretation of possible adverse events reported following the introduction of a new vaccine in the paediatric population. Further, effects of vaccination on malaria transmission, existing malaria control strategies, and possible vaccine-mediated selective pressure on Plasmodium falciparum variants, could also impact long-term malaria control. To address this data gap and as part of its post-approval commitments, GSK has developed a post-approval plan comprising of 4 complementary Phase IV studies that will evaluate safety, effectiveness and impact of RTS,S/AS01E through active participant follow-up in the context of its real-life implementation. Methods EPI-MAL-002 (NCT02374450) is a pre-implementation safety surveillance study that is establishing the background incidence rates of protocol-defined adverse events of special interest. EPI-MAL-003 (NCT03855995) is an identically designed post-implementation safety and vaccine impact study. EPI-MAL-005 (NCT02251704) is a cross-sectional pre- and post-implementation study to measure malaria transmission intensity and monitor the use of other malaria control interventions in the study areas, and EPI-MAL-010 (EUPAS42948) will evaluate the P. falciparum genetic diversity in the periods before and after vaccine implementation. Conclusion GSK’s post-approval plan has been designed to address important knowledge gaps in RTS,S/AS01E vaccine safety, effectiveness and impact. The studies are currently being conducted in the MVIP areas. Their implementation has provided opportunities and posed challenges linked to conducting large studies in regions where healthcare infrastructure is limited. The results from these studies will support ongoing evaluation of RTS,S/AS01E’s benefit-risk and inform decision-making for its potential wider implementation across sub-Saharan Africa. Graphic abstract

Abstract Background Antibiotic consumption is increasing worldwide, particularly in low and middle-income countries (LMICs). Access to lifesaving antibiotics in LMICs is crucial while minimising inappropriate use. Studies assessing the economic impact of inappropriate antibiotic use in LMICs are lacking. We explored the economic impact of inappropriate antibiotic use using the example of upper respiratory tract infections (URIs) in Ghana, as part of the ABACUS (AntiBiotic ACcess and USe) project. Methods A top-down, retrospective economic impact analysis of inappropriate antibiotic use for URIs was conducted. Two inappropriate antibiotic use situations were considered: (1) URIs treated with antibiotics, against recommendations from clinical guidelines; and (2) URIs that should have been treated with antibiotics according to clinical guidelines, but were not. The analysis included data collected in Ghana during the ABACUS project (household surveys and exit-interviews among consumers buying antibiotics), scientific literature and stakeholder consultations. Included cost types related to health care seeking behaviour for URIs. Additionally, cost saving projections were computed based on potential effects of future interventions that improve antibiotic use. Results Health care costs related to inappropriate antibiotic use for URIs were estimated to be around 20 million (M) USD annually, including 18 M USD for situation 1 and 2 M USD for situation 2. Travel costs and lost income due to travel, together, were estimated to be around 44 M USD for situation 1 and 18 M USD for situation 2. Possible health care cost savings range from 2 to 12 M USD for situation 1 and from 0.2 to 1 M USD for situation 2. Conclusions This study indicates that inappropriate antibiotic use leads to substantial economic costs in a LMIC setting that could have been prevented. We recommend investment in novel strategies to counter these unnecessary expenditures. As the projections indicate, this may result in considerable cost reductions. By tackling inappropriate use, progress can be made in combatting antibiotic resistance.

The recording of antimicrobial use data is critical for the development of interventions for the containment of antimicrobial resistance. This cross-sectional study assessed whether dissemination activities and recommendations made after an operational research (OR) study in 2021 resulted in better data recording and improved the use of antimicrobials in a rural veterinary clinic. Routinely collected data from treatment record books were compared between 2013 and 2019 (pre-OR) and from July 2021 to April 2023 (post-OR). The most common animals presenting for care in the the pre – and post OR periods were dogs (369 and 206, respectively). Overall, antimicrobial use in animals increased from 53% to 77% between the two periods. Tetracycline was the most commonly used antimicrobial (99%) during the pre-OR period, while Penicillin-Streptomycin was the most commonly used antimicrobial (65%) during the post-OR period. All animals that received care at the clinic were documented in the register during both periods. Whereas the diagnosis was documented in 269 (90%) animals in the post-OR period compared to 242 (47%) in the pre-OR period, the routes and dosages were not adequately recorded during the both periods. Therefore, the quality of data recording was still deficient despite the dissemination and the recommendations made to some key stakeholders. Recommendations are made for a standardized antimicrobial reporting tool, refresher training, and continuous supervisory visits to the clinic.

BackgroundSub-Saharan Africa faces prolonged COVID-19 related impacts on economic activity, livelihoods and nutrition, with recovery slowed down by lagging vaccination progress.ObjectiveThis study investigated the economic impacts of COVID-19 on food prices, consumption and dietary quality in Burkina Faso, Ethiopia, Ghana, Nigeria, and Tanzania.MethodsWe conducted a repeated cross-sectional study using a mobile platform to collect data from July-December, 2021 (round 2). We assessed participants' dietary intake of 20 food groups over the previous seven days and computed the primary outcome, the Prime Diet Quality Score (PDQS), and Dietary Diversity Score (DDS), with higher scores indicating better quality diets. We used generalized estimating equation (GEE) linear regression models to assess factors associated with diet quality during COVID-19.ResultsMost of the respondents were male and the mean age was 42.4 (±12.5) years. Mean PDQS (±SD) was low at 19.4(±3.8), out of a maximum score of 40 in this study. Respondents (80%) reported higher than expected prices for all food groups. Secondary education or higher (estimate: 0.73, 95% CI: 0.32, 1.15), medium wealth status (estimate: 0.48, 95% CI: 0.14, 0.81), and older age were associated with higher PDQS. Farmers and casual laborers (estimate: -0.60, 95% CI: -1.11, -0.09), lower crop production (estimate: -0.87, 95% CI: -1.28, -0.46) and not engaged in farming (estimate: -1.38, 95% CI: -1.74, -1.02) were associated with lower PDQS.ConclusionHigher food prices and lower diet quality persisted during the COVID-19 pandemic. Economic and social vulnerability and reliance on markets (and lower agriculture production) were negatively associated with diet quality. Although recovery was evident, consumption of healthy diets remained low. Systematic efforts to address the underlying causes of poor diet quality through transforming food system value chains, and mitigation measures, including social protection programs and national policies are critical.

Guidance on contextually tailored implementation strategies for the prevention, treatment, and control of hypertension is limited in lower-middle income countries (Lower-MIC). To address this limitation, we compiled implementation strategies and accompanying outcomes of evidence-based hypertension interventions currently being implemented in five Lower-MIC. The Global Research on Implementation and Translation Science (GRIT) Coordinating Center (CC) (GRIT-CC) engaged its global network sites at Ghana, Guatemala, India, Kenya, and Vietnam. Purposively sampled implementation science experts completed an electronic survey assessing implementation outcomes, in addition to implementation strategies used in their ongoing hypertension interventions from among 73 strategies within the Expert Recommendations for Implementing Change (ERIC). Experts rated the strategies based on highest priority to their interventions. We analyzed the data by sorting implementation strategies utilized by sites into one of the nine domains in ERIC and summarized the data using frequencies, proportions, and means. Seventeen implementation experts (52.9% men) participated in the exercise. Of Proctor's implementation outcomes identified across sites, all outcomes except for appropriateness were broadly assessed by three or more countries. Overall, 59 out of 73 (81%) strategies were being utilized in the five countries. The highest priority implementation strategies utilized across all five countries focused on evaluative and iterative strategies (e.g., identification of context specific barriers and facilitators) to delivery of patient- and community-level interventions, while the lowest priority was use of financial and infrastructure change strategies. More capacity building strategies (developing stakeholder interrelationships, training and educating stakeholders, and supporting clinicians) were incorporated into interventions implemented in India and Vietnam than Ghana, Kenya, and Guatemala. Although robust implementation strategies are being used in Lower -MICs, there is minimum use of financial and infrastructure change strategies. Our study contributes to the growing literature that demonstrates the use of Expert Recommendations for Implementing Change (ERIC) implementation strategies to deliver evidence-based hypertension interventions in Lower-MICs and will inform future cross-country data harmonization activities in resource-constrained settings.

Background:. Supermicrosurgery has allowed the replantation/revascularization of the pulp, but how does this currently compare with more proximal digit replantation/revascularization? Methods:. In a retrospective case study over a 5-year period at our institute, a total of 21 patients (n = 21) had either finger or pulp replantation-revascularization posttrauma. All pulp replants had a single-vessel anastomosis viz., “artery-to-artery” or “artery-to-vein” only, with venous outflow dependent on the skin-shave technique, while more proximal replants had both arterial and venous anastomoses. Age, sex, ischemic time, handedness, smoker status, and injury-replant interval were compared between the two groups, with all procedures performed by a single surgeon. The outcome parameters studied were length of hospital stay, timeline for wound healing, viability, and functional outcomes. Results:. Our patients consisted of 18 men and three women, of which 14.3% were smokers and 85.7% were right-handed. There were 11 finger replantation/revascularizations (n = 11) versus 10 pulp replantation/revascularizations (n = 10). The average age of digit replantation/revascularization patients was 44.8 years compared with 26.4 years in pulp replantation/revascularization patients (Student t test, P = 0.04). Mean ischemia time in digital replants was 67 minutes versus 32.3 minutes in pulp replantation/revascularization (Student t test, P = 0.056). Digital replantation/revascularization was viable in 72% of cases versus a 90% viability in the pulp subcohort. Conclusions:. In our patient cohort, pulp replantation/revascularizations produced better postoperative viability. Where supermicrosurgery expertise is available, pulp replantation/revascularization should be considered a worthwhile option when compared with digital replantation/revascularization.

Background: Human existence is being challenged by an outbreak of coronavirus disease 2019 (COVID-19) caused by the virus SARS-CoV-2 that began in Wuhan, China in December 2019. Efforts to avoid the spread of COVID-19 are undermined by the appearance of disease-associated avoidance of infected persons due to reasons such as social stigma and discrimination. Objective: This study seeks to investigate avoidance and discrimination against persons suspected of COVID-19 in a predominantly rural setting in Ghana. Methods: The study is a cross-sectional survey. A random sample of 517 individuals drawn from a health and demographic surveillance system database was used for this study. Participants resided in six contiguous districts and municipalities of predominantly rural setting in the Bono East Region of Ghana. Results: The findings showed that majority (60%) of the respondents agreed that they won’t have anything to do with someone suspected of COVID-19. However, 67% of them were willing to accommodate persons that recovered from the infection. Majority (91%) of respondents agreed that there is a need to adopt tolerant attitude towards persons who recovered from the infection, whilst another 98% also reported the need to show compassion towards persons who recovered from COVID-19. Conclusion: There is a high-level avoidance of persons suspected of COVID-19, but little or no discrimination of those who recovered from the infection.

Background: A positive relationship between a healthcare provider (HCP) and a patient is likely to build trust and improve care for People Living with HIV (PLWH). The study explored the individual and external factors influencing HCP behaviour towards PLWH and compares HCP in antiretroviral therapy clinics (AHCP) with general health care settings HCP (GHCP). Methods: This qualitative study used a semi-structured interview protocol to guide individual in-depth interviews among 33 HCPs. The interview protocol was informed by empirical literature and included topics such as perceptions and experiences working with PLWH, HIV-related training received, knowledge about HIV, emotions towards PLWH and support related to patient care. The interview data were thematically analysed. Results: Both AHCP and GHCP claimed that their thoughts and judgments never influenced the way they managed PLWH, but there appears to be reflections of either sympathy or positive discrimination, especially for AHCP, or stigmatizing behaviours such as using gloves for PLWH-only among GHCP. The findings from this study suggest that individual factors such as perceptions about HIV, attitude towards HIV patients, different emotions, HIV-related training received and external factors such as availability of guidelines, logistics, infrastructural and reimbursement challenges influenced HCP behaviour towards PLWH. Conclusion: The study suggests that individual and external factors influence AHCP and GHCP behaviour towards PLWH. We recommend the use of Intervention Mapping to develop and evaluate interventions addressing the behaviour and emotions of AHCPs and GHCPs to reduce stigmatization of PLWH in the healthcare sector, hence improving hospital visits and medication adherence.

Abstract Background Ghana is facing the public health “double burden” of both communicable and chronic diseases. To combat increased chronic disease prevalence, physical activity promotion efforts are necessary. The Ministry of Health (MOH) developed physical activity guidelines in 2009, but community members are unaware of the guidelines and sample activities (e.g., ballroom dancing) are not culturally appropriate. The purposes of this study were to investigate 1) dissemination of the physical activity guidelines through MOH and Ghana Health Service (GHS) and 2) culturally appropriate physical activities. Methods Data were collected in urban and rural areas of Ghana through focus groups (N = 2) with community representatives and in-depth interviews (N = 15) with GHS health workers. Focus group and interview questions included recommended types of physical activity; interview questions included dissemination factors based on Diffusion of Innovations. The research team analyzed the data through an inductive, grounded theory approach. Results Together, the focus groups and in-depth interviews generated 942 meaning units coded into themes of Physical Activity Perceptions (N = 337 meaning units), Suggested Physical Activities (N = 317), and Dissemination and Implementation Factors (N = 290). Participants had positive perceptions of physical activity but expressed concerns over individual abilities; barriers included the built environment and a lack of time. Suggested physical activities included walking, jogging, football, and dancing for adults; traditional games and football for youth, and walking and daily chores for older adults. Participants noted that guideline implementation was influenced by leadership engagement at multiple levels, relative advantage, and compatibility. Respondents suggested implementation strategies to resolve barriers, including involving partner organizations and developing an implementation plan. Participants were largely unaware of the physical activity guidelines; typical dissemination methods included written materials and the internet. Conclusions The results of this study suggest that physical activity guidelines should include familiar physical activities such as traditional games. Results also suggest that public health workers within GHS experience challenges in disseminating the physical activity guidelines. Adapting, disseminating, and implementing physical activity guidelines is a necessary step in increasing physical activity levels and preventing chronic diseases. These results contribute to understanding translation of physical activity policy to practice.

Abstract Background The novel anti-malarial cipargamin (KAE609) has potent, rapid activity against Plasmodium falciparum. Transient asymptomatic liver function test elevations were previously observed in cipargamin-treated subjects in two trials: one in malaria patients in Asia and one in volunteers with experimentally induced malaria. In this study, the hepatic safety of cipargamin given as single doses of 10 to 150 mg and 10 to 50 mg once daily for 3 days was assessed. Efficacy results, frequency of treatment-emerging mutations in the atp4 gene and pharmacokinetics have been published elsewhere. Further, the R561H mutation in the k13 gene, which confers artemisinin-resistance, was associated with delayed parasite clearance following treatment with artemether–lumefantrine in Rwanda in this study. This was also the first study with cipargamin to be conducted in patients in sub-Saharan Africa. Methods This was a Phase II, multicentre, randomized, open-label, dose-escalation trial in adults with uncomplicated falciparum malaria in five sub-Saharan countries, using artemether–lumefantrine as control. The primary endpoint was ≥ 2 Common Terminology Criteria for Adverse Events (CTCAE) Grade increase from baseline in alanine aminotransferase (ALT) or aspartate transaminase (AST) during the 4-week trial. Results Overall, 2/135 patients treated with cipargamin had ≥ 2 CTCAE Grade increases from baseline in ALT or AST compared to 2/51 artemether–lumefantrine patients, with no significant difference between any cipargamin treatment group and the control group. Cipargamin exposure was comparable to or higher than those in previous studies. Hepatic adverse events and general safety and tolerability were similar for all cipargamin doses and artemether–lumefantrine. Cipargamin was well tolerated with no safety concerns. Conclusions This active-controlled, dose escalation study was a detailed assessment of the hepatic safety of cipargamin, across a wide range of doses, in patients with uncomplicated falciparum malaria. Comparison with previous cipargamin trials requires caution as no clear conclusion can be drawn as to whether hepatic safety and potential immunity to malaria would differ with ethnicity, patient age and or geography. Previous concerns regarding hepatic safety may have been confounded by factors including malaria itself, whether natural or experimental infection, and should not limit the further development of cipargamin. Trial registration ClinicalTrials.gov number: NCT03334747 (7 Nov 2017), other study ID CKAE609A2202

AbstractThis study examined the socio-economic, physical and health-related determinants of causes of death among women of reproductive age (WRA) in the Kintampo North Municipality and Kintampo South District of Ghana. Longitudinal data from the Kintampo Health and Demographic Surveillance System (HDSS) was used. Causes of death data from 2005 to 2014 for 846 WRA aged 15–49 were categorized into three broad groups: maternal, infectious and non-communicable diseases. Three hierarchical multinomial logistic regression models were used to examine the determinants of causes of death, with the maternal causes of death as the reference category. Distal, intermediate and proximate factors were entered cumulatively one after the other in Models 1, 2 and 3, respectively, to account for their separate effects on the outcome variable. Across all three models, ever-married (RRR = 0.12; p

Objective: Over 900 million people in sub-Saharan Africa (SSA) live in energy poverty, relying on cooking polluting fuels (e.g. wood, charcoal). The association between energy poverty and mental/physical health-related quality of life (HRQoL) among women in SSA, who are primarily tasked with cooking, is unknown. Methods: Females (n ​= ​1,150) from peri-urban Cameroon, Kenya and Ghana were surveyed on their household energy use and mental/physical health status using the standardized Short-Form 36 (SF-36) questionnaire. Random effects linear regression linked household energy factors to SF-36 mental (MCS) and physical component summary (PCS) scores. A binary outcome of ‘likely depression’ was derived based on participants' MCS score. Random effects Poisson regression with robust error variance assessed the relationship between household energy factors and odds of likely depression. Results: The prevalence of likely depression varied by a factor of four among communities (36%-Mbalmayo, Cameroon; 20%-Eldoret, Kenya; 9%-Obuasi, Ghana). In the Poisson model (coefficient of determination (R2) ​= ​0.28), females sustaining 2 or more cooking-related burns during the previous year had 2.7 (95%CI:[1.8,4.1]) times the odds of likely depression as those not burned. Females cooking primarily with charcoal and wood had 1.6 times (95%CI:[0.9,2.7]) and 1.5 times (95%CI:[0.8,3.0]) the odds of likely depression, respectively, as those primarily using liquefied petroleum gas. Women without electricity access had 1.4 (95%CI:[1.1,1.9]) times the odds of likely depression as those with access. In the MCS model (R2 ​= ​0.23), longer time spent cooking was associated with a lower average MCS score in a monotonically increasing manner. In the PCS model (R2 ​= ​0.32), women injured during cooking fuel collection had significantly lower (−4.8 95%CI:[-8.1,-1.4]) PCS scores. Conclusion: The burden of energy poverty in peri-urban communities in SSA extends beyond physical conditions. Experiencing cooking-related burns, using polluting fuels for cooking or lighting and spending more time cooking are potential risk factors for lower mental HRQoL among women.

Background: 76% of the population in Ghana uses solid fuels as their primary source of cooking energy, including 41.3% firewood and 31.5% charcoal. Consequently, household air pollution (HAP) continues to be the leading risk factor for the majority of illness burden in the country. In the past, aggressive LPG distribution and adoption schemes have been implemented to reduce HAP in Ghana. Nevertheless, just 22% of Ghanaian households utilize LPG for cooking. Aims: The purpose of this study was to determine the viability and acceptability of four clean fuels among rural households in central Ghana, both separately and in combination. Methods: Quantitative and qualitative methods were used to conduct this study. The Kintampo Health Demographic Surveillance System was used to randomly pick ten homes who exclusively utilized biomass fuel. For each family (n = 10), we gave four stove and fuel combinations that were both clean. The stoves were utilized for two weeks, and free fuel was supplied. After each two-week trial period, interviews were conducted to gauge stove acceptance, with an emphasis on finding the specific energy requirements that each stove satisfied. Conclusions: LPG and ethanol stoves were the most popular among rural families, according to our data. In comparison to Mimi Moto and electric induction stoves, the two stoves were favoured because they were easier to use and clean, cooked faster, were deemed safer, and enabled a variety of cooking styles. Participants’ stove preferences appear to be primarily influenced by two domains: 1) realizing the benefits of clean stove technology and 2) overcoming early anxiety of clean stove use, particularly LPG.

Introduction Assessing mental health literacy has implications for the identification and treatment of mental health problems. Adolescents have been identified as a particularly important target group for initiating and improving mental health literacy. However, much of what we know about adolescent mental health literacy comes from high-income countries. This proposed review seeks to synthesise the available published primary evidence from sub-Saharan Africa on the status and measurement of mental health literacy among school-going adolescents.Methods and analysis We will perform a systematic review reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA-2020). We will systematically search selected global databases (EMBASE, PsycINFO, PubMed and MEDLINE) and regional electronic databases (African Index Medicus and African Journals OnLine) up to December 2021 for observational and qualitative studies published in English and French. The standard quality assessment criteria for evaluating primary research papers from a variety of fields (QualSyst criteria) will be used to appraise the methodological quality of the included studies. The Petticrew-Roberts 3-step approach to narrative synthesis will be applied to the included studies.Ethics and dissemination We will not seek ethical approval from an institutional review board, as this is a systematic review of available and accessible literature. When completed, the full report of this review will be submitted to a journal for peer-reviewed publication; the key findings will be presented at local and international conferences with—partial or full—focus on (adolescent) mental health (literacy).PROSPERO registration number CRD42021229011.

Abstract Background In sub-Saharan Africa, most government mental health facilities are under-resourced to cater for the mental health needs of the population, including the provision of treatment and recovery support services for persons with substance use disorders (SUDs). However, in other settings, non-governmental organizations (NGOs) play significant roles by complementing governments’ efforts in the provision of care for vulnerable groups. Presently, no study exists that examines the contributions of NGOs in the recovery support of individuals with SUDs in the Ghanaian context. This study sets out to explore the role of NGOs in the recovery of persons with SUDs in Ghana. Method Using a descriptive qualitative design, eight staff (directors and senior recovery practitioners) from eight NGOs in southern Ghana were purposively selected and interviewed face-to-face using semi-structured interview guide. The interviews were audio-taped, transcribed verbatim, and analyzed using the thematic analysis within an inductive approach. Results The results showed that NGOs provide three main services: treatment of drug addiction (through psychotherapy and recovery capital), re-integration of recovered individuals into society, and advocacy and awareness creation in schools and communities. These efforts are thwarted by limited qualified professionals and inadequate government support. Conclusion Our results underscore the need for government agencies to collaborate with NGOs involved in the recovery management of persons with SUDs and other mental disorders to complement their efforts in strategizing, designing, and implementing context-appropriate substance misuse prevention and intervention programs and policies in Ghana.

Abstract Background Understanding why some infants tolerate infections, remaining asymptomatic while others succumb to repeated symptomatic malaria is beneficial for studies of naturally acquired immunity and can guide control interventions. This study compared demographic, host and maternal factors associated with being either parasite negative or having asymptomatic infections versus developing symptomatic malaria in the first year of life. Methods A birth cohort (n = 1264) was monitored longitudinally over two years for malaria infections in Kintampo, Ghana. Symptomatic and asymptomatic infections were detected actively through monthly home visits, complemented by passive case detection. Light microscopy was used to detect parasitaemia. Based on data from a minimum of eight monthly visits within the first year of life, infants were classified into one of four groups: “parasite negative”, “only-asymptomatic”, “only-symptomatic” or “alternating” i.e., sometimes symptomatic and other times asymptomatic. The host and maternal characteristics and demographic factors in relation to these four groups were compared. Results The parasite negative group formed 36% of the cohort, whilst the only-symptomatic were 35%. The alternating group were 22% and the only-asymptomatic were 7% of the cohort. There were significant associations between residence, socio-economic status (SES), parity, IPTp doses, delivery place of infant and having or not having malaria parasites. Maternal factors such as early commencement and frequency of ante-natal care (ANC) were significantly higher in the parasite negative group compared to all others. ITN use in pregnancy increased the odds of infant having only asymptomatic infections (“protected against disease”). Placental malaria was more common in the groups of infants with symptomatic malaria. Urban residence was significantly higher in the parasite negative group, while birth in the malaria transmission season were significantly more common in the alternating and parasite negative groups. Risk factors for infants with symptomatic malaria included low SES, birth in private maternity homes, sickle cell normal variant, lower MUAC, reported intake of anti-malarials and increased morbidity before the first microscopic infection was detected. Conclusion Strengthening ANC by encouraging early and regular attendance, the use of IPTp, maternal bed nets and improving the nourishment of infants help reduce the frequency of symptomatic malaria over the first year of life.

Abstract Background Prevalence among adolescents with mental disorders are about 20% worldwide. In 2012, Ghana enacted the Mental Health Act, Act 846 to regulate mental health care, but did not include specific programmatic details of service provision nor any measurable indicators for adolescent mental health. Currently no service programmes focused on adolescents and no aggregated data exists documenting prevalence of mental and neurological disorders among adolescents. In the Brong Ahafo region, mental health providers carry out simultaneous programmes to diagnose, treat, and counsel patients. There is a need to investigate how these service programmes are currently functioning as measured by World Health Organisation guidelines. This study therefore, investigated quality of service provision for adolescents with mental disorders in Kintampo North and South districts of central Ghana. Methods Mixed method approach of quantitative and qualitative data collection, organization, and analysis was implored. Quantitative method data collection used case registers to identify mental and neurological disorders among adolescents. Qualitative methods used in-depth interviews of service providers, primary caregivers, and users of healthcare on the services available to treat mental and neurological disorders among adolescents. A combination of quality standards tools was used to assess services. Results Epilepsy was the most common treated disorder among adolescents receiving services at the four facilities in the two districts. Providers and stakeholders had limited or no training in adolescent mental health. Validated diagnostic tools were not being used to rule out differential diagnosis; medication procurement was a challenge to consistent treatment. Data collection and analysis was not standardized. Providers, stakeholders, patients, and their primary caregivers reported challenges with funding, transportation logistics, and stigma against people with mental and neurological disorders. Conclusion There are few mental health service providers for people living with mental disorders in the two Kintampo districts, with no specific services for adolescents. The Mental Health Act 846 of 2012 is an important milestone in mental health care but there are not specific plans for its implementation. Community sensitization, education in mental health and neurological disorders, and advocacy against stigma are all successful programmes that have the potential to be scaled up.

Abstract Background The prevalence of disclosure of status to children living with the Human Immunodeficiency Virus (HIV) is low in most sub-Saharan African countries, leading to poor compliance and adverse psychological outcomes in these children. This study examined the influence of disclosure on health outcomes in children living with HIV and their caregivers. Methods Using a cross-sectional design, 155 HIV-positive children between age 6–15 years and their caregivers were administered standardized questionnaires measuring adherence to medication, children's psychological well-being, caregiver burden, and caregivers’ psychological health. Results Results indicated that only 33.5% of the children sampled knew their status. Disclosure of HIV status was significantly related to medication adherence, psychological wellbeing, the burden of caregiving, and the length of the disclosure. A child’s age and level of education were the only demographic variables that significantly predicted disclosure of HIV status. In a hierarchical analysis, after controlling for all demographic variables medication adherence, psychological well-being and burden of caregiving were found to be significant predictors of disclosure of status in children living with HIV. Conclusions Findings suggest the need for disclosure of status among children living with HIV for a positive impact on their medication adherence and psychological health. These findings underscore the need for the development of context-specific interventions that will guide and encourage disclosure of status by caregivers to children living with HIV.

Abstract Background Termination of pregnancy (TOP) is a common cause of maternal morbidity and mortality in low- and middle-income countries. Population-based surveys are the major data source for TOP data in LMICs but are known to have shortcomings that require improving. The EN-INDEPTH multi-country survey employed a full pregnancy history approach with roster and new questions on TOP and Menstrual Restoration. This mixed methods paper assesses the completeness of responses to questions eliciting TOP information from respondents and reports on practices, barriers, and facilitators to TOP reporting. Methods The EN-INDEPTH study was a population-based cross-sectional study. The Full Pregnancy History arm of the study surveyed 34,371 women of reproductive age between 2017 and 2018 in five Health and Demographic Surveillance System (HDSS) sites of the INDEPTH network: Bandim, Guinea-Bissau; Dabat, Ethiopia; IgangaMayuge, Uganda; Kintampo, Ghana; and Matlab, Bangladesh. Completeness and time spent in answering TOP questions were evaluated using simple tabulations and summary statistics. Exact binomial 95% confidence intervals were computed for TOP rates and ratios. Twenty-eight (28) focus group discussions were undertaken and analysed thematically. Results Completeness of responses regarding TOP was between 90.3 and 100.0% for all question types. The new questions elicited between 2.0% (1.0–3.4), 15.5% (13.9–17.3), and 11.5% (8.8–14.7) lifetime TOP cases over the roster questions from Dabat, Ethiopia; Matlab, Bangladesh; and Kintampo, Ghana, respectively. The median response time on the roster TOP questions was below 1.3 minutes in all sites. Qualitative results revealed that TOP was frequently stigmatised and perceived as immoral, inhumane, and shameful. Hence, it was kept secret rendering it difficult and uncomfortable to report. Miscarriages were perceived to be natural, being easier to report than TOP. Interviewer techniques, which were perceived to facilitate TOP disclosure, included cultural competence, knowledge of contextually appropriate terms for TOP, adaptation to interviewee’s individual circumstances, being non-judgmental, speaking a common language, and providing detailed informed consent. Conclusions Survey roster questions may under-represent true TOP rates, since the new questions elicited responses from women who had not disclosed TOP in the roster questions. Further research is recommended particularly into standardised training and approaches to improving interview context and techniques to facilitate TOP reporting in surveys.

Abstract Background Accurate measurement of anti-malarial drug concentrations in therapeutic efficacy studies is essential to distinguish between inadequate drug exposure and anti-malarial drug resistance, and to inform optimal anti-malarial dosing in key target population groups. Methods A sensitive and selective LC–MS/MS method was developed and validated for the simultaneous determination of amodiaquine and its active metabolite, desethylamodiaquine, and used to describe their pharmacokinetic parameters in Ghanaian patients with uncomplicated falciparum malaria treated with the fixed-dose combination, artesunate-amodiaquine. Results The day-28 genotype-adjusted adequate clinical and parasitological response rate in 308 patients studied was > 97% by both intention-to-treat and per-protocol analysis. After excluding 64 patients with quantifiable amodiaquine concentrations pre-treatment and 17 with too few quantifiable concentrations, the pharmacokinetic analysis included 227 patients (9 infants, 127 aged 1–4 years, 91 aged ≥ 5 years). Increased median day-3 amodiaquine concentrations were associated with a lower risk of treatment failure [HR 0.87 (95% CI 0.78–0.98), p = 0.021]. Amodiaquine exposure (median AUC0-∞) was significantly higher in infants (4201 ng h/mL) and children aged 1–5 years (1994 ng h/mL) compared to older children and adults (875 ng h/mL, p = 0.001), even though infants received a lower mg/kg amodiaquine dose (median 25.3 versus 33.8 mg/kg in older patients). Desethylamodiaquine AUC0-∞ was not significantly associated with age. No significant safety concerns were identified. Conclusions Efficacy of artesunate-amodiaquine at currently recommended dosage regimens was high across all age groups. Reassuringly, amodiaquine and desethylamodiaquine exposure was not reduced in underweight-for-age young children or those with high parasitaemia, two of the most vulnerable target populations. A larger pharmacokinetic study with close monitoring of safety, including full blood counts and liver function tests, is needed to confirm the higher amodiaquine exposure in infants, understand any safety implications and assess whether dose optimization in this vulnerable, understudied population is needed.

Abstract Background In the phase III RTS,S /AS01 trial, significant heterogeneity in efficacy of the vaccine across study sites was seen. Question on whether variations in socio - economic status (SES) of participant contributed to the heterogeinity of the vaccine efficacy (VE) remains unknown. Methods Data from the Phase III RTS,S /AS01 trial in children aged 5–17 months in Kintampo were re-analysed. SES of each child was derived from the Kintampo Health and Demographic Surveillance System, using principal component analysis of household assets. Extended Cox regression was used to estimate the interaction between RTS,S/AS01 VE and household SES. Results Protective efficacy of the RTS,S/AS0 vaccine significantly varied by participant’s household SES, thus increase in household SES was associated with an increase in protective efficacy (P-value = 0.0041). Effect modification persisted after adjusting for age at first vaccination, gender, distance from community to the health facility, child’s haemoglobin level, household size, place of residence and mothers’ educational level. Conclusion Household SES may be a proxy for malaria transmission intensity. The study showed a significant modification of the RTS,S/AS01 malaria vaccine efficacy by the different levels of child’s household socio - economic status. Trial registration Efficacy of GSK Biologicals’ candidate malaria vaccine (25049) against malaria disease in infants and children in Africa. NCT00866619 prospectively registered on 20 March 2009.

Abstract Background Whereas suicide remains in the top 12 leading causes of death among young people aged 10–24 in sub-Saharan Africa, little is known about suicidal behaviours among adolescents in Liberia. We aimed to estimate the 12-month prevalence and describe some of the correlates of suicide behaviours (ideation, planning, and attempt) among school-going adolescents in Liberia. Methods We analysed data from the 2017 Liberia Global School-based Student Health Survey conducted nationwide among secondary school students. We performed bivariate and multivariable analyses to assess the correlates of suicidal ideation, planning, and attempt in the previous 12 months. Results Of the 2744 students, 26.8% reported suicidal ideation, 36.5% made a specific plan to attempt suicide and 33.7% attempted suicide during the 12 months preceding the survey. In the final adjusted logistic models, bullying victimisation and food insecurity were associated with increased odds of ideation, planning, and attempt. Whereas no factor was uniquely associated with suicidal ideation, having many close friends, and parental monitoring were associated with the increased odds of suicidal planning only. Leisure-time sedentary behaviour was associated with increased odds of suicidal planning and attempt. Cannabis use, alcohol drunkenness, being physically attacked, and parental supervision were uniquely associated with increased odds of suicidal attempt, while parental understanding and having a smaller number of close friends were uniquely associated with reduced odds of suicidal attempt. Conclusions The relatively high prevalence estimates of suicide behaviours and the multi-contextual nature of the associated factors warrant the need for the design and implementation of universal and multi-level, collaborative targeted intervention efforts towards the prevention of the onset of ideation, planning, and attempt, and the possible transition to deaths by suicide among school-going adolescents in Liberia.

The RTS,S/AS01E vaccine targets the circumsporozoite protein (CSP) of the Plasmodium falciparum (P. falciparum) parasite. Protein microarrays were used to measure levels of IgG against 1000 P. falciparum antigens in 2138 infants (age 6–12 weeks) and children (age 5–17 months) from 6 African sites of the phase III trial, sampled before and at 4 longitudinal visits after vaccination. One month postvaccination, IgG responses to 17% of all probed antigens showed differences between RTS,S/AS01E and comparator vaccination groups, whereas no prevaccination differences were found. A small subset of antigens presented IgG levels reaching 4- to 8-fold increases in the RTS,S/AS01E group, comparable in magnitude to anti-CSP IgG levels (~11-fold increase). They were strongly cross-correlated and correlated with anti-CSP levels, waning similarly over time and reincreasing with the booster dose. Such an intriguing phenomenon may be due to cross-reactivity of anti-CSP antibodies with these antigens. RTS,S/AS01E vaccinees with strong off-target IgG responses had an estimated lower clinical malaria incidence after adjusting for age group, site, and postvaccination anti-CSP levels. RTS,S/AS01E-induced IgG may bind strongly not only to CSP, but also to unrelated malaria antigens, and this seems to either confer, or at least be a marker of, increased protection from clinical malaria.

Abstract Background Physician shortage is a major barrier to hypertension (HTN) control in Ghana, with only one physician to 10,000 patients in 2015, thus limiting its capacity for HTN control at the primary care level such as the Community Health Planning and Services (CHPS) compounds, where most Ghanaians receive care. A Task-Shifting Strategy for HTN control (TASSH) based on the WHO Cardiovascular (CV) Risk Package is an evidence-based strategy for mitigating provider- and systems-level barriers to optimal HTN control. Despite its effectiveness, TASSH remains untested in CHPS zones. Additionally, primary care practices in low- and middle-income countries (LMICs) lack resources and expertise needed to coordinate multilevel system changes without assistance. The proposed study will evaluate the effectiveness of practice facilitation (PF) as a quality improvement strategy for implementing TASSH within CHPS zones in Ghana. Methods Guided by the Consolidated Framework for Implementation Research and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, we will evaluate, in a hybrid clinical effectiveness-implementation design, the effect of PF on the uptake of an evidence-based TASSH, among 700 adults who present to 70 CHPS zones with uncontrolled HTN. Components of the PF strategy include (a) an advisory board that provides leadership support for implementing the intervention within the CHPS zones and (b) trained task-strengthening facilitators (TSFs) who serve as practice coaches to provide training, and performance feedback to community health officers (CHOs) who will deliver TASSH at the CHPS zones. For this purpose, the TSFs are trained to identify, counsel, and refer adults with uncontrolled HTN to community health centers in Bono East Region of Ghana. Discussion Uptake of community-based evidence-supported interventions for hypertension control in Ghana is urgently needed to address the CVD epidemic and its associated morbidity, mortality, and societal costs. Findings from this study will provide policymakers and other stakeholders the “how to do it” empirical literature on the uptake of evidence-based task-strengthening interventions for HTN control in Ghana and will serve as a model for similar action in other low, middle-income countries. Trial registration ClinicalTrials.gov, NCT03490695 . Registered on 6 April 2018. Protocol version and date Version 1, date: 21 August, 2019.