Survival trends among people living with human immunodeficiency virus on antiretroviral treatment in two rural districts in Ghana

BACKGROUND

The human immunodeficiency virus (HIV) has caused a lot of havoc since the early 1970s, affecting 37.6 million people worldwide. The 90-90-90 treatment policy was adopted in Ghana in 2015 with the overall aim to end new infections by 2030, and to improve the life expectancy of HIV seropositive individuals. With the scale-up of Highly Active Antiretroviral Therapy, the lifespan of People Living with HIV (PLWH) on antiretrovirals (ARVs) is expected to improve. In rural districts in Ghana, little is known about the survival probabilities of PLWH on ARVs. Hence, this study was conducted to estimate the survival trends of PLWH on ARVs.

METHODS

A retrospective evaluation of data gathered across ARV centres within Tatale and Zabzugu districts in Ghana from 2016 to 2020 among PLWH on ARVs. A total of 261 participants were recruited for the study. The data was analyzed using STATA software version 16.0. Lifetable analysis and Kaplan-Meier graph were used to assess the survival probabilities. "Stptime" per 1000 person-years and the competing risk regression were used to evaluate mortality rates and risk.

RESULTS

The cumulative survival probability was 0.8847 (95% CI: 0.8334-0.9209). The overall mortality rate was 51.89 (95% CI: 36.89-72.97) per 1000 person-years. WHO stage III and IV [AHR: 4.25 (95%CI: 1.6-9.71) p = 0.001] as well as age group (50+ years) [AHR: 5.02 (95% CI: 1.78-14.13) p = 0.002] were associated with mortality.

CONCLUSION

Survival probabilities were high among the population of PLWH in Tatale and Zabzugu with declining mortality rates. Clinicians should provide critical attention and care to patients at HIV WHO stages III and IV and intensify HIV screening at all entry points since early diagnosis is associated with high survival probabilities.

No Evidence for an Association of HIV and Antiviral Treatment With Changes in Framingham Cardiovascular Risk Score in the Ndlovu Cohort Study

BACKGROUND

HIV and antiretroviral therapy (ART) have been associated with increased cardiovascular disease (CVD) risk in high-income countries. The authors studied the longitudinal association between HIV and ART and nonlaboratory Framingham Risk Score (FRS) in a middle-income country.

METHODS AND RESULTS

This longitudinal analysis of the NCS (Ndlovu Cohort Study), South Africa used baseline to 36-month follow-up data. Demographics, HIV, ART status, and cardiometabolic measures were obtained. FRS was used as a CVD risk measure. Through linear mixed models, FRS trends over time and the association with HIV were studied. Analysis included 1136 participants, with 609 (54%) having HIV, and 495 (81%) taking ART. At baseline, 9.8% of participants had a high FRS. People living with HIV (PLHIV) had a 3.2% lower FRS than HIV-negative participants (P<0.001). FRS increased similarly for both groups over time. Other factors associated with FRS were secondary and higher education (ß value: -0.075, P<0.001; ß value: -0.084, P<0.001) and alcohol consumption (ß value: 0.011, P<0.001).

CONCLUSIONS

CVD risk increased for all participants over 36 months, suggesting classic risk factors rather than HIV status or ART to be drivers of CVD risk. People living with HIV had a significantly lower FRS than their HIV-negative counterparts, possibly related to HIV itself or a more frequent interaction with healthcare services. No association of HIV and ART with changes in FRS over 36 months was observed, suggesting the need for research using clinical endpoints to elucidate the effects of HIV and ART on CVD risk. Population-based prevention of CVD risk factors in sub-Saharan Africa is warranted, regardless of HIV status.

Prevalence, patterns, and determinants of multimorbidity among childhood and adult cancer survivors: A systematic review

Development of multimorbidity is common among cancer survivors due to their previous cancer, treatments, or changes in lifestyle. We summarized evidence on the prevalence, patterns, and determinants of multimorbidity among childhood and adult cancer survivors. We searched PubMed and EMBASE databases for articles reporting prevalence, patterns, and determinants of multimorbidity in cancer survivors. Finally, 23/500 articles were included. There was a large variation in the prevalence of multimorbidity (13-89%) among cancer survivors. Bone marrow transplantation, radiation, female sex, lower level of physical activity, increasing age, minority ethnicity, low-income, and low-education were associated with a higher prevalence of multimorbidity. Patterns of multimorbidity were both concordant and discordant. In conclusion, multimorbidity is highly prevalent and a major concern among cancer survivors. A personalized care plan that takes into account the identified risk may be beneficial to reduce the burden of multimorbidity and improve the quality of life among cancer survivors.

Using the multiple streams model to elicit an initial programme theory: from policy dialogues to a roadmap for scaling up integrated care

INTRODUCTION

The 'SCale-Up diaBetes and hYpertension care' Project aims to support the scale-up of integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium through the co-creation, implementation and evaluation of contextualised roadmaps. These roadmaps offer avenues for action and are built on evidence as well as stakeholder engagement in policy dialogues. Roadmaps and policy dialogues are very much intertwined and considered to be key elements for successful stakeholder-supported scale-up in integrated chronic care. Yet, little is known about how, why and under which conditions policy dialogue leads to successful roadmap implementation and scale-up of integrated care. Therefore, this study aims to use a realist approach to elicit an initial programme theory (IPT), using political science theories on the policy process.

METHODS

To develop the IPT, information from different sources was collected. First, an exploratory literature review on policy dialogue and scale-up definitions and success factors was performed, identifying theoretical frameworks, empirical (case) studies and realist studies (information gleaning). Second, research workshops on applying theory to the roadmap for scale-up (theory gleaning) were conducted with a multidisciplinary expert team. We used the intervention-context-actors-mechanism-outcome configuration to synthesise information from the sources into a configurational map.

RESULTS

The information and theory gleaning resulted into an IPT, hypothesising how policy dialogues can contribute to roadmap success in different policy stages. The IPT draws on political science theory of the multiple streams model adapted by Howlett et al to include five streams (problem, solution, politics, process and programme) that can emerge, converge and diverge across all five policy stages.

CONCLUSION

This paper aims to extend the knowledge base on the use of policy dialogues to build a roadmap for scale-up. The IPT describes how (dynamics) and why (theories) co-created roadmaps are expected to work in different policy stages.

Cardiovascular Risk Estimation Based on Country-of-Birth- and Country-of-Residence-Specific Scores among Migrants in the Netherlands: The HELIUS Study

BACKGROUND

Regional and country-specific cardiovascular risk algorithms have been developed to improve CVD risk prediction. But it is unclear whether migrants' country-of-residence or country-of-birth algorithms agree in stratifying the CVD risk of these populations. We evaluated the risk stratification by the different algorithms, by comparing migrant country-of-residence-specific scores to migrant country-of-birth-specific scores for ethnic minority populations in the Netherlands.

METHOD

data from the HELIUS study was used in estimating the CVD risk scores for participants using five laboratory-based (Framingham, Globorisk, Pool Cohort Equation II, SCORE II, and WHO II) and three nonlaboratory-based (Framingham, Globorisk, and WHO II) risk scores with the risk chart for the Netherlands. For the Globorisk, WHO II, and SCORE II risk scores, we also computed the risk scores using risk charts specified for the migrant home country. Risk categorization was first done according to the specification of the risk algorithm and then simplified to low (green), moderate (yellow and orange), and high risk (red).

RESULTS

we observed differences in risk categorization for different risk algorithms ranging from 0% (Globorisk) to 13% (Framingham) for the high-risk category, as well as differences in the country-of-residence- and country-of-birth-specific scores. Agreement between different scores ranged from none to moderate. We observed a moderate agreement between the Netherlands-specific SCORE II and the country-of-birth SCORE II for the Turkish and a nonagreement for the Dutch Moroccan population.

CONCLUSION

disparities exist in the use of the country-of-residence-specific, as compared to the country-of-birth, risk algorithms among ethnic minorities living in the Netherlands. Hence, there is a need for further validation of country-of-residence- and country-of-birth-adjusted scores to ascertain appropriateness and reliability.

Validation of the GetReal Trial Tool - Facilitating discussion and understanding more pragmatic design choices and their implications

BACKGROUND

The GetReal Trial Tool is a decision support tool to assess the impact of design choices on generalizability of clinical trials to routine clinical practice, while taking into account the risk of bias, precision, acceptability and operational feasibility. This study describes the validation of the GetReal Trial Tool.

METHODS

Twelve experts took part in the GetReal Trial tool validation using the protocols of 6 trials conducted with pragmatic elements. The tool entails 7 domains with a total of 43 questions. A pooled Kappa statistic (95% CI) using random effects model was estimated using Open Meta (analyst) software. The possible operational challenges were collated and discussed with the trialists that conducted the trials.

RESULTS

Agreement in the design choices made for the trial protocols was >50% for all the trials and all teams reached consensus during discussion. The pooled Kappa statistic (95% CI) was 0.236 (0.154-0.318). The GetReal Trial tool highlighted several operational challenges, of which almost half had been experienced previously by the trialists. Out of 25 additional operational challenges mentioned by the trialists, 76% were already highlighted by the tool. The tool was considered helpful to optimize trials right from the design stage.

CONCLUSION

The GetReal Trial Tool helps to scrutinize the choice of study design in the light of Real World Evidence generation. The tool identifies most of the operational challenges experienced by trialists to date. The tool serves the intended purpose of facilitating discussion and understanding more pragmatic design choices and their implications.

Process evaluation of the scale-up of integrated diabetes and hypertension care in Belgium, Cambodia and Slovenia (the SCUBY Project): a study protocol

INTRODUCTION

Integrated care interventions for type 2 diabetes (T2D) and hypertension (HT) are effective, yet challenges exist with regard to their implementation and scale-up. The 'SCale-Up diaBetes and hYpertension care' (SCUBY) Project aims to facilitate the scale-up of integrated care for T2D and HT through the co-creation and implementation of contextualised scale-up roadmaps in Belgium, Cambodia and Slovenia. We hereby describe the plan for the process and scale-up evaluation of the SCUBY Project. The specific goals of the process and scale-up evaluation are to (1) analyse how, and to what extent, the roadmap has been implemented, (2) assess how the differing contexts can influence the implementation process of the scale-up strategies and (3) assess the progress of the scale-up.

METHODS AND ANALYSIS

A comprehensive framework was developed to include process and scale-up evaluation embedded in implementation science theory. Key implementation outcomes include acceptability, feasibility, relevance, adaptation, adoption and cost of roadmap activities. A diverse range of predominantly qualitative tools-including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping-were developed to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. The role of context is considered relevant, and barriers and facilitators to scale-up will be continuously assessed.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Institutional Review Board (ref. 1323/19) at the Institute of Tropical Medicine (Antwerp, Belgium). The SCUBY Project presents a comprehensive framework to guide the process and scale-up evaluation of complex interventions in different health systems. We describe how implementation outcomes, mechanisms of impact and scale-up outcomes can be a basis to monitor adaptations through a co-creation process and to guide other scale-up interventions making use of knowledge translation and co-creation activities.

PREvalence Study on Surgical COnditions (PRESSCO) 2020: A Population-Based Cross-Sectional Countrywide Survey on Surgical Conditions in Post-Ebola Outbreak Sierra Leone

Background

Understanding the burden of diseases requiring surgical care at national levels is essential to advance universal health coverage. The PREvalence Study on Surgical COnditions (PRESSCO) 2020 is a cross-sectional household survey to estimate the prevalence of physical conditions needing surgical consultation, to investigate healthcare-seeking behavior, and to assess changes from before the West African Ebola epidemic.

Methods

This study (ISRCTN: 12353489) was built upon the Surgeons Overseas Surgical Needs Assessment (SOSAS) tool, including expansions. Seventy-five enumeration areas from 9671 nationwide clusters were sampled proportional to population size. In each cluster, 25 households were randomly assigned and visited. Need for surgical consultations was based on verbal responses and physical examination of selected household members.

Results

A total of 3,618 individuals from 1,854 households were surveyed. Compared to 2012, the prevalence of individuals reporting one or more relevant physical conditions was reduced from 25 to 6.2% (95% CI 5.4–7.0%) of the population. One-in-five conditions rendered respondents unemployed, disabled, or stigmatized. Adult males were predominantly prone to untreated surgical conditions (9.7 vs. 5.9% women; p < 0.001). Financial constraints were the predominant reason for not seeking care. Among those seeking professional health care, 86.7% underwent surgery.

Conclusion

PRESSCO 2020 is the first surgical needs household survey which compares against earlier study data. Despite the 2013–2016 Ebola outbreak, which profoundly disrupted the national healthcare system, a substantial reduction in reported surgical conditions was observed. Compared to one-time measurements, repeated household surveys yield finer granular data on the characteristics and situations of populations in need of surgical treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06695-7.

Molecular epidemiology of bovine tuberculosis in Northern Ghana identifies several uncharacterized bovine spoligotypes and suggests possible zoonotic transmission

Objective

We conducted an abattoir-based cross-sectional study in the five administrative regions of Northern Ghana to determine the distribution of bovine tuberculosis (BTB) among slaughtered carcasses and identify the possibility of zoonotic transmission.

Methods

Direct smear microscopy was done on 438 tuberculosis-like lesions from selected cattle organs and cultured on Lowenstein-Jensen media. Acid-fast bacilli (AFB) isolates were confirmed as members of the Mycobacterium tuberculosis complex (MTBC) by PCR amplification of IS6110 and rpoß. Characterization and assignment into MTBC lineage and sub-lineage were done by spoligotyping, with the aid of the SITVIT2, miruvntrplus and mbovis.org databases. Spoligotype data was compared to that of clinical M. bovis isolates from the same regions to identify similarities.

Results

A total of 319/438 (72.8%) lesion homogenates were smear positive out of which, 84.6% (270/319) had microscopic grade of at least 1+ for AFB. Two hundred and sixty-five samples (265/438; 60.5%) were culture positive, of which 212 (80.0%) were MTBC. Approximately 16.7% (34/203) of the isolates with correctly defined spoligotypes were negative for IS6110 PCR but were confirmed by rpoß. Spoligotyping characterized 203 isolates as M. bovis (198, 97.5%), M. caprae (3, 1.5%), M. tuberculosis (Mtbss) lineage (L) 4 Cameroon sub-lineage, (1, 0.5%), and M. africanum (Maf) L6 (1, 0.5%). A total of 53 unique spoligotype patterns were identified across the five administrative regions (33 and 28 were identified as orphan respectively by the SITVIT2 and mbovis.org databases), with the most dominant spoligotype being SIT1037/ SB0944 (77/203, 37.93%). Analysis of the bovine and human M. bovis isolates showed 75% (3/4) human M. bovis isolates sharing the same spoligotype pattern with the bovine isolates.

Conclusion

Our study identified that approximately 29% of M. bovis strains causing BTB in Northern Ghana are caused by uncharacterized spoligotypes. Our findings suggest possible zoonotic transmission and highlight the need for BTB disease control in Northern Ghana.

Structured diabetes self-management education and glycaemic control in low- and middle-income countries: A systematic review

AIM

To determine the association between structured diabetes self-management education (DSME) and glycaemic control in persons living with diabetes (PLD) in low- and middle-income countries (LMICs).

METHODS

PubMed, Embase and Cochrane databases were searched up to June 2020 for intervention studies on the effect of structured DSME on glycaemic control in PLD in LMICs (PROSPERO registration CRD42020164857). The primary outcome was reduction in glycated haemoglobin. Included studies were assessed for risk of bias (RoB) with the Cochrane RoB tool for randomised trials. Findings were summarized in a narrative synthesis.

RESULTS

Out of 154 abstracts retrieved and screened for eligibility, nine studies with a total of 1389 participants were included in the review. The structured DSME interventions were culturally tailored and were delivered in-person. They were associated with reductions in glycated haemoglobin in all studies: mean/median reduction ranged between 0.5% and 2.6% relative to baseline.

CONCLUSIONS

There is a dearth of literature on the association between structured DSME and glycaemic control among PLD in LMICs. The evidence available suggests that in LMICs; particularly in sub-Saharan Africa, structured DSME is associated with reduction in glycated haemoglobin. We recommend further intervention studies on the effects of structured DSME in LMICs.

Contribution of diabetes to amputations in sub-Sahara Africa: A systematic review and meta-analysis

Diabetes related amputations remain a major global problem, with devastating complications. We critically appraised relevant literature to quantify the prevalence of diabetes related amputations in sub-Saharan Africa (SSA). An electronic search was performed using the EMBASE and PubMed databases until 2020. Twenty-four out of 834 studies retrieved were included. The pooled prevalence of diabetic-related amputations was 36.9% (95%CI: 32.9%-40.8%). Complications of diabetes related amputations included infection, anaemia, foot deformity and mortality. The study revealed a substantial contribution of diabetes to the burden of amputations in SSA and suggests the need for further studies to assess how to reduce the incidence of diabetes, reduce the incidence of and or delay the progression of macro and microvascular complications of diabetes in SSA.

Availability and Affordability of Primary Health Care Among Vulnerable Populations in Urban Kumasi Metropolis: Family Health Perspective

Purpose

Health-related expenditures pose a significant burden on vulnerable populations. This study assessed the availability and affordability of primary health care among disadvantaged populations in urban Kumasi Metropolis, Ghana.

Methods

This study was a descriptive cross-sectional study conducted among multi-level participants of vulnerable populations ≥18 years of age (n=710) constituting the older adults/aged, pregnant women, head porters, sex workers, and other vulnerable groups (people with disabilities and the homeless). Data were collected using a semistructured questionnaire. Poisson regression with robust variance was used to assess the association between vulnerability and access to health care.

Results

There were significant differences in the availability and adequacy of health care among the vulnerable groups studied. Distance to the source of care was >5 km for majority of the vulnerable groups and the average expenditure on a visit to the health facility was GH¢ 27.04 (∼US$ 5.55 as at January 2019). Challenges to health care among the vulnerable groups included monetary (37.9%), stigmatization (18.6%), and staff attitude (25.9%). Head porters and other vulnerable groups were less likely to view health care as affordable compared with older adults. The difference in the perception of health care affordability was, however, explained by sociodemographic characteristic and health care-related factors.

Conclusion

Despite the introduction of a National Health Insurance Scheme in Ghana, this study highlights challenges in health care access among vulnerable populations independent of the type of vulnerability. This suggests the need for stakeholders to adopt other innovative care strategies that may have broader applicability for all populations.

Carotid Atherosclerosis, Microalbuminuria, and Estimated 10-Year Atherosclerotic Cardiovascular Disease Risk in Sub-Saharan Africa

IMPORTANCE

Carotid atherosclerosis and microalbuminuria are associated with atherosclerotic cardiovascular disease (ASCVD) but are understudied in sub-Saharan Africa.

OBJECTIVE

To evaluate the association of carotid atherosclerosis and microalbuminuria with 10-year ASCVD risk in middle-aged sub-Saharan African individuals.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study conducted analyses of baseline data from the African-Wits-INDEPTH (International Network for the Demographic Evaluation of Populations and Their Health in Low- and Middle-Income Countries) genomic study (AWI-Gen). Women and men aged 40 to 60 years without baseline CVD and drawn from Burkina Faso, Ghana, Kenya, and South Africa were included.

MAIN OUTCOMES AND MEASURES

Hypotheses for the analyses were formulated after data collection. The main exposures were carotid atherosclerosis, assessed using carotid intima-media thickness (CIMT) using B-mode ultrasonography, and microalbuminuria, measured using spot urine albumin (SUA) and urine albumin-creatinine ratio (uACR). The main outcome was high ASCVD risk, defined as a 2018 Pooled Cohort Equations score of 7.5% or greater. Associations were estimated using adjusted multivariable logistic regression analyses.

FINDINGS

A total of 9010 participants with a mean (SD) age of 50 (6) years and 4533 (50.3%) women were included. High CIMT, SUA, and uACR were each associated with older age (eg, mean [SD] age of participants with high vs reference range CIMT: 55 [5] years vs 50 [6] years; P < .001) and high prevalence of both diabetes and hypertension (eg, hypertension among those with high vs reference range SUA: 213 of 1117 [19.1%] vs 356 of 2549 [14.0%]; P < .001). Smokers were likely to have higher vs reference range SUA (210 [18.8%] vs 407 [16.0%]) and uACR (138 of 707 [19.5%] vs 456 of 2797 [16.3%]). Carotid atherosclerosis was common in Burkina Faso (82 of 262 [31.3%]) and Ghana (91 [34.7%]), while microalbuminuria, measured by SUA, was common in Kenya (272 [24.4%]) and South Africa (519 [46.5%]). SUA was associated with higher odds of carotid atherosclerosis (odds ratio [OR], 1.77; 95% CI, 1.04-3.01) compared with uACR (OR, 0.51; 95% CI, 0.27-0.95). Common CIMT, SUA, and uACR were associated with 10-year ASCVD risk, with CIMT having a stronger association with 10-year ASCVD risk in both women (OR, 1.95; 95% CI, 1.78-2.14) and men (OR, 1.73; 95% CI, 1.55-1.93) than SUA (women: OR, 1.29; 95% CI, 1.12-1.43; men: OR, 1.46; 95% CI, 1.26-1.55) and uACR (women: OR, 1.32; 95% CI, 1.10-1.54; men: OR, 1.35; 95% CI, 1.15-1.46).

CONCLUSIONS AND RELEVANCE

The presence of microalbuminuria measured by SUA may indicate risk of subclinical carotid atherosclerosis and high 10-year ASCVD risk in middle-aged residents of sub-Saharan Africa. These data should be confirmed in longitudinal studies of cardiovascular events.

Socioeconomic Determinants of Cardiovascular Diseases, Obesity, and Diabetes among Migrants in the United Kingdom: A Systematic Review

There has been little agreement on the role that socioeconomic factors play in the aetiology of cardiovascular diseases (CVDs), obesity, and diabetes among migrants in the United Kingdom (UK). We systematically reviewed the existing evidence on this association to contribute to filling this gap in the literature. Two reviewers were involved at each stage of the review process to ensure validity. We comprehensively searched through several electronic databases and grey literature sources to identify potentially eligible papers for our review. We extracted data from our finally included studies and appraised the methodological rigour of our studies. A narrative synthesis approach was used to synthesise and interpret the extracted data. We sieved through 2485 records identified from our search and finally obtained 10 studies that met our inclusion criteria. The findings of this review show that there is a trend towards an association between socioeconomic factors and CVDs, diabetes, and obesity among migrants in the UK. However, the picture was more complex when specific socioeconomic variables and migrant subgroups were analysed. The evidence for this association is inconclusive and its causal relationship remains speculative. There is, therefore, the need for further research to understand the exact association between socioeconomic factors and CVD, diabetes, and obesity among migrants in the UK.

Incidence and correlates of high blood pressure from childhood to adulthood: the Birth to Twenty study

BACKGROUND

There is growing evidence from high-income countries suggesting that hypertension developed in childhood and adolescence persists into adulthood. The objective of this study was to investigate the incidence and risk factors of high blood pressure (BP) in urban black children.

METHODS

We used data from the Birth to Twenty (BT20+) cohort in Johannesburg, South Africa constituting of children born in 1990 and who had their growth, development and blood pressure measured at six follow-up periods over the course of 13 years. High BP was classified as at least 95th percentile for age, sex and height. Incidence rate of high BP was calculated using survival analysis and risk factors were determined by use of Cox proportional hazard regression.

RESULTS

Over a follow-up period of 13 years, the overall incidence rate of high BP was 57 cases per 1000 person-years (95% CI 53.2-61.1). Risk for incident high BP increased with rapid relative weight gain in early childhood (hazard ratio =1.11, 95% CI 1.00-1.22), mid-childhood (hazard ratio = 1.13, 95% CI 1.03-1.24) and adolescence (hazard ratio = 1.21, 95% CI 0.99-1.47). Maternal parity significantly increased the risk for incident high BP (hazard ratio = 1.08, 95% CI 1.01-1.15).

CONCLUSION

Maternal parity and relative weight gain were determinants for incident high blood pressure in urban black South African children and adolescents. To reduce the high incidence and the disease burden of high BP, national programs should focus on promoting healthy lifestyle in early stages of life to prevent rapid weight gain and later cardiovascular disease risk. Further research is required to investigate whether incident high BP in childhood predict clinical outcomes in adulthood.

Multimorbidity of non-communicable diseases in low-income and middle-income countries: a systematic review and meta-analysis

INTRODUCTION

Multimorbidity is a major public health challenge, with a rising prevalence in low/middle-income countries (LMICs). This review aims to systematically synthesise evidence on the prevalence, patterns and factors associated with multimorbidity of non-communicable diseases (NCDs) among adults residing in LMICs.

METHODS

We conducted a systematic review and meta-analysis of articles reporting prevalence, determinants, patterns of multimorbidity of NCDs among adults aged >18 years in LMICs. For the PROSPERO registered review, we searched PubMed, EMBASE and Cochrane libraries for articles published from 2009 till 30 May 2020. Studies were included if they reported original research on multimorbidity of NCDs among adults in LMICs.

RESULTS

The systematic search yielded 3272 articles; 39 articles were included, with a total of 1 220 309 participants. Most studies used self-reported data from health surveys. There was a large variation in the prevalence of multimorbidity; 0.7%-81.3% with a pooled prevalence of 36.4% (95% CI 32.2% to 40.6%). Prevalence of multimorbidity increased with age, and random effect meta-analyses showed that female sex, OR (95% CI): 1.48, 1.33 to 1.64, being well-off, 1.35 (1.02 to 1.80), and urban residence, 1.10 (1.01 to 1.20), respectively were associated with higher odds of NCD multimorbidity. The most common multimorbidity patterns included cardiometabolic and cardiorespiratory conditions.

CONCLUSION

Multimorbidity of NCDs is an important problem in LMICs with higher prevalence among the aged, women, people who are well-off and urban dwellers. There is the need for longitudinal data to access the true direction of multimorbidity and its determinants, establish causation and identify how trends and patterns change over time.

PROSPERO REGISTRATION NUMBER

CRD42019133453.

Multimorbidity Among Migrant and Non-Migrant Ghanaians: The RODAM Study

Objectives: Multimorbidity is a growing public health concern due to the increasing burden of non-communicable diseases, yet information about multimorbidity in low- and middle-income countries and migrant populations is scarce. We aimed to investigate the distribution and patterns of multimorbidity in rural and urban areas in Ghana and Ghanaian migrants in Europe. Methods: The RODAM cross-sectional study included 4,833 participants. Multimorbidity was defined as presence of multiple non-communicable chronic conditions. Patterns were determined from frequent combination of conditions. Prevalence ratios were estimated by logistic regression. Results: Prevalence of multimorbidity was higher in women and in urban Ghana and Europe. We observed a cardiometabolic pattern in all sites as well as circulatory-musculoskeletal and metabolic-musculoskeletal combinations in Ghana. Multimorbidity prevalence ratios were higher in Europe (men 1.47, 95% CI 1.34-1.59, women 1.18, 1.10-1.26) and urban Ghana (men 1.46, 1.31-1.59, women 1.27, 1.19-1.34). Conclusion: Distribution and patterns of multimorbidity differed by sex and site. With a higher burden of multimorbidity in urban areas, prevention strategies should focus on forestalling its increase in rapidly growing rural areas.

Multimorbidity of communicable and non-communicable diseases in low- and middle-income countries: A systematic review

OBJECTIVE

The aim of this systematic review is to analyse existing evidence on prevalence, patterns, determinants, and healthcare challenges of communicable and non-communicable disease multimorbidity in low- and middle-income countries (LMICs).

METHODS

PubMed, Cochrane, and Embase databases were searched from 1^st January 2000 to 31^st July 2020. The National Institute of Health (NIH) quality assessment tool was used to critically appraise studies. Findings were summarized in a narrative synthesis. The review was registered with PROSPERO (CRD42019133453).

RESULTS

Of 3718 articles screened, 79 articles underwent a full text review of which 11 were included for narrative synthesis. Studies reported on 4 to 20 chronic communicable and non-communicable diseases; prevalence of multimorbidity ranged from 13% in a study conducted among 242,952 participants from 48 LMICS to 87% in a study conducted among 491 participants in South Africa. Multimorbidity was positively associated with older age, female sex, unemployment, and physical inactivity. Significantly higher odds of multimorbidity were noted among obese participants (OR 2.33; 95% CI: 2.19-2.48) and those who consumed alcohol (OR 1.44; 95% CI: 1.25-1.66). The most frequently occurring dyads and triads were HIV and hypertension (23.3%) and HIV, hypertension, and diabetes (63%), respectively. Women and participants from low wealth quintiles reported higher utilization of public healthcare facilities.

CONCLUSION

The identification and prevention of risk factors and addressing evidence gaps in multimorbidity clustering is crucial to address the increasing communicable and non-communicable disease multimorbidity in LMICs. To identify communicable and non-communicable diseases trends over time and identify causal relationships, longitudinal studies are warranted.

Maternal near-miss and mortality associated with hypertensive disorders of pregnancy remote from term: A multicenter observational study in Ghana

BACKGROUND

Maternal death rates remain high in many low- and middle-income countries. Hypertensive disorders of pregnancy account for 18% of maternal mortality in Ghana. The maternal near-miss approach was designed to evaluate severe (acute) complications in pregnancy, which is useful to detect potential areas for clinical care improvement.

OBJECTIVE

This study aimed (1) to determine the incidence of severe maternal complications, maternal near-miss cases, and mortality cases associated with hypertensive disorders of pregnancy remote from term and (2) to assess the health system's performance indicators for the management of hypertensive disorders of pregnancy remote from term in middle-income country referral hospitals.

STUDY DESIGN

This study was nested in the ongoing Severe Preeclampsia adverse Outcome Triage study, a multicenter observational cohort study, and included women recruited from December 1, 2017, to May 31, 2020, from 5 referral hospitals in Ghana. Women aged >16 years, admitted to the hospital with hypertensive disorders of pregnancy, with gestational age between 26 and 34 weeks were eligible. Near miss was defined according to the World Health Organization and sub-Saharan African near-miss criteria. Descriptive statistics of pregnancy and maternal and perinatal outcomes up to 6 weeks after delivery of women with severe maternal outcomes were presented for maternal deaths and maternal near-miss casigurees and compared with that of women without severe maternal outcomes. The health system's maternal and perinatal performance indicators were calculated.

RESULTS

Overall, 447 women with hypertensive disorders of pregnancy were included in the analyses with a mean maternal age of 32 (±5.8) years and mean gestational age at recruitment of 30.5 (±2.4) weeks. Of these patients, 46 (10%) had gestational hypertension, 338 (76%) had preeclampsia, and 63 (14%) had eclampsia. There were 148 near-miss cases (33.1%) and 12 maternal deaths (2.7%). Severe maternal outcomes constituted complications from severe preeclampsia (80/160 [50%]) and eclampsia (63/160 [39.4%]). Concerning organ dysfunction, hematologic and respiratory dysfunctions constituted 59/160 [38.6%] and 23/160 [14.8%] respectively. Nearly all women had a cesarean delivery (347/447 [84%] and 140/160 [93%] in the severe maternal outcome group) and delivered prematurely (83%, with 178/379 [93%] at <32 weeks of gestation). Stillbirth and neonatal deaths occurred in 63 of 455 women (14%) and 81 of 392 women (19%), respectively, constituting a stillbirth ratio of 161 per 1000 live births and neonatal mortality rate of 207 per 1000 live births as there were 392 live births in this cohort. Overall, the intensive care unit admission rate was 12.7% (n=52/409); moreover, 45 of 52 women (86.5%) admitted to the intensive care unit had severe maternal outcomes. The maternal death ratio was 3100 per 100,000 live births, the maternal near-miss–to–mortality ratio was 12.3, and the mortality index was 8%.

CONCLUSION

Maternal near miss and maternal and perinatal mortalities were common in women with hypertensive disorders of pregnancy remote from term in referral hospitals in Ghana. Providing appropriate patient-centered and multidisciplinary quality care for these women is crucial in improving pregnancy outcomes. Context-tailored interventions should be considered in the clinical management of complications associated with hypertensive disorders of pregnancy in resource-limited settings. Further research on interventions to improve timely referral and reduce in-hospital delays in care provision is recommended to facilitate emergency care services for women with hypertensive emergencies.

The GetReal Trial Tool: Design, Assess and Discuss Clinical Drug Trials in Light of RWE Generation

Methodologies incorporating Real World Elements into clinical trial design (also called pragmatic trials) offer an attractive opportunity to assess the effect of a treatment strategy in routine care and as such guide decision making in practice. Uptake of these methods is slow for several reasons, including uncertainty about acceptability of trial results, lack of experience with the methodology and operational challenges. We developed the 'Get Real Trial Tool', an easy-to-use interface, which allows users to assess the impact of design choices on generalisability to routine clinical practice, while taking into account risk of bias, precision, acceptability and operational feasibility. The tool is grounded in the scientific literature on pragmatic trials combined with knowledge of experts from academia, pharmaceutical companies, HTA bodies, patient organisations, and regulators. The aim is to help researchers optimise trial design and facilitate translation of evidence from pragmatic trials to clinical practice. In this paper we describe the development, structure and application of the GetReal Trial Tool.

Process evaluation of care scale up for hypertension in diabetes in Belgium, Slovenia and Cambodia

Background

Effective integrated care interventions for hypertension (HT) and type 2 diabetes (T2D) exist and need to be scaled-up. The ‘SCale-Up diaBetes and hYpertension care' SCUBY project aims to facilitate scale-up of integrated care for HT and T2D through the implementation of contextualised scale-up roadmaps in Cambodia, Slovenia and Belgium and co-creation in policy dialogues. We herewith describe the plan for the process and scale-up evaluation of the SCUBY project, including the development, adoption and implementation of the roadmaps. The specific goals of the process evaluation are to (i) analyse how the reality of scale-up adheres to the developed roadmaps and (ii) assess how the different contexts can influence the implementation process of the scale-up strategies.

Methods

A comprehensive framework was developed to include context, process, scale-up and impact evaluation that is embedded in implementation and political theory. A diverse range of mostly qualitative tools - including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping - will be used to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. Key implementation outcomes include acceptability, feasibility relevance, adaptation, adoption and cost of roadmap activities. The role of context is relevant, and barriers and facilitators to scale-up will be continuously assessed.

Conclusions

The SCUBY project presents a comprehensive framework to guide the evaluation of scale-up of complex interventions. We describe three contextualised roadmaps, for Belgium, Slovenia and Cambodia, each adopting their own (horizontal/diversification/vertical) scale-up strategy(ies) as a basis to monitor adaptations through a co-creation process. This study protocol will be a guide for other scale-up interventions making use of knowledge translation and co-creation activities.

Key messages

Process evaluation is needed to keep track of complex interventions including scale up. The SCUBY project developed an evaluation plan to comprehensively monitor the scale-up of HT and T2D care.

Evaluating the cascade of care for hypertension in Sierra Leone

OBJECTIVE

To assess the care for hypertension in Sierra Leone, by the use of a cascade-of-care approach, to identify where the need for healthcare system interventions is greatest.

METHODS

Using data from a nationwide household survey on surgical conditions undertaken in 1956 participants ≥18 years from October 2019 to March 2020, a cascade of care for hypertension consisting of four categories - hypertensive population, those diagnosed, those treated and those controlled - was constructed. Hypertension was defined as having a blood pressure ≥140/90 mmHg, or self-reported use of antihypertensive medication. Logistic regression analysis was used to investigate factors associated with undiagnosed hypertension.

RESULTS

The prevalence of hypertension was 22%. Among those with hypertension, 23% were diagnosed, 11% were treated and 5% had controlled blood pressure. The largest loss to care (77%) was between being hypertensive and receiving a diagnosis. Male sex, age and living in a rural location, were significantly associated with the odds of undiagnosed hypertension. There was no significant difference between men and women in the number of patients with controlled blood pressure. Adults aged 40 or older were observed to be better retained in care compared with those younger than 40 years of age.

CONCLUSION

There is a significant loss to care in the care cascade for hypertension in Sierra Leone. Our results suggest that increasing awareness of cardiovascular risk and risk factor screening for early diagnosis might have a large impact on hypertension care.

Rural and urban migration to Europe in relation to cardiovascular disease risk: does it matter where you migrate from?

OBJECTIVES

To assess whether the environmental context (i.e. rural vs urban) in which individuals in low- and middle-income countries have resided most of their lives is associated with estimated cardiovascular disease (CVD) risk after migration to a high-income country.

STUDY DESIGN

Data from the Research on Obesity and Diabetes among African Migrants (RODAM) study were used including 1699 Ghanaian participants aged 40-79 years who had migrated to Europe from Ghana (1549 of urban origin, 150 of rural origin).

METHODS

Ten-year CVD risk was estimated using the Pooled Cohort Equation, with estimates ≥7.5% defining elevated CVD risk. Comparisons between urban and rural origin migrant groups were made using proportions and adjusted odds ratios (ORs).

RESULTS

The proportion of migrants with an elevated CVD-risk score was substantially higher among rural migrants than among urban migrants (45% vs. 37%, OR = 1.44, 95% confidence interval [CI]:1.03-2.02), which persisted after adjustment for education level, site of residence in Europe (London, Amsterdam or Berlin), length of stay in Europe, physical activity, energy intake and alcohol consumption (OR = 1.67, 95% CI: 1.05-2.67).

CONCLUSION

Our findings indicate that migrants who spent most of their lives in a rural setting before migration to Europe may have a higher CVD risk than those of urban origins. Further work is needed to confirm these findings in other migrant populations and to unravel the mechanisms driving the differential CVD risk between urban and rural migrants.

Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium (SCUBY): a study design for a quasi-experimental multiple case study

Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.

Association between Practising Religion and Cardiovascular Disease Risk among Ghanaian Non-Migrants and Migrants in Europe: The RODAM Study

(1) Background: Sub-Saharan African migrants residing in high-income countries are more affected by cardiovascular diseases (CVDs) and associated risk factors than host populations for unclear reasons. The aim was to explore the associations of religion and religious affiliations with CVD risk among Ghanaian non-migrants and migrants in Europe. (2) Methods: The 10-year CVD risk was estimated using pooled cohort equations for 3004 participants from the cross-sectional Research on Obesity and Diabetes among African Migrants (RODAM) study. Logistic regression analyses were conducted to assess associations between religion and elevated CVD risk (score ≥ 7.5) with adjustment for covariates. (3) Results: Religious men in Europe had a lower 10-year CVD risk compared with non-religious men (adjusted OR 0.51; 95% confidence interval 0.30–0.85), specifically men affiliated with Seventh-Day Adventism (0.24; 0.11–0.53) followed by other affiliations (0.32; 0.11–0.94) and Roman Catholicism (0.42; 0.21–0.86). The opposite was found in Ghana, with religious women having higher odds for elevated 10-year CVD risk (1.53; 1.02–2.30) compared with their non-religious counterparts, specifically women affiliated with Reformed Christianity (1.73; 1.03–2.90) and other denominations (2.81; 1.20–6.54). Associations were not significant for men in Ghana and women in Europe. Adjustments for social support, stress, and health behaviors did not meaningfully alter the associations. (4) Conclusions: Christian religious Ghanaian men living in Europe seem to have lower CVD risk compared with their non-religious counterparts, while Christian religious women in Ghana appear to have increased CVD risk. Further unravelling the contributing factors and the differences between sex and environmental settings is needed.

Anthropometric indices and their cut-off points in relation to type 2 diabetes among Ghanaian migrants and non-migrants: The RODAM study

AIMS

To compare body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) as determinants of type 2 diabetes (T2DM) and determine optimal cut-offs in a sub-Saharan African population.

METHODS

Data from the RODAM study including Ghanaians aged 25-70 living in rural Ghana, urban Ghana and Europe were used. Logistic regression was used to assess associations between BMI, WC, WHR and T2DM status, by sex and site. Area under the curve (AUC) were constructed to discriminate between indices and establish performance and cut-off values.

RESULTS

WHR had the strongest association with T2DM in men and women across sites, except for rural men. The highest adjusted odds ratio (aOR) and AUC were in rural women for WHR (aOR = 2.09, 95%CI = 1.47-2.99; AUC = 0.71). Among migrants, WHR had higher AUCs compared with BMI (p < 0.01) and WC (p < 0.05). Cut-offs for BMI and WC in men were lower compared with the WHO reference across sites (WC: 85.4-93.7 vs 102 cm, BMI: 23.1-28.2 vs 30.0 kg/m²).

CONCLUSIONS

WHR outperformed BMI and WC as anthropometric indices in relation to T2DM among Ghanaian migrants. The lower BMI and WC cut-offs for T2DM than WHO established standards, highlights the need for African specific cut-offs to avoid missing high risk populations.

Comparative performance of pooled cohort equations and Framingham risk scores in cardiovascular disease risk classification in a slum setting in Nairobi Kenya

BACKGROUND

Cardiovascular diseases (CVD) cause 18 million deaths annually. Low- and middle-income countries (LMICs) account for 80% of the CVD burden, and the burden is expected to grow in the region in the coming years. Screening for and identification of individuals at high risk for CVD in primary care settings can be accomplished using available CVD risk scores. However, few of these scores have been validated/recalibrated for use in sub-Saharan Africa (SSA).

METHODS

Pooled cohort equations (PCE) and Framingham risk scores for 10-year CVD risk were applied on 1960 men and women aged 40 years and older from the AWI-Gen (Africa, Wits-INDEPTH Partnership for GENomic studies) study 2015. Low, moderate/intermediate or high CVD risk classifications correspond to <10%, 10-20% and >20% chance of developing CVD in 10 years respectively. Agreement between the risk scores was assessed using kappa and correlation coefficients.

RESULTS

High CVD risk was 10.3% in PCE 2013, 0.4% in PCE 2018, 2.9% in Framingham and 3.6% in Framingham non-laboratory scores. Conversely, low CVD risk was 62.2% in PCE 2013 and 95.6% in PCE 2018, 84.0% and 80.1% in Framingham and Framingham non-laboratory scores, respectively. A moderate agreement existed between the Framingham functions (kappa = 0.64, 95% CI 0.59-0.68, correlation, rs = 0.711). There was no agreement between the PCE 2013 and 2018 functions (kappa = 0.05, 95% CI 0.04-0.06).

CONCLUSIONS

Newer cohort-based data is necessary to validate and recalibrate existing CVD risk scores in order to develop appropriate functions for use in SSA.

Maternal dietary diversity and pattern during pregnancy is associated with low infant birth weight in the Cape Coast metropolitan hospital, Ghana: A hospital based cross-sectional study

BACKGROUND

This study investigated the associations between mother's dietary diversity score and dietary patterns during pregnancy and the odds of low birth weight at the Cape Coast Metropolitan Hospital in Ghana.

METHODS

Mothers attending the postnatal clinic from January to August 2016 at the Cape Coast Metropolitan Hospital were included. Dietary information during pregnancy was assessed with a food frequency questionnaire. In reference to the women's dietary diversity score, women were categorized into low, medium or high dietary diversity score groups. The primary outcome was low birth weight and was defined as weight <2500 g at birth. Factor analysis was conducted to identify maternal dietary patterns and a multivariable logistic regression analysis was used to determine the associations between dietary diversity score and dietary patterns with low birth weight.

RESULTS

The prevalence of low birth weight in infants was 43.8% (95% CI = 39%-49%). After adjusting for covariates, the odds of low birth weight was four times higher in the low dietary diversity score group compared to the high dietary diversity score group (odds ratio [OR] = 4.29, 95% confidence interval [CI], 1.24-6.48). Three dietary patterns namely "Western", "Traditional" and "Healthy", which explained 58.23% of the total variance in food intake were identified. The subjects in the highest quartiles of "healthy" and "traditional" dietary pattern scores had significantly lower odds of low birth weight (healthy: OR = 0.23, 95% CI, 0.19-0.39, P trend <0.0001; traditional: OR = 0.14, 95% CI, 0.06-0.35, P trend <0.0001, respectively) compared to those in the lowest quartiles of dietary pattern score.

CONCLUSION

Low dietary diversity score during pregnancy was associated with higher odds of infant low birth weight whereas dietary patterns considered as "healthy" and "traditional" during pregnancy were associated with lower odds of infant low birth weight. Findings of this study suggests that higher dietary diversity and "healthy" and "traditional" dietary patterns during pregnancy may be protective of LBW in the study area.

Obesity and cardiovascular disease risk among Africans residing in Europe and Africa: the RODAM study

BACKGROUND

The association between anthropometric variables and cardiovascular disease (CVD) risk among Africans is unclear. We examined the discriminative ability of anthropometric variables and estimate cutoffs for predicting CVD risk among Africans.

METHODS

The Research on Obesity and Diabetes among African Migrants (RODAM) study was a multisite cross-sectional study of Africans in Ghana and Europe. We calculated AHA/ACC Pooled Cohort Equations (PCE) scores for 3661 participants to ascertain CVD risk, and compared a body shape index (ABSI), body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), Relative Fat Mass (RFM), and Waist to Height Ratio (WHtR). Logistic regression and receiver operating curve analyses were performed to derive cutoffs for identifying high predicted CVD risk (PCE score ≥7.5%).

RESULTS

Among men, WC (adjusted Odds Ratio (aOR): 2.25, 95% CI; 1:50-3:37) was strongly associated with CVD risk. Among women, WC (aOR: 1.69, 95% CI: 1:33-2:14) also displayed the strongest association with CVD risk in the BMI-adjusted model but WHR displayed the strongest fit. All variables were superior discriminators of high CVD risk in men (c-statistic range: 0.887-0.891) than women (c-statistic range: 0.677-0.707). The optimal WC cutoff for identifying participants at high CVD risk was 89 cm among men and identified the most cases (64%). Among women, the recommended WC cutoff of 94 cm or WHR cutoff of 0.90 identified the most cases (92%).

CONCLUSIONS

Anthropometric variables were stronger discriminators of high CVD risk in African men than women. Greater WC was associated with high CVD risk in men while WHR and WC were associated with high CVD risk in women.

Acculturation and Food Intake Among Ghanaian Migrants in Europe: Findings From the RODAM Study

OBJECTIVE

This study examined the role of migration and acculturation in the diet of Ghanaian migrants in Europe by (1) comparing food intake of Ghanaian migrants in Europe with that of Ghanaians living in Ghana and (2) assessing the association between acculturation and food intake.

DESIGN

Data from the cross-sectional multicenter study Research on Obesity and Diabetes among African Migrants were used. Food intake was assessed using a Ghana-specific food propensity questionnaire (134 items and 14 food groups); foods were grouped based on a model of dietary change proposed by Koctürk-Runefors.

SETTING

Ghana, London, Amsterdam, and Berlin.

PARTICIPANTS

A total of 4,534 Ghanaian adults living in Ghana and Europe, with complete dietary data. Of these, 1,773 Ghanaian migrants had complete acculturation data.

MAIN OUTCOME MEASURE

Food intake (the weighted intake frequency per week of food categories).

ANALYSIS

Linear regression.

RESULTS

Food intake differed between Ghanaians living in Ghana and Europe. Among Ghanaian migrants in Europe, there were inconsistent and small associations between acculturation and food intake, except for ethnic identity, which was consistently associated with intake only of traditional staples.

CONCLUSIONS AND IMPLICATIONS

Findings indicate that migration is associated with dietary changes that cannot be fully explained by ethnic, cultural, and social acculturation. The study provides limited support to the differential changes in diet suggested by the Koctürk-Runefors' model of dietary change.

Differential associations between psychosocial stress and obesity among Ghanaians in Europe and in Ghana: findings from the RODAM study

PURPOSE

Psychosocial stress is associated with obesity in some populations, but it is unclear whether the association is related to migration. This study explored associations between psychosocial stress and obesity among Ghanaian migrants in Europe and non-migrant Ghanaians in Ghana.

METHODS

Cross-sectional data from the RODAM study were used, including 5898 Ghanaians residing in Germany, the UK, the Netherlands, rural Ghana, and urban Ghana. Perceived discrimination, negative life events and stress at work or at home were examined in relation to body mass index (BMI) and waist circumference (WC). Linear regression analyses were performed separately for migrants and non-migrants stratified by sex.

RESULTS

Perceived discrimination was not associated with BMI and WC in both migrants and non-migrants. However, negative life events were positively associated with BMI (β = 0.78, 95% CI 0.34-1.22) and WC (β = 1.96, 95% CI 0.79-3.12) among male Ghanaian migrants. Similarly, stress at work or at home was positively associated with BMI (β = 0.28, 95% CI 0.00-0.56) and WC (β = 0.84, 95% CI 0.05-1.63) among male Ghanaian migrants. Among non-migrant Ghanaians, in contrast, stress at work or at home was inversely associated with BMI and WC in both males (β = - 0.66, 95% CI - 1.03 to - 0.28; β = - 1.71 95% CI - 2.69 to - 0.73, respectively) and females (β = - 0.81, 95% CI - 1.20 to - 0.42; β = - 1.46, 95% CI - 2.30 to - 0.61, respectively).

CONCLUSIONS

Negative life events and stress at work or at home are associated with increased body weight among male Ghanaians in European settings, whereas stress at work or at home is associated with reduced body weight among Ghanaians in Ghana. More work is needed to understand the underlying factors driving these differential associations to assist prevention efforts.

Early-life factors are associated with waist circumference and type 2 diabetes among Ghanaian adults: The RODAM Study

Early-life experiences may fuel the emergence of obesity and type 2 diabetes among African populations. We evaluated childhood socio-economic status (SES) and childhood nutritional status as risk factors for increased waist circumference and type 2 diabetes among Ghanaian adults. In the multi-center, cross-sectional Research on Obesity and Diabetes among African Migrants (RODAM) Study, we calculated associations (adjusted for demographics and lifestyle) of parental education and anthropometric markers of childhood nutrition [leg length, leg length-to-height ratio (LHR)] with waist circumference and type 2 diabetes, respectively. Among 5,575 participants (mean age: 46.2 years; 62% female), lower education of either parent (vs. higher) was consistently associated with higher waist circumference (∆: 1.6-3.4 cm). Lower father's education tended to increase the odds of type 2 diabetes by 50% in women (95% confidence interval (CI): 1.0, 2.4). Reduced leg length and LHR were associated with higher waist circumference. But only in men, leg length was inversely related to type 2 diabetes (OR per 1 standard deviation decrease: 1.1; 95% CI: 1.0, 1.3). In this study, markers of poor childhood SES and early-life nutritional status relate to abdominal obesity in men and women and to type 2 diabetes in men. Thus, prevention efforts should start in early childhood.

Dietary Patterns Are Associated with Predicted 10-Year Risk of Cardiovascular Disease Among Ghanaian Populations: the Research on Obesity and Diabetes in African Migrants (RODAM) Study

BACKGROUND

Sub-Saharan African populations are disproportionately affected by cardiovascular disease (CVD). Although diet is an important lifestyle factor associated with CVD, evidence on the relation between dietary patterns (DPs) and CVD risk among sub-Saharan African populations is limited.

OBJECTIVE

We assessed the associations of DPs with estimated 10-y atherosclerotic cardiovascular disease (ASCVD) risk in Ghanaian adults in Ghana and Europe.

METHODS

Three DPs ('mixed'; 'rice, pasta, meat, and fish'; and 'roots, tubers, and plantain') were derived by principal component analysis (PCA) based on intake frequencies obtained by a self-administered Food Propensity Questionnaire in the multi-center, cross-sectional RODAM (Research on Obesity and Diabetes among African Migrants) study. The 10-y ASCVD risk was estimated using the Pooled Cohort Equations (PCE) for 2976 subjects, aged 40-70 y; a risk score ≥7.5% was defined as 'elevated' ASCVD risk. The associations of DPs with 10-y ASCVD risk were determined using Poisson regression with robust variance.

RESULTS

Stronger adherence to a 'mixed' DP was associated with a lower predicted 10-y ASCVD in urban and rural Ghana and a higher 10-y ASCVD in Europe. The observed associations were attenuated after adjustment for possible confounders with the exception of urban Ghana (prevalence ratio [PR] for Quintile 5 compared with 1: 0.70; 95% CI: 0.53, 0.93, P-trend = 0.013). The 'rice, pasta, meat, and fish' DP was inversely associated with 10-y ASCVD across all study sites, with the adjusted effect being significant only in urban Ghana. A 'roots, tubers, and plantain' DP was directly associated with increased 10-y ASCVD risk.

CONCLUSIONS

Adherence to 'mixed' and 'rice, pasta, meat, and fish' DPs appears to reduce predicted 10-y ASCVD risk in adults in urban Ghana. Further investigations are needed to understand the underlying contextual-level mechanisms that influence dietary habits and to support context-specific dietary recommendations for CVD prevention among sub-Saharan African populations.

Access and utilization of maternal healthcare in a rural district in the forest belt of Ghana

BACKGROUND

Poor maternal health delivery in developing countries results in more than half a million maternal deaths during pregnancy, childbirth or within a few weeks of delivery. This is partly due to unavailability and low utilization of maternal healthcare services in limited-resource settings. The aim of this study was to investigate the access and utilization of maternal healthcare in Amansie-West district in the Ashanti Region of Ghana.

METHODS

An analytical cross-sectional study, involving 720 pregnant women systematically sampled from antenatal clinics in five sub-districts was conducted from February to May 2015 in the Amansie-West district. Data on participants' socio-economic characteristics, knowledge level and access and utilization of maternal health care services were collected with a structured questionnaire. Odds ratios were estimated to describe the association between explanatory variables and maternal healthcare using generalized estimating equations (GEE).

RESULTS

68.5, 83.6 and 33.6% of the women had > 3 antenatal care visits, utilized skilled delivery and postnatal care services respectively. The mothers' knowledge level of pregnancy emergencies and newborn danger signs was low. Socio-economic characteristics and healthcare access influenced the utilization of maternal healthcare. Compared to the lowest wealth quintile, being in the highest wealth quintile was associated with higher odds of receiving postnatal care (adjusted odds ratio [aOR]; 95%CI: 2.84; 1.63, 4.94). Use of health facility as a main source of healthcare was also associated with higher odds of antenatal care and skilled delivery.

CONCLUSION

This study demonstrates suboptimal access and utilization of maternal healthcare in rural districts of Ghana, which are influenced by socio-economic characteristics of pregnant mothers. This suggests the need for tailored intervention to improve maternal healthcare utilization for mothers in this and other similar settings.

Perceived discrimination and stressful life events are associated with cardiovascular risk score in migrant and non-migrant populations: The RODAM study

BACKGROUND

Psychosocial stress could be an underlying factor for emerging risk of cardiovascular diseases (CVD) in Africans. We assessed the association between psychosocial stress and estimated CVD risk among non-migrant Ghanaians and migrant Ghanaians living in Europe.

METHODS

Data from the Research on Obesity and Diabetes among African Migrants (RODAM) study, involving 2315 migrant and 1549 non-migrants aged 40-70 years were used for this study. Psychosocial stress included self-reported stress at work and home, recent negative life events and perceived discrimination. CVD risk was estimated using the pooled cohort equations with estimates ≥7.5% over 10 years defining high CVD risk. Adjusted Odds Ratios (AOR) and 95% confidence intervals (95% CI) were calculated by logistic regression with adjustments for socioeconomic status.

RESULTS

Prevalence for migrant and non-migrants were; 72.5% and 84.9% for psychosocial stress and 35.9% and 27.4% for high estimated CVD risk. Stress at work and home was not associated with a high estimated CVD risk in either group. Recent negative life events were associated with a high estimated CVD risk in non-migrants only (AOR 1.29, 95%CI 1.02-1.68, p = 0.048). Higher levels of perceived discrimination were associated with a high estimated CVD risk in migrants only (AOR 2.74, 95%CI 1.95-3.86, p < 0.001).

CONCLUSIONS

Among migrant populations, higher levels of perceived discrimination were associated with a high estimated CVD risk, and this was also true for recent negative life events among non-migrant populations. Further research is needed to identify context specific mechanisms that underlie associations between psychological characteristics and CVD risk.

Prevalence and knowledge of hypertension among people living in rural communities in Ghana: a mixed method study

BACKGROUND

Knowledge and understanding of hypertension and its associated health risks remain inadequate despite increasing trend of hypertension prevalence. This study was conducted to assess the prevalence, knowledge and perceptions of hypertension in rural communities in Ghana.

METHODS

A mixed method study involving 534 subjects was employed. Data was collected in six communities from May to December 2014 with structured questionnaires and interview guides. A logistic regression analysis was conducted to estimate the influence of the socio-demographic factors on knowledge of hypertension. Qualitative data was thematically analyzed.

RESULTS

The mean systolic blood pressure (BP) was higher in men than women (127.42mmHg versus 124.42mmHg). The proportion of hypertensives was 21.4% and was higher among men in all age categories. Knowledge on some risk factors of hypertension was extremely low. Having formal education was associated with higher odds of knowledge of hypertension (Adjusted odds ratio [AOR]; 95% confidence interval [CI]=2.28; 1.25-4.16). Several misconceptions such as the use of agro-chemicals, fertilizers and excess vitamins were identified as causes of hypertension.

CONCLUSION

This study demonstrates an increased prevalence of hypertension, knowledge gaps and misconceptions surrounding hypertension in rural communities in Ghana. This evidence is useful in streamlining interventional programmes aimed at improving knowledge and prevention of hypertension.

Effectiveness of short message services and voice call interventions for antiretroviral therapy adherence and other outcomes: A systematic review and meta-analysis

BACKGROUND

The potential of using mobile phone technologies to improve antiretroviral therapy (ART) adherence has provided a new facet to human immunodeficiency virus (HIV) research. The quality of evidence and the strength of recommendations of existing reviews, however, do not adequately support large-scale adoption of the intervention. This review adopted broad selection criteria to include all mobile phone-based interventions designed to improve patient's adherence to ART.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials and quasi-experimental studies. PUBMED, MEDLINE, EMBASE, PsychINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, AMED and Web of Science were searched. Online abstracts archives of relevant conference proceedings and trial registries were also searched. Thirty-Five (35) full-text articles were assessed for eligibility. Included studies were conducted in high, low and middle-income countries and reported ART adherence interventions delivered by mobile phones (standard or smartphones) in the form of voice calls, interactive voice response calls (IVR), and short message service (SMS).

RESULTS

Thirteen (13) studies met the inclusion criteria, and 11 were used in the meta-analysis. Intervention characteristics of included studies ranged from mobile phone functionalities to provision of study phones to participants. SMS and voice call contents were tailored to participants' specific adherence needs. Mobile SMS interventions improved adherence to ART compared with control conditions (OR, 95% CI = 1.59, 1.27-1.98). In subgroup analysis, only scheduled SMS was significant whereas triggered SMS had no effect on adherence to ART. Mobile voice calls did not significantly increase adherence to ART. The interventions were highly rated by > 90% of participants in the studies that reported on the experiences and satisfaction with the intervention.

CONCLUSION

Scheduled mobile phone text-messaging have demonstrated significant improvement in adherence to ART. Mobile SMS adherence interventions that allow for two-way communication may, however, be more acceptable than standalone SMS reminders, which are seen to be intrusive, producing habituation and response fatigue. Voice calls and triggered SMS functionalities do not have a significant effect on adherence to ART although there is a higher preference for voice functionality over SMS especially in limited-resource and low-literacy settings. Further exploration of the mobile voice functionality and its possible combination with scheduled SMS functionality is recommended. Evidence provided in this study will guide the implementation of mobile phone intervention to improve adherence to ART, by addressing practical challenges that could militate against scalability especially in resource limited settings.

Migration and Cardiovascular Disease Risk Among Ghanaian Populations in Europe: The RODAM Study (Research on Obesity and Diabetes Among African Migrants)

BACKGROUND

For migrant populations from sub-Saharan Africa, adverse cardiovascular disease (CVD) risk factors have been observed to be higher than found in their home country-based counterparts or among the host populations in high-income countries. Differences in absolute overall CVD risk, however, remain largely unexplained. We, therefore, predicted the differences in 10-year CVD risk among sub-Saharan African migrants (Ghanaians) living in 3 European cities and Ghana.

METHODS AND RESULTS

For 3864 subjects aged 40 to 70 years from the multicenter RODAM study (Research on Obesity and Diabetes Among African Migrants) conducted among Ghanaian adults residing in rural and urban Ghana and 3 European cities (Amsterdam, Berlin, and London), 10-year risk of CVD was estimated using the Pooled Cohort Equations with estimates ≥7.5% defining high CVD risk. Logistic regressions were used to determine the association of migration on CVD risk. The proportion with CVD risk ≥7.5% among Ghanaian men was 34.7% in rural Ghana, 45.4% in urban Ghana, 53.9% in Amsterdam, 61.0% in Berlin, and 52.2% in London. Compared with rural Ghana, CVD risk was significantly increased for Ghanaian men living in Berlin (adjusted odds ratio, 2.80; 95% confidence interval, 1.76-4.45) and Amsterdam (1.88; 1.25-2.84). Increased risk observed for men was largely not seen for women. CVD risk increased with longer stay in Europe.

CONCLUSIONS

Knowledge about predictors of increased CVD risk among sub-Saharan African migrants in Europe and nonmigrants in urban centers will inform and support targeted health care and interventions to these populations.

Cardiovascular disease risk prediction in sub-Saharan African populations - Comparative analysis of risk algorithms in the RODAM study

BACKGROUND

Validated absolute risk equations are currently recommended as the basis of cardiovascular disease (CVD) risk stratification in prevention and control strategies. However, there is no consensus on appropriate equations for sub-Saharan African populations. We assessed agreement between different cardiovascular risk equations among Ghanaian migrant and home populations with no overt CVD.

METHODS

The 10-year CVD risks were calculated for 3586 participants aged 40-70years in the multi-centre RODAM study among Ghanaians residing in Ghana and Europe using the Framingham laboratory and non-laboratory and Pooled Cohort Equations (PCE) algorithms. Participants were classified as low, moderate or high risk, corresponding to <10%, 10-20% and >20% respectively. Agreement between the risk algorithms was assessed using kappa and correlation coefficients.

RESULTS

19.4%, 12.3% and 5.8% were ranked as high 10-year CVD risk by Framingham non-laboratory, Framingham laboratory and PCE, respectively. The median (25th-75th percentiles) estimated 10-year CVD risk was 9.5% (5.4-15.7), 7.3% (3.9-13.2) and 5.0% (2.3-9.7) for Framingham non-laboratory, Framingham laboratory and PCE, respectively. The concordance between PCE and Framingham non-laboratory was better in the home Ghanaian population (kappa=0.42, r=0.738) than the migrant population (kappa=0.24, r=0.732) whereas concordance between PCE and Framingham laboratory was better in migrant Ghanaians (kappa=0.54, r=0.769) than the home population (kappa=0.51, r=0.758).

CONCLUSION

CVD prediction with the same algorithm differs for the migrant and home populations and the interchangeability of Framingham laboratory and non-laboratory algorithms is limited. Validation against CVD outcomes is needed to inform appropriate selection of risk algorithms for use in African ancestry populations.

Knowledge and awareness of and perception towards cardiovascular disease risk in sub-Saharan Africa: A systematic review

INTRODUCTION

Cardiovascular diseases (CVDs) are the most common cause of non-communicable disease mortality in sub-Saharan African (SSA) countries. Gaps in knowledge of CVD conditions and their risk factors are important barriers in effective prevention and treatment. Yet, evidence on the awareness and knowledge level of CVD and associated risk factors among populations of SSA is scarce. This review aimed to synthesize available evidence of the level of knowledge of and perceptions towards CVDs and risk factors in the SSA region.

METHODS

Five databases were searched for publications up to December 2016. Narrative synthesis was conducted for knowledge level of CVDs, knowledge of risk factors and clinical signs, factors influencing knowledge of CVDs and source of health information on CVDs. The review was registered with Prospero (CRD42016049165).

RESULTS

Of 2212 titles and abstracts screened, 45 full-text papers were retrieved and reviewed and 20 were included: eighteen quantitative and two qualitative studies. Levels of knowledge and awareness for CVD and risk factors were generally low, coupled with poor perception. Most studies reported less than half of their study participants having good knowledge of CVDs and/or risk factors. Proportion of participants who were unable to identify a single risk factor and clinical symptom for CVDs ranged from 1.8% in a study among hospital staff in Nigeria to a high of 73% in a population-based survey in Uganda and 7% among University staff in Nigeria to 75.1% in a general population in Uganda respectively. High educational attainment and place of residence had a significant influence on the levels of knowledge for CVDs among SSA populations.

CONCLUSION

Low knowledge of CVDs, risk factors and clinical symptoms is strongly associated with the low levels of educational attainment and rural residency in the region. These findings provide useful information for implementers of interventions targeted at the prevention and control of CVDs, and encourages them to incorporate health promotion and awareness campaigns in order to enhance knowledge and awareness of CVDs in the region.

Integrating herbal medicine into mainstream healthcare in Ghana: clients' acceptability, perceptions and disclosure of use

Background

Although there are current efforts to integrate herbal medicine (HM) into mainstream healthcare in Ghana, there is paucity of empirical evidence on the acceptability and concurrent use of HM, in the formal health facilities in Ghana. This study sought to determine client perception, disclosure and acceptability of integrating herbal medicine in mainstream healthcare in Kumasi, Ghana.

Methods

A cross-sectional study was conducted from May to August, 2015. Five hundred patients presenting at the outpatient departments of Kumasi South, Suntreso and Tafo Government Hospitals in Kumasi were randomly selected. Interviews were conducted with the use of structured questionnaires. A logistic regression analysis, using backward selection, was conducted to determine the influence of socio-demographic and facility related factors on the odds of using HM at the facility. All statistical tests were two-sided and considered significant at a p-value of <0.05.

Results

Majority of the study respondents were females (64.8%) and the median age was 36 years. Less than half, 42.2%, of the respondents utilized HM services when they visited the health facility. Reasons for using HM at the facility level included ‘being effective’ (24.4%), ‘easy to access’ (25.3%) and ‘being comparatively cheaper’ (16%). About 86% never disclosed previous use of HM to their health care providers. Socio-economic status and perception of service provision influenced use of herbal medicines. Respondents who rated themselves wealthy had increased odds of using herbal medicines at the health facility as compared to those who rated themselves poor (OR = 4.9; 95%CI = 1.6–15.3).

Conclusion

This study shows that integration of herbal medicine is feasible and herbal medicines may be generally accepted as a formal source of healthcare in Ghana. The results of this study might serve as a basis for improvement and upscale of the herbal medicine integration programme in Ghana.

Electronic supplementary material

The online version of this article (10.1186/s12906-017-2025-4) contains supplementary material, which is available to authorized users.

Barriers to early presentation and diagnosis of breast cancer among African women living in sub-Saharan Africa

Background

Breast cancer (BC) has been described as the leading cause of cancer deaths among women especially in the developing world including sub Saharan Africa (SSA). Delayed presentation and late diagnosis at health facilities are parts of the contributing factors of high BC mortality in Africa. This review aimed to appraise the contributing factors to delayed breast cancer presentation and diagnosis among SSA women.

Methods

Five databases encompassing medical and social sciences were systematically searched using predefined search terms linked with breast cancer presentation and diagnosis and sub Saharan Africa. Reference lists of relevant papers were also hand searched. Quality of quantitative and qualitative articles were assessed using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the Critical Appraisal Skills Programme (CASP) quality appraisal checklist. Thematic analysis was used to synthesize the qualitative studies to integrate findings.

Results

Fourteen (14) quantitative studies, two (2) qualitative studies and one (1) mixed method study merited inclusion for analysis. This review identified low knowledge of breast cancer among SSA women. This review also found lack of awareness of early detection treatment, poor perception of BC, socio-cultural factors such as belief, traditions and fear as factors impacting African women’s health seeking behavior in relation to breast cancer.

Conclusion

Improving African women’s knowledge and understanding will improve behaviors related to breast cancer and facilitate early presentation and detection and enhance proper management and treatment of breast cancer.

Overweight and obesity epidemic in Ghana-a systematic review and meta-analysis

Background

In many low and middle income countries (LMICs), the distribution of adulthood nutritional imbalance is shifting from a predominance of undernutrition to overnutrition. This complex problem poses a huge challenge to governments, non-state actors, and individuals desirous of addressing the problem of malnutrition in LMICs. The objective of this study was to systematically review the literature towards providing an estimate of the prevalence of overweight and obesity among adult Ghanaians.

Methods

This study followed the recommendations outlined in the PRISMA statement. Searches were performed in PubMed, Science Direct, google scholar, Africa Journals Online (AJOL) and the WHO African Index Medicus database. This retrieved studies (published up to 31st March 2016) that reported overweight and obesity prevalence among Ghanaians. All online searches were supplemented by reference screening of retrieved papers to identify additional studies.

Results

Forty-three (43) studies involving a total population of 48,966 sampled across all the ten (10) regions of Ghana were selected for the review. Our analysis indicates that nearly 43% of Ghanaian adults are either overweight or obese. The national prevalence of overweight and obesity were estimated as 25.4% (95% CI 22.2–28.7%) and 17.1% (95% CI = 14.7–19.5%), respectively. Higher prevalence of overweight (27.2% vs 16.7%) and obesity (20.6% vs 8.0%) were estimated for urban than rural dwellers. Prevalence of overweight (27.8% vs 21.8%) and obesity (21.9% vs 6.0%) were also significantly higher in women than men. About 45.6% of adult diabetes patients in Ghana are either overweight or obese. At the regional level, about 43.4%, 36.9%, 32.4% and 55.2% of residents in Ashanti, Central, Northern and Greater Accra region, respectively are overweight or obese. These patterns generally mimic the levels of urbanization. Per studies’ publication years, consistent increases in overweight and obesity prevalence were observed in Ghana in the period 1998–2016.

Conclusions

There is a high and rising prevalence of overweight and obesity among Ghanaian adults. The possible implications on current and future population health, burden of chronic diseases, health care spending and broader economy could be enormous for a country still battling many infectious and parasitic diseases. Public health preventive measures that are appropriate for the Ghanaian context, culturally sensitive, cost-effective and sustainable are urgently needed to tackle this epidemic.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3901-4) contains supplementary material, which is available to authorized users.

Incentives to yield to Obstetric Referrals in deprived areas of Amansie West district in the Ashanti Region, Ghana

BACKGROUND

Obstetric referrals, otherwise known as maternal referrals constitute an eminent component of emergency care, and key to ensuring safe delivery and reducing maternal and child mortalities. The efficiency of Obstetric referral systems is however marred by the lack of accessible transportation and socio-economic disparities in access to healthcare. This study evaluated the role of socio-economic factors, perception and transport availability in honouring Obstetric referrals from remote areas to referral centres.

METHODS

This was a cross-sectional study, involving 720 confirmed pregnant women randomly sampled from five (5) sub-districts in the Amansie west district in Ghana, from February to May 2015. Data were collected through structured questionnaire using face-to-face interviewing and analyzed using STATA 11.0 for windows. Logistic regression models were fitted to determine the influence of socio-demographic characteristics and pregnancy history on obstetric referrals.

RESULTS

About 21.7 % of the women studied honoured referral by a community health worker to the next level of care. Some of the pregnant women however refused referrals to the next level due to lack of money (58 %) and lack of transport (17 %). A higher household wealth quintile increased the odds of being referred and honouring referral as compared to those in the lowest wealth quintile. Women who perceived their disease conditions as emergencies and severe were also more likely to honour obstetric referrals (OR = 2.3; 95 % CI = 1.3, 3.9).

CONCLUSION

Clients' perceptions about severity of health condition and low income remain barriers to seeking healthcare and disincentives to honour obstetric referrals in a setting with inequitable access to healthcare. Implementing social interventions could improve the situation and help attain maternal health targets in deprived areas.

Health service barriers to HIV testing and counseling among pregnant women attending Antenatal Clinic; a cross-sectional study

BACKGROUND

HIV testing and counseling (HTC) remains critical in the global efforts to reach a goal of universal access to prevention and timely human immunodeficiency virus (HIV) treatment and health care. Routine HIV testing has been shown to be cost-effective and life-saving by prolonging the life expectancy of HIV patients and reducing the annual HIV transmission rate. However, these benefits of routine HIV testing may not be seen among pregnant women attending antenatal clinic (ANC) due to health facility related factors. This paper presents the influence of health facility related factors on HTC to inform HTC implementation.

METHODS

The study was cross-sectional in design and used structured questionnaire and interview guides to gather information from 300 pregnant women aged 18 to 49 years and had attended ANC for more than twice at the time of the study. Twelve health workers were interviewed as key informants. Respondents were selected from the five sub metro health facilities in the Kumasi Metropolis through systematic random sampling from August to November 2011. Pregnant women who had not tested after two or more ANC visits were classified as not utilizing HTC. Data was analyzed with STATA 11. Logistic regression was run to assess the odds ratios at 95% confidence level.

RESULTS

Twenty-four percent of the pregnant women had not undergone HTC, with "never been told" emerging as the most cited reason as reported by 29.5% of respondents. Decisions by pregnant women to take up HTC were mostly influenced by factors such as lack of information, perceptions of privacy and confidentiality, waiting time, poor relationship with health staff and fear of being positive.

CONCLUSIONS

Access to HTC health facility alone does not translate into utilization of HTC service. Improving health facility related factors such as health education and information, confidentiality, health staff turnaround time and health staff-client relationship related to HTC will improve implementation.

Knowledge, perceptions and expectations of capitation payment system in a health insurance setting: a repeated survey of clients and health providers in Kumasi, Ghana

BACKGROUND

Health insurance is improving access to quality health care in Ghana. However, there are implementation challenges which call for reform of the current health insurance system. There is no doubt that reforming the current health insurance in Ghana is besieged with a myriad of problems due to misconceptions and misinformation. This study explored the perceptions and understanding of clients and health providers on the capitation payment system in the Kumasi metropolis.

METHODS

The study employed a cross - sectional design and repeated surveys were conducted with a cohort of 422 NHIS policy holders aged 18-69 years in each survey. The surveys were conducted in every three months. Health service providers and clients from thirteen (13) Hospitals, seven (7) Maternity homes and twenty (20) Clinics were also interviewed. Data was collected with interviewer-administered questionnaires. STATA software (version 11) was used for cleaning, standardizing and analysing data.

RESULTS

A majority, 97.9% of the clients interviewed had heard of capitation payment although this did not translate into their level of understanding. About two-thirds, 61.2% disclosed that capitation was not important to them as clients are restricted to one Preferred Primary Provider (PPP) for a long period of time. About 94% of health providers also believed that people did not like the capitation payment system due to their misconception that it has been politicized (34%); does not give clients free choice of providers (26%) and capitation not covering most drugs (17%).

CONCLUSION

Although awareness of the capitation was high among clients, attitudes towards the capitation payment system were somewhat poor. A good understanding of the capitation payment system is key to ensuring client and provider acceptance and smooth implementation of the system.