Skin-lightening practices among female high school students in Ghana.

OBJECTIVE: The practice of skin lightening (SL) persist despite warnings about its harmful health effects. Adolescents are particularly vulnerable and at risk of prolonged use of SL products. We explored SL practices among high school students in Ghana, West Africa. STUDY DESIGN: Cross-sectional survey. METHODS: We used a self-administered questionnaire in a survey on SL practices among randomly selected female students in five Senior High Schools in the Brong Ahafo Region of Ghana. We determined prevalence and used bivariate and multivariate analysis to identify factors associated with the practice. RESULTS: A total of 410 students with a mean age of 17.6 years (±1.6) participated in the study. While 71.5% of students indicated that they had been approached by relatives and friends to use SL creams, 65.6% admitted to actually using it. Most (85.5%) students identified at least five friends who were using SL products at the time of the survey. Between 22.0% and 44.0% of students knew female teachers who practiced SL. Students in first year were twice as likely to practice SL compared with students in third year (odds ratio [OR] = 1.90, 95% confidence interval [CI] 1.15-3.13). Compared with those who had never been approached, students who had been approached by relatives and friends to use SL products were likely to be using it (OR = 2.24, 95% CI 1.43-3.53). Students who had sisters who used SL products were twice as likely to be users themselves (OR = 1.82, 95% CI 1.12-2.95). CONCLUSION: The practice of SL among female students in this study is high, and about the same as reported among adults in Ghana and other parts of sub-Saharan Africa. This suggests that the practice is well entrenched. A ban on the sale of SL products to adolescents in Ghana should be considered.

Covert contraceptive use among women attending a reproductive health clinic in a municipality in Ghana.

BACKGROUND: Covert contraceptive use (CCU) in sub-Saharan Africa is an indication of women's inability to exercise autonomy in their reproductive choices. The aim of this study was to assess the prevalence and determinants of CCU among a sample of FP clients in a municipality of Ghana. METHODS: We conducted a mixed method study among women attending a public reproductive health clinic in Sunyani, a city of over 250,000 inhabitants in Ghana. An initial survey inquired into sociodemographic characteristics, use of family planning (FP) methods and partner awareness of contraceptive use. The predictors of CCU were explored using logistic regressions. We used the findings to develop a guide which we applied in-depth interviews and focus group discussions with attendants at the same facility. Qualitative data analysis was conducted using a framework approach. RESULTS: We interviewed 300 women, 48 % of whom were aged between 26-33 years. The injectable was the most widely used method (56 %). The prevalence of CCU was 34 %. In multivariate analysis, single women were more likely to practice CCU than married or co-habiting women (Adjusted OR = 12.12, 95 % C.I. 4.73-31.1). Muslim and traditionalist women were similarly more likely to practice CCU than non-Muslim, non-traditionalist (Adjusted OR = 4.56, 2.29-9.06). Women who preferred to have their first or next child in 4 or more years from the time of the interview were more likely to be in CCU than women who intended to have children within 4 years of the interview (2.57; 1.37-4.83). Single women saw in covert use a statement of their social autonomy. To succeed in CCU, women wished that clinic attendance cards would not be given to them to keep at home. Though many participants saw in CCU a source of anxiety, they expected health workers to consider it and uphold confidentiality in the provision of services. CONCLUSIONS: Covert contraceptive use was high in this municipality and being single was the strongest predictor of the practice. Providers of FP services should reflect on how to adequately address the challenges faced by women who practice CCU.

Willingness to undergo HIV testing in the Kintampo districts of Ghana.

BACKGROUND: HIV testing is currently a major prevention intervention and remains an entry point to early treatment, care and support. Uptake is however low and alternative approaches are currently being adopted. OBJECTIVE: An HIV module was incorporated into the routine survey of the Kintampo Health and Demographic Surveillance System (KHDSS) to assess the willingness of adults living in the Kintampo North and South districts to undergo HIV testing. DESIGN: The study was a descriptive cross-sectional household survey. Univariate and multivariate analysis were used to identify predictors of the willingness to undergo HIV testing. PARTICIPANTS: Respondents were community members aged 15 to 49 years and selected from randomly generated household listings from the KHDSS. RESULTS: A total of 11,604 respondents were interviewed, 10,982 (94.6%) of respondents had good general knowledge on HIV/AIDS. Among those with knowledge about HIV/AIDS, 10,819 (98.5%) indicated their willingness to get tested for HIV. Rural residents were more willing to undergo HIV testing than urban dwellers Odds ratio=1.42 (95% Confidence interval: 1.03, 1.96; P-value=0.031). Respondents with primary education were more likely to go for testing relative to those without any education OR=2.02 (95% CI: 0.87, 4.70; P-value=0.046). CONCLUSION: Expressed willingness to test for HIV is high in this population. Exploring community and population-based interventions to HIV testing and counseling could increase uptake of HIV testing services and should be considered. The underlying motivations need to be explored in order to translate willingness into actual testing.

Shifting from presumptive to test-based management of malaria - technical basis and implications for malaria control in Ghana.

The presumptive approach was the World Health Organisation (WHO) recommended to the management of malaria for many years and this was incorporated into syndromic guidelines such as the Integrated Management of Childhood Illnesses (IMCI). In early 2010 however, WHO issued revised treatment guidelines that call for a shift from the presumptive to the test-based approach. Practically, this implies that in all suspected cases, the diagnosis of uncomplicated malaria should be confirmed using rapid test before treatment is initiated. This revision effectively brings to an end an era of clinical practice that span several years. Its implementation has important implications for the health systems in malaria-endemic countries. On the basis of research in Ghana and other countries, and evidence from program work, the Ghana National Malaria Control Program has issued revised national treatment guidelines that call for implementation of test-based management of malaria in all cases, and across all age groups. This article reviews the evidence and the technical basis for the shift to test-based management and examines the implications for malaria control in Ghana.

How are surgical theatres in rural Africa utilized? A review of five years of services at a district hospital in Ghana.

Although the extent of the unmet need for surgeries is well-known, little is known about the surgery performed in district hospitals in sub-Saharan Africa. We review five years of utilization of theatre services at the Kintampo Hospital in rural Ghana. The source of data was the theatre logbook and other hospital records for the period 2005-2009. During this time, 1391 surgeries were performed in the theatre. This approximates a rate of 250/100,000 population. Fifty-two percent were performed in patients aged 18-35 years. The most frequently performed surgeries were: caesarean sections (46%); hernia repair (41%); and other laparotomies (10%). The major indications were cephalopelvic disproportion, right inguinal hernia and typhoid perforation, respectively. Typhoid perforation was the main indication for surgery in children aged less than 10 years. The potential for an expansion of the scope of services should be explored in order to improve access to essential surgery for this population.

Pre-referral rectal artesunate to prevent death and disability in severe malaria: a placebo-controlled trial.

BACKGROUND: Most malaria deaths occur in rural areas. Rapid progression from illness to death can be interrupted by prompt, effective medication. Antimalarial treatment cannot rescue terminally ill patients but could be effective if given earlier. If patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate can be given before referral and acts rapidly on parasites. We investigated whether this intervention reduced mortality and permanent disability. METHODS: In Bangladesh, Ghana, and Tanzania, patients with suspected severe malaria who could not be treated orally were allocated randomly to a single artesunate (n=8954) or placebo (n=8872) suppository by taking the next numbered box, then referred to clinics at which injections could be given. Those with antimalarial injections or negative blood smears before randomisation were excluded, leaving 12 068 patients (6072 artesunate, 5996 placebo) for analysis. Primary endpoints were mortality, assessed 7-30 days later, and permanent disability, reassessed periodically. All investigators were masked to group assignment. Analysis was by intention to treat. This study is registered in all three countries, numbers ISRCTN83979018, 46343627, and 76987662. RESULTS: Mortality was 154 of 6072 artesunate versus 177 of 5996 placebo (2.5%vs 3.0%, p=0.1). Two versus 13 (0.03%vs 0.22%, p=0.0020) were permanently disabled; total dead or disabled: 156 versus 190 (2.6%vs 3.2%, p=0.0484). There was no reduction in early mortality (56 vs 51 deaths within 6 h; median 2 h). In patients reaching clinic within 6 h (median 3 h), pre-referral artesunate had no significant effect on death after 6 h or permanent disability (71/4450 [1.6%] vs 82/4426 [1.9%], risk ratio 0.86 [95% CI 0.63-1.18], p=0.35). In patients still not in clinic after more than 6 h, however, half were still not there after more than 15 h, and pre-referral rectal artesunate significantly reduced death or permanent disability (29/1566 [1.9%] vs 57/1519 [3.8%], risk ratio 0.49 [95% CI 0.32-0.77], p=0.0013). INTERPRETATION: If patients with severe malaria cannot be treated orally and access to injections will take several hours, a single inexpensive artesunate suppository at the time of referral substantially reduces the risk of death or permanent disability. FUNDING: UNICEF/UNDP/World Bank Special Programme for Research and Training in Tropical Diseases (WHO/TDR); WHO Global Malaria Programme (WHO/GMP); Sall Family Foundation; the European Union (QLRT-2000-01430); the UK Medical Research Council; USAID; Irish Aid; the Karolinska Institute; and the University of Oxford Clinical Trial Service Unit (CTSU).

Using lay counsellors to promote community-based voluntary counselling and HIV testing in rural northern Ghana: a baseline survey on community acceptance and stigma.

Access to voluntary counselling and HIV testing (VCT) remains limited in most parts of Ghana with rural populations being the least served. Services remain facility-based and employ the use of an ever-dwindling number of health workers as counsellors. This study assessed approval for the use of lay counsellors to promote community-based voluntary counselling and testing for HIV and the extent of HIV/AIDS-related stigma in the Kassena-Nankana district of rural northern Ghana. A cross-sectional questionnaire survey was conducted. Logistic regression was used to identify predictors of the tendency to stigmatize people living with HIV/AIDS (PLWHAs). Focus group discussions were held and analytical coding of the data performed. The majority (91.1%) of the 403 respondents indicated a desire to know their HIV status. Most (88.1%) respondents considered locations outside of the health facility as preferred places for VCT. The majority (98.7%) of respondents approved the use of lay counsellors. About a quarter (24%) of respondents believed that it was possible to acquire HIV through sharing a drinking cup with a PLWHA. About half (52.1%) of the respondents considered that a teacher with HIV/AIDS should not be allowed to teach, while 77.2% would not buy vegetables from a PLWHA. Respondents who believed that sharing a drinking cup with a PLWHA could transmit HIV infection (OR 2.50, 95%CI 1.52-4.11) and respondents without formal education (OR 2.94, 95%CI 1.38-6.27) were more likely to stigmatize PLWHAs. In contrast, respondents with knowledge of the availability of antiretroviral (ARV) drugs were less likely to do so (OR 0.40, 95%CI 0.22-0.73). Findings from the thirteen focus group discussions reinforced approval for community-based VCT and lay counsellors but revealed concerns about stigma and confidentiality. In conclusion, community-based VCT and the use of lay counsellors may be acceptable options for promoting access. Interventional studies are required to assess feasibility and cost-effectiveness.

Unmet need for essential obstetric services in a rural district in northern Ghana: complications of unsafe abortions remain a major cause of mortality.

AIM: The aim of this study was to review 4 years of hospital data on antenatal services, deliveries and maternal deaths as the baseline evaluation for a programme to improve care. METHODS: Descriptive analyses were made of data extracted from the monthly returns charts and clinical notes on all maternal deaths from January 2001 to December 2003 at the district hospital in the Kassena-Nankana district of rural northern Ghana. RESULTS: The majority (56.6%) of women first attended an antenatal clinic during the second trimester, and about 70% had haemoglobin levels of <10 g/dl. A total of 3160 deliveries were recorded. The prevalence of female genital cutting was 21.4%. Hospital and population rates of Caesarean section were 9.1 and 1.8%, respectively. Only one-third of women in need of a Caesarean section were able to access this intervention. Twenty-four maternal deaths were recorded, giving a hospital maternal mortality ratio of 759 per 100,000 live births. Complications of unsafe abortion (29.1%) and haemorrhage (20.8%) were the leading causes of death. Seventy-one percent of deaths occurred in women living within 15 km of the district hospital, and 50% occurred within 24 h of arrival. CONCLUSION: Late recourse to the health facility and complications of unsafe abortion are major contributory factors to maternal mortality in this district. A high level of unmet need for essential obstetric services, including access to contraceptive services, exists in this district. Decentralizing the availability of essential obstetric services through health centres to community level is necessary to reduce maternal mortality in developing countries.

Trend and causes of neonatal mortality in the Kassena-Nankana district of northern Ghana, 1995-2002.

OBJECTIVES: To describe the trend and causes of neonatal deaths in a rural district in northern Ghana. METHODS: Descriptive analysis of data collected from the Navrongo Demographic Surveillance System and verbal autopsies conducted on all neonatal deaths from 1995-2002. RESULTS: Of 1118 recorded neonatal deaths 1068 (95.5%) could be analysed. Only 13.2% of deaths occurred at the health facility; 62.7% occurred in the early neonatal period, with prematurity (38%) and birth injuries (19%) as leading causes. Infectious causes (66%) were the major contributors to late neonatal deaths. Infanticide accounted for 4.9% of all neonatal deaths. The cause-specific mortality rate for neonatal tetanus remained under 2.5% throughout the 8-year period. Overall, the neonatal mortality rate declined at an average of 2.5 per 1000 live births per year: Down by nearly 50% from 40.9 (95%C.I. 34.1-46.8) in 1995 to 20.5 (95%C.I.17.3-22.7) in 2002. CONCLUSION: The various health interventions undertaken in this district have had the collateral effect of causing decline in neonatal mortality. Neonatal mortality could be further reduced by preventing and treating neonatal infections, having skilled attendance at delivery and the elimination of infanticide. Data from demographic surveillance sites may be useful in monitoring trends in child mortality.

Trends in the prevalence of female genital mutilation and its effect on delivery outcomes in the kassena-nankana district of northern ghana.

UNLABELLED: Summary RATIONAL: Female genital mutilation (FGM) is prevalent in northern Ghana, as the practice is seen as a passage rite to women adulthood and thus undertaken just before marriage. OBJECTIVES: We determined the changes in trend of FGM in deliveries at the Navrongo War Memorial hospital, and compared the outcomes and FGM status. DESIGN: Retrospective extraction and analysis of delivery data at the hospital from 1(st) January 1996 to 31(st) December 2003. RESULTS: Of the 5071 deliveries, about 29% (1466/5071) were associated with FGM. The highest prevalence (95% CI) of 61.5% (50.9, 71.2) was in women aged 40 years and above, and the lowest of 14.4% (11.7, 17.0) was in women below 20 years. The all-age prevalence of FGM showed a significant decline (p-value for linear trend < 0.01) from 35.2% in 1996 to 21.1% in 2003. About 6% (89/1466) of mothers with FGM had stillbirths compared with about 3% (123/3605) of mothers without FGM. Again FGM was associated with 8.2% (120/1466) caesarean section rate compared with 6.7% (241/3605) in mothers without FGM. Mean birth weight and frequency of low birth weights were not significantly associated with FGM status. CONCLUSION: Although there is a high rate of FGM among mothers in the district and is associated with a higher proportion of stillbirths and caesarean sections, practice has shown a significant decline in the district in recent years due to the prevailing campaigns and intervention studies. There is therefore the need to sustain the ongoing intervention efforts.

Review of Antenatal-Linked Voluntary Counseling and HIV Testing in Sub-Saharan Africa: Lessons and Options for Ghana.

SummaryVoluntary counselling and HIV testing has become an integral part of HIV prevention and care programs in many countries in sub-Saharan Africa. A number of interventions offer potential to reduce mother-to-child HIV transmission. These interventions, including antenatal and or intrapartum administration of antiretroviral drugs require the integration of voluntary counselling and HIV testing for pregnant women into antenatal care. Ghana's strategic framework for HIV control calls for the integration of voluntary counselling and HIV testing to antenatal care nationwide. It sets as target, the year 2005 when VCT would be widely available and accessible in the country. This paper reviews medline-indexed publications on antenatal-linked VCT programs of sub-Saharan Africa. Four critical themes were used in the medline search. These are acceptability, rates of return for test, disclosure of results vis-à-vis confidentiality and cost effectiveness. The growing consensuses on these issues are discussed in relations to the findings of a recent study conducted among 270 pregnant women in Navrongo in the Kassena-Nankana district of northern Ghana. Suggestions are made to guide the on-going pilot VCT and prevention of mother-to-child programs in Ghana. It is also suggested on the basis of the review and the findings of the Navrongo study that Ghana should explore options likely to promote universal access and overall acceptability. These include couple counselling, guarantee of confidentiality, free testing and continuum of care for mothers who are test positive.