Impact of kinship support on child mortality in the Upper East Region of Ghana: assessing the Grandmother Hypothesis

BACKGROUND

The grandmother is an important kin member whose contribution to childcare and survival has been recognized in the literature, hence the Grandmother Hypothesis. This article examines the effect of the presence of a grandmother on child mortality.

METHODS

Data were obtained from the Navrongo Health and Demographic Surveillance System, located in the Upper East Region of Ghana. Children born between January 1999 and December 2018 were included in the analysis. Person-months lived for each child were generated. The multilevel Poisson regression technique was employed to investigate the effect of a grandmother on child survival.

RESULTS

In all, 57 116 children were included in the analysis, of which 7% died before age 5 y. Person-months were generated for the children, which produced 2.7 million records, with about 487 800 person-years. After controlling for confounders, results showed that children in households with paternal grandmothers are 11% less likely to die compared with those without paternal grandmothers. However, when other confounders were taken into accounts, the beneficial effect of maternal grandmothers disappeared.

CONCLUSIONS

We conclude that the presence of grandmothers improves child survival, thus sustaining the Grandmother Hypothesis. The experiences of these grandmothers should be tapped to improve child survival, particularly in rural areas.

'Joy, not sorrow': Men's perspectives on gender, violence, and cash transfers targeted to women in northern Ghana

Evidence indicates that cash transfers can decrease intimate partner violence (IPV) against women, although most research has focused on women's perspectives and experiences, with less attention to men. We analyzed data from four focus group discussions with male partners of women who participated in the Ghana Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program. We elicited men's perceptions of poverty, relationship dynamics, IPV and cash transfers targeted to their wives using thematic analysis. Men largely viewed the effects of the cash transfer as positive - they felt decreased provider role strain when women used the cash to cover household expenses such as food and school fees. Men also indicated that they felt respected when women used the cash to cover sudden expenses, such as funeral costs, thus preventing the need to borrow from community members and exposing their inability to fulfill provider roles. These feelings of relief and respect helped improve men's overall wellbeing, their marital relationships and reduced the potential for IPV. Despite these positive results, men revealed that they still expected to be informed and consulted about the transfer and its expenditure, and felt disrespected when women did not do so, thus heightening the potential for household conflict. Further research and innovation in programming is needed to integrate gender transformative strategies into cash transfer programs, explicitly aimed at changing gender norms to enhance and sustain beneficial impacts on gender relations and IPV.

Evaluation of Container Clinics as an Urban Immunization Strategy: Findings from the First Year of Implementation in Ghana, 2017-2018

BACKGROUND

In 2017, the Expanded Programme on Immunization in Ghana opened two container clinics in Accra, which were cargo containers outfitted to deliver immunizations. At each clinic, we assessed performance and clinic acceptance during the first 12 months of implementation.

METHODS

We employed a descriptive mixed-method design using monthly administrative immunization data, exit interviews with caregivers of children of <5 years (N = 107), focus group discussions (FGDs) with caregivers (n = 6 FGDs) and nurses (n = 2 FGDs), and in-depth interviews (IDIs) with community leaders (n = 3) and health authorities (n = 3).

RESULTS

Monthly administrative data showed that administered vaccine doses increased from 94 during the opening month to 376 in the 12th month across both clinics. Each clinic exceeded its target doses for the 12-23 month population (second dose of measles). Almost all (98%) exit interview participants stated that the clinics made it easier to receive child health services compared to previous health service interactions. The accessibility and acceptability of the container clinics were also supported from health worker and community perspectives.

CONCLUSIONS

Our initial data support container clinics as an acceptable strategy for delivering immunization services in urban populations, at least in the short term. They can be rapidly deployed and designed to serve working mothers in strategic areas.

Community perspectives on cardiovascular disease control in rural Ghana: A qualitative study

BACKGROUND

Cardiovascular disease (CVD) prevalence is high in Ghana-but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors.

METHODS

We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes.

RESULTS

CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital.

CONCLUSIONS

CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors-in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD-including its behavioral and mental health causes-in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise.

Social and demographic correlates of cardiovascular mortality in the Kassena-Nankana districts of Ghana: a verbal post-mortem analysis

BACKGROUND

The burden of cardiovascular disease (CVD) in Ghana is rising, but details on its epidemiology are scarce. We sought to quantify mortality due to CVD in two districts in rural Ghana using verbal post-mortem (VPM) data.

METHODS

We conducted a proportional sub-hazards analysis of 10 232 deaths in the Kassena-Nankana East and West districts from 2005 to 2012, to determine adult mortality attributed to CVD over time. We stratified results by age, gender and socio-economic status (SES), and compared CVD mortality among SES and gender strata over time. A competing risk model estimated the cumulative effect of eliminating CVD from the area.

RESULTS

From 2005 to 2012, CVD mortality more than doubled overall, from 0.51 deaths for every 1000 person-years in 2005 to 1.08 per 1000 person-years in 2012. Mortality peaked in 2008 at 1.23 deaths per 1000 person-years. Increases were comparable in men (2.0) and women (2.3), but greater among the poorest residents (3.3) than the richest (1.3), and among persons aged 55-69 years (2.1) than those aged ≥70 years (1.8). By 2012, male and female CVD mortality was highest in middle-SES persons. We project that eliminating CVD would increase the number of individuals reaching age 73 years from 35% to 40%, adding 1.6 years of life expectancy.

CONCLUSIONS

The burden of CVD on overall mortality in the Upper East Region is substantial and markedly increasing. CVD mortality has especially increased in lower-income persons and persons in middle age. Further initiatives for the surveillance and control of CVD in these vulnerable populations are needed.

Effect of a lay counselor-delivered integrated maternal mental health and early childhood development group-based intervention in Northern Ghana: a cluster-randomized controlled trial

BACKGROUND

Caregiver mental health is linked to early childhood development, yet more robust evidence of community-based interventions to prevent maternal depression and optimize socio-emotional development of young children is needed. Objectives of this cluster-randomized controlled trial (cRCT), based in Northern Ghana, are to assess the impact of the lay counselor-delivered, group-based Integrated Mothers and Babies Course and Early Childhood Development (iMBC/ECD) program on (1) the mental health of mothers of children under age 2; and (2) the socio-emotional development of their children.

METHODS

This cRCT randomized 32 women's groups - 16 received iMBC/ECD content (intervention) and 16 received general health education content (control). Surveys were administered at baseline, immediate post-intervention, and 8-month post-intervention. The primary outcome was maternal depression [Patient Health Questionnaire (PHQ-9)], and the secondary outcome was child's socio-emotional development [Ages and Stages Questionnaire: Social Emotional (ASQ:SE-2)]. Qualitative interviews with 33 stakeholders were also conducted.

RESULTS

In total, 374 participants were enrolled at baseline while pregnant with the index child, 19% endorsing moderate/severe depression. Of these, 266 (71.1%) completed the 8-month post-intervention survey (~19 months post-baseline). There were no significant effects of iMBC/ECD on PHQ-9 and ASQ:SE-2 scores. However, results favored the intervention arm in most cases. iMBC participants were highly satisfied with the program but qualitative feedback from stakeholders indicated some implementation challenges.

CONCLUSIONS

This real-world evaluation had null findings; however, post-intervention depression levels were very low in both arms (3%). Future research should examine the potential impact of women's groups on postpartum mental health more broadly with varying content.

Prevalence and correlates of maternal early stimulation behaviors during pregnancy in northern Ghana: a cross-sectional survey

BACKGROUND

Per UNICEF's Nurturing Care Framework, early childhood development (ECD) begins during pregnancy and many lower-resource settings need data to inform their programs for optimal child development. The maternal-fetal relationship can be partly examined via a series of bonding activities called early stimulation behaviors (ESB). This study describes early stimulation behaviors and the associated correlates among pregnant women in Ghana.

METHODS

This cross-sectional study used data from a cluster-randomized trial in two districts of Northern Ghana. A total of 374 pregnant women were enrolled at baseline and administered a pre-intervention survey. Communication-related early stimulation behaviors was the primary outcome which was evaluated using three maternal-fetal bonding activities; did the woman self-report touching and/or talking, singing, and/or talking about family to her belly. A generalized estimating equation modified Poisson model was used for the bivariate and multivariable analysis.

RESULTS

About half of the participants reported performing communication-related ESB during pregnancy frequently or sometimes. Bivariate analysis revealed that negative life experiences including higher rates of emotional, physical and sexual intimate partner violence (IPV) and having moderate to severe depressive symptoms were associated with women performing early stimulation behaviors more often. In the multivariable model, physical intimate partner violence remained significantly associated with early stimulation behaviors.

CONCLUSION

Research on early stimulation behaviors is still in a nascent phase. It is unclear why our results revealed an association between intimate partner violence and early stimulation behaviors; this could reflect a coping mechanism for the expectant mother. Further research is needed to better understand this association and explore potential long-term impacts of early stimulation behaviors during pregnancy on child development.

TRIAL REGISTRATION

Clinical Trials # NCT03665246 , August 29, 2018.

Adapting a nurse-led primary care initiative to cardiovascular disease control in Ghana: a qualitative study

Background

Cardiovascular Disease (CVD) is a growing cause of morbidity and mortality in Ghana, where rural primary health care is provided mainly by the Community-based Health Planning and Services (CHPS) initiative. CHPS locates nurses in community-level clinics for basic curative and preventive health services and provides home and outreach services. But CHPS currently lacks capacity to screen for or treat CVD and its risk factors.

Methods

In two rural districts, we conducted in-depth interviews with 21 nurses and 10 nurse supervisors to identify factors constraining or facilitating CVD screening and treatment. Audio recordings were transcribed, coded for content, and analyzed for key themes.

Results

Respondents emphasized three themes: community demand for CVD care; community access to CVD care; and provider capacity to render CVD care. Nurses and supervisors noted that community members were often unaware of CVD, despite high reported prevalence of risk factors. Community members were unable to travel for care or afford treatment once diagnosed. Nurses lacked relevant training and medications for treating conditions such as hypertension. Respondents recognized the importance of CVD care, expressed interest in acquiring further training, and emphasized the need to improve ancillary support for primary care operations.

Conclusions

CHPS staff expressed multiple constraints to CVD care, but also cited actions to address them: CVD-focused training, provision of essential equipment and pharmaceuticals, community education campaigns, and referral and outreach transportation equipment. Results attest to the need for trial of these interventions to assess their impact on CVD risk factors such as hypertension, depression, and alcohol abuse.

Prevalence and Correlates of Depression Among Pregnant Women Enrolled in a Maternal and Newborn Health Program in Rural Northern Ghana: a Cross-sectional Survey

Women in many sub-Saharan African countries are at elevated risk of depression during pregnancy. However, there are still gaps in the estimates of antenatal depression and associated risk factors in very low-resource settings such as Northern Ghana. This study describes the prevalence of depression among rural pregnant women, participating in a maternal and child health program, in Ghana, and examines associated risk factors for depression. Pregnant women who were registered for group-based maternal and child health community programs were recruited for study participation from 32 communities in two rural districts in Northern Ghana (n = 374). Baseline surveys were conducted and depression was assessed using the Patient Health Questionnaire (PHQ-9). Bivariate and multivariable analyses used a modified Poisson and generalized estimating equations (GEE) model. Of the women in our study population, 19.7% reported symptoms indicative of moderate to severe depression (PHQ-9 score ≥ 10), with 14.1% endorsing suicidal ideation in the last 2 weeks. Bivariate analyses revealed that lower hopefulness, moderate and severe hunger, experiences of emotional, physical, and/or sexual intimate partner violence (IPV), and insufficient social support from female relatives were associated with symptoms indicating moderate to severe depression. In the multivariable analyses, low hopefulness, household hunger, emotional IPV, physical and/or sexual IPV, and insufficient female relative support remained significantly associated with depression. Antenatal depression is associated with unmet basic needs and safety. Perinatal mental health programming must take an ecological perspective and address personal, familial, and community-level factors.

Why do community members believe mothers and babies are dying? Behavioral versus situational attribution in rural northern Ghana

OBJECTIVE

Rates of maternal and neonatal death remain high in the Global South, especially in Sub-Saharan Africa. In addition, indicators vary significantly by geography. This study aimed to understand what communities in northern Ghana with frequent maternal and newborn deaths or near deaths (near-misses) perceive to be the causes. As part of a larger study, four communities in Ghana's Northern Region were identified as areas with high concentrations of deaths and near-misses of mothers and babies.

DESIGN

Stakeholders were interviewed using in-depth interviews (IDIs) and focus-group discussions (FGDs). Field workers conducted 12 FGDs and 12 IDIs across a total of 126 participants.

SETTING

This exploratory descriptive study was conducted in the East Mamprusi District in the Northern Region of Ghana, in the communities of Jawani, Nagboo, Gbangu and Wundua.

PARTICIPANTS

FGDs were led by trained field workers and attended by traditional chiefs and their elders, members of women's groups, and traditional birth attendants in each of the four study communities. IDIs, or one-on-one interviews, were conducted with traditional healers who manage maternal and neonatal cases, community health nurses, and midwives.

MEASUREMENTS AND FINDINGS

Qualitative data were audio-recorded, transcribed, and thematically analyzed using the Attride-Sterling analytical framework. Discussions focused on where blame should be attributed for the negative outcomes of mothers and babies - with blame either being directed at the actions or inactions of the mothers (behavioral), or at the larger factors associated with poverty (situational) that necessitate mothers' behavior. For example, some respondents blamed women for their poor diets, while others blamed the lack of money or household support to buy nutritious foods. Blame was rarely attributed to the fathers despite local gender norms of males being the household decision-makers with regard to spending and care-seeking.

KEY CONCLUSIONS

These findings contribute to a small but growing body of literature on the blaming of mothers for their own deaths and those of their newborns - a phenomenon also described in high-income countries - and is supported by blame attribution theories that explain the self-protective nature of victim-blaming.

IMPLICATIONS FOR PRACTICE

These results carry important implications for education and intervention design related to maternal and neonatal mortality, including more focused efforts at incorporating men and the larger community. More research is warranted on blame attribution for these adverse outcomes and its effects on the victims.

Prevalence and factors associated with female genital mutilation among women of reproductive age in the Bawku municipality and Pusiga District of northern Ghana

BACKGROUND

Globally, three million girls are at risk of female genital mutilation (FGM) and an estimated 200 million girls and women in the world have undergone FGM. While the overall prevalence of FGM in Ghana is 4%, studies have shown that the overall prevalence in the Upper East Region is 38%, with Bawku municipality recording the highest at 82%.

METHODS

This study used a cross-sectional design with a quantitative approach: a survey with women of reproductive age (15-49).

RESULTS

Among all respondents, 830 women who participated in the study, 61% reported having undergone FGM. Of those circumcised, 66% indicated their mothers influenced it. Three quarters of the women think FGM could be stopped through health education. Women who live in the Pusiga district (AOR: 1.66; 95% CI: 1.16-2.38), are aged 35-49 (AOR: 4.24; 95% CI: 2.62-6.85), and have no formal education (AOR: 2.78; 95% CI: 1.43-5.43) or primary education (AOR: 2.10; 95% CI: 1.03-4.31) were more likely to be circumcised relative to those who reside in Bawku Municipal, are aged 15-24, and had tertiary education. Likewise, married women (AOR: 3.82; 95% CI: 2.53-5.76) were more likely to have been circumcised compared with unmarried women. At a site-specific level, factors associated with FGM included age and marital status in Bawku, and age, marital status, and women's education in Pusiga.

CONCLUSION

Female Genital Mutilation is still being practiced in the Bawku Municipality and the Pusiga District of northern Ghana, particularly among women with low socio-economic status. Implementing interventions that would provide health education to communities and promote girl-child education beyond the primary level could help end the practice.

Using social autopsy to understand maternal, newborn, and child mortality in low-resource settings: a systematic review of the literature

Background: Social, cultural, and behavioral factors are often potent upstream contributors to maternal, neonatal, and child mortality, especially in low- and middle-income countries (LMICs). Social autopsy is one method of identifying the impact of such factors, yet it is unclear how social autopsy methods are being used in LMICs.

Objective: This study aimed to identify the most common social autopsy instruments, describe overarching findings across populations and geography, and identify gaps in the existing social autopsy literature.

Methods: A systematic search of the peer-reviewed literature from 2005 to 2016 was conducted. Studies were included if they were conducted in an LMIC, focused on maternal/neonatal/infant/child health, reported on the results of original research, and explicitly mentioned the use of a social autopsy tool.

Results: Sixteen articles out of 1950 citations were included, representing research conducted in 11 countries. Five different tools were described, with two primary conceptual frameworks used to guide analysis: Pathway to Survival and Three Delays models. Studies varied in methods for identifying deaths, and recall periods for respondents ranged from 6 weeks to 5+ years. Across studies, recognition of danger signs appeared to be high, while subsequent care-seeking was inconsistent. Cost, distance to facility, and transportation issues were frequently cited barriers to care-seeking, however, additional barriers were reported that varied by location. Gaps in the social autopsy literature include the lack of: harmonized tools and analytical methods that allow for cross-study comparisons, discussion of complexity of decision making for care seeking, qualitative narratives that address inconsistencies in responses, and the explicit inclusion of perspectives from husbands and fathers.

Conclusion: Despite the nascence of the field, research across 11 countries has included social autopsy methods, using a variety of tools, sampling methods, and analytical frameworks to determine how social factors impact maternal, neonatal, and child health outcomes.

Addressing the continuum of maternal and newborn care in Ghana: implications for policy and practice

Although the past decade has brought global reductions in maternal, infant and child mortality, many low-resource settings have failed to make significant gains relative to their high-income counterparts. In Ghana, nearly 50% of under-five mortality in 2014 could be attributed to deaths during the first 28 days after birth. This article analyses the data across a mixed-methods study of the factors impacting maternal and neonatal care in northern Ghana. The stillbirth and neonatal death study (SANDS) was conducted in 2010 and included both quantitative (N = 20 497) and qualitative data collection (N = 253) to explore the issues associated with the continuum of reproductive health care. Findings were compared against an adaptation of the WHO/UNICEF framework for integrated maternal and newborn care and used to generate concrete recommendations for clinicians, policymakers and programmers across the continuum of care, from pregnancy through delivery and postnatal care. SANDS elucidated epidemiological trends: 40% of neonatal deaths occurred on the first day after birth, and the leading causes of early neonatal mortality were birth asphyxia/injury, infection and complications of prematurity. Qualitative data reflect findings along two axes-community to facility-based care, and pre-pregnancy through the postnatal period. Resulting recommendations include the need to improving clinicians' understanding of and sensitization to local traditional practices, the need for policies to better address quality of care and coordination of training efforts, and the need for comprehensive, integrated programmes that ensure continuity of care from pre-pregnancy through the post-partum period. SANDS illustrates complex medical-social-cultural knowledge, attitudes and practices that span the reproductive period in rural northern Ghana. Data illustrate that not only are the first few days of life critical in infant survival but also there are significant social and cultural barriers to ensuring that mothers and their newborns are cared for in a timely, evidence-based manner.

Factors influencing adverse events reporting within the health care system: the case of artemisinin-based combination treatments in northern Ghana

Background

The use of artemisinin-based combination therapy (ACT) as first-line treatment for uncomplicated malaria was a policy recommended by World Health Organization. In 2004, Ghana changed her first-line anti-malarial drug policy to use ACT. This study examined factors affecting adverse events reporting in northern Ghana after the introduction of ACT.

Methods

This was a qualitative study based on sixty in-depth interviews with health workers, chemical shop owners and patients with malaria who were given ACT at the health facilities. Purposive sampling method was used to select study participants. The interviews were transcribed, coded into themes using Nvivo 9 software. The thematic analysis framework was used to analyse the data.

Results

Study respondents reported body weakness and dizziness as the most frequent side effects they had experienced from the used of ACT. Other side effects they reported were swollen testes, abdominal pain and shivering. These side effects were mostly associated with the use of artesunate-amodiaquine compared to other artemisinin-based combinations. Patients were not provided information about the side effects of the drugs and so did not report when they experienced them. Also long queues at health facilities and unfriendly health worker attitude were the main factors affecting adverse events reporting. Other factors such as wrong use of ACT at home, farming and commercial activities also affected effective adverse events reporting in the study area.

Conclusion

Patients’ lack of knowledge and health sector drawbacks affected side effect reporting on ACT. Intensive health education on likely side effects of ACT should be provided to patients by health workers. Also, improving health worker attitude toward clients will encourage patients to visit the health facilities when they react negatively to ACT and, subsequently, will improve on adverse events reporting.

"I don't know anything about their culture": the disconnect between allopathic and traditional maternity care providers in rural northern Ghana

The provision of maternal and neonatal health care in rural northern Ghana is pluralistic, consisting of traditional and allopathic providers. Although women often use these providers interchangeably, important differences exist. This study explored the differences in approaches to maternal and neonatal care provision by these two different types of providers. This research was part of the Stillbirth and Neonatal Death Study (SANDS), conducted in northern Ghana in 2010. Trained field staff of the Navrongo Health Research Centre conducted in-depth interviews with 13 allopathic and 8 traditional providers. Interviews were audio-recorded, transcribed, and analyzed using in vivo coding and discussion amongst the research team. Three overarching themes resulted: 1) many allopathic providers were isolated from the culture of the communities in which they practiced, while traditional providers were much more aware of the local cultural beliefs and practices. 2) Allopathic and traditional healthcare providers have different frameworks for understanding health and disease, with allopathic providers relying heavily on their biomedical knowledge, and traditional providers drawing on their knowledge of natural remedies. 3) All providers agreed that education directed at pregnant women, providers (both allopathic and traditional), and the community at large is needed to improve maternal and neonatal outcomes. Our findings suggest that, among other things, programmatic efforts need to be placed on the cultural education of allopathic providers.

Female autonomy and reported abortion-seeking in Ghana, West Africa

OBJECTIVE

To investigate factors associated with self-reported pregnancy termination in Ghana and thereby appreciate the correlates of abortion-seeking in order to understand safe abortion care provision.

METHODS

In a retrospective study, data from the Ghana 2008 Demographic and Health Survey were used to investigate factors associated with self-reported pregnancy termination. Variables on an individual and household level were examined by both bivariate analyses and multivariate logistic regression. A five-point autonomy scale was created to explore the role of female autonomy in reported abortion-seeking behavior.

RESULTS

Among 4916 women included in the survey, 791 (16.1%) reported having an abortion. Factors associated with abortion-seeking included being older, having attended school, and living in an urban versus a rural area. When entered into a logistic regression model with demographic control variables, every step up the autonomy scale (i.e. increasing autonomy) was associated with a 14.0% increased likelihood of reporting the termination of a pregnancy (P < 0.05).

CONCLUSION

Although health system barriers might play a role in preventing women from seeking safe abortion services, autonomy on an individual level is also important and needs to be addressed if women are to be empowered to seek safe abortion services.

Does the National Health Insurance Scheme in Ghana reduce household cost of treating malaria in the Kassena-Nankana districts?

Introduction

The Government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 to replace out-of-pocket (OOP) payment for health services with the inherent aim of reducing the direct cost of treating illness to households.

Objective

To assess the effects of the NHIS in reducing cost of treating malaria to households in the Kassena-Nankana districts of northern Ghana.

Methods

We conducted a cross-sectional survey between October 2009 and October 2011 in the Kassena-Nankana districts. A sample of 4,226 households was randomly drawn from the Navrongo Health and Demographic Surveillance System household database and administered a structured interview. The costs of malaria treatment were collected from the patient perspective.

Results

Of the 4,226 households visited, a total of 1,324 (31%) household members reported fever and 51% (675) reported treatment for malaria and provided information on where they sought care. Most respondents sought malaria treatment from formal health facilities 63% (424), with the remainder either self-medicating with drugs from chemical shops 32% (217) or with leftover drugs or herbs 5% (34). Most of those who sought care from formal health facilities were insured 79% (334). The average direct medical cost of treating malaria was GH¢3.2 (US$2.1) per case with the insured spending less (GH¢2.6/US$1.7) per case than the uninsured (GH¢3.2/US$2.1). The overall average cost (direct and indirect) incurred by households per malaria treatment was GH¢20.9 (US$13.9). Though the insured accounted for a larger proportion of admissions at health facilities 76% (31) than the uninsured 24% (10), the average amount households spent on the insured was less (GH¢4/US$2.7) than their uninsured counterparts (GH¢6.4/US$4.3). The difference was not statistically significant (p=0.2330).

Conclusion

Even though some insured individuals made OOP payments for direct medical care, there is evidence that the NHIS has a protective effect on cost (outpatient and in-patient) of malaria treatment.

Seeking consent to genetic and genomic research in a rural Ghanaian setting: a qualitative study of the MalariaGEN experience

Background

Seeking consent for genetic and genomic research can be challenging, particularly in populations with low literacy levels, and in emergency situations. All of these factors were relevant to the MalariaGEN study of genetic factors influencing immune responses to malaria in northern rural Ghana. This study sought to identify issues arising in practice during the enrolment of paediatric cases with severe malaria and matched healthy controls into the MalariaGEN study.

Methods

The study used a rapid assessment incorporating multiple qualitative methods including in depth interviews, focus group discussions and observations of consent processes. Differences between verbal information provided during community engagement processes, and consent processes during the enrolment of cases and controls were identified, as well as the factors influencing the tailoring of such information.

Results

MalariaGEN participants and field staff seeking consent were generally satisfied with their understanding of the project and were familiar with aspects of the study relating to malaria. Some genetic aspects of the study were also well understood. Participants and staff seeking consent were less aware of the methodologies employed during genomic research and their implications, such as the breadth of data generated and the potential for future secondary research.

Moreover, trust in and previous experience with the Navrongo Health Research Centre which was conducting the research influenced beliefs about the benefits of participating in the MalariaGEN study and subsequent decision-making about research participation.

Conclusions

It is important to recognise that some aspects of complex genomic research may be of less interest to and less well understood by research participants and that such gaps in understanding may not be entirely addressed by best practice in the design and conduct of consent processes. In such circumstances consideration needs to be given to additional protections for participants that may need to be implemented in such research, and how best to provide such protections.

Capacity building for research ethics committees with limited familiarity with genetic and genomic research, and appropriate engagement with communities to elicit opinions of the ethical issues arising and acceptability of downstream uses of genome wide association data are likely to be important.