Sanitation investments in Ghana: An ethnographic investigation of the role of tenure security, land ownership and livelihoods.

BACKGROUND: Ghana's low investment in household sanitation is evident from the low rates of improved sanitation. This study analysed how land ownership, tenancy security and livelihood patterns are related to sanitation investments in three adjacent rural and peri-urban communities in a district close to Accra, Ghana's capital. METHODS: Qualitative data was gathered for this comparative ethnographic study over seven months, (June, 2011-January, 2012) using an average of 43 (bi-weekly) participant observation per community and 56 in-depth interviews. Detailed observational data from study communities were triangulated with multiple interview material and contextual knowledge on social structures, history of settlement, land use, livelihoods, and access to and perceptions about sanitation. RESULTS: This study shows that the history of settlement and land ownership issues are highly correlated with people's willingness and ability to invest in household sanitation across all communities. The status of being a stranger i.e. migrant in the area left some populations without rights over the land they occupied and with low incentives to invest in sanitation, while indigenous communities were challenged by the increasing appropriation of their land for commercial enterprises and for governmental development projects. Interview responses suggest that increasing migrant population and the high demand for housing in the face of limited available space has resulted in general unwillingness and inability to establish private sanitation facilities in the communities. The increasing population has also created high demand for cheap accommodation, pushing tenants to accept informal tenancy agreements that provided for poor sanitation facilities. In addition, poor knowledge of tenancy rights leaves tenants in no position to demand sanitation improvements and therefore landlords feel no obligation or motivation to provide and maintain domestic sanitation facilities. CONCLUSIONS: The study states that poor land rights, the history of settlements, in-migration and insecure tenancy are key components that are associated with local livelihoods and investments in private sanitation in rapidly changing rural and peri-urban communities of Ghana. Sanitation policy makers and programme managers must acknowledge that these profound local, ethnic and economic forces are shaping people's abilities and motivations for sanitation investments.

Free tuberculosis diagnosis and treatment are not enough: patient cost evidence from three continents.

SETTING: The National Tuberculosis Programs of Ghana, Viet Nam and the Dominican Republic. OBJECTIVE: To assess the direct and indirect costs of tuberculosis (TB) diagnosis and treatment for patients and households. DESIGN: Each country translated and adapted a structured questionnaire, the Tool to Estimate Patients' Costs. A random sample of new adult patients treated for at least 1 month was interviewed in all three countries. RESULTS: Across the countries, 27-70% of patients stopped working and experienced reduced income, 5-37% sold property and 17-47% borrowed money due to TB. Hospitalisation costs (US$42-118) and additional food items formed the largest part of direct costs during treatment. Average total patient costs (US$538-1268) were equivalent to approximately 1 year of individual income. CONCLUSION: We observed similar patterns and challenges of TB-related costs for patients across the three countries. We advocate for global, united action for TB patients to be included under social protection schemes and for national TB programmes to improve equitable access to care.

Spatial variations in childhood mortalities at the Dodowa Health and Demographic Surveillance System site of the INDEPTH Network in Ghana.

OBJECTIVE: To determine the distribution of under-five deaths in Dodowa Health and Demographic Surveillance Area (DHDSA) and to identify possible clustering of deaths. METHODS: Data from the Dodowa Health and Demographic Surveillance System (DHDSS) were used for the analysis. These data covered a population of about 89 371 in 371 communities in seven area councils from 2005-2006. Under-five crude mortality rates were calculated for each community and area council. The central feature command in ArcGIS 9.2 was used to locate the centroid of each community from a shapefile of housing structures of communities. A spatial scan statistic was used to identify and test for clusters of under-five deaths. Data on socioeconomic indicators and insecticide treated net (ITN) ownership were analysed to determine the status of the clustered communities. RESULTS: Although several clusters of high under-five mortality were identified, only two were significant in two area councils: one cluster comprising three communities and another involving one community. Analysis of probable risk factors indicates that the single community which formed a significant cluster in Osuwem area council was seriously disadvantaged. About 71% of its households were in the poorest quintile, no household had ITN, electricity connection, good source of water or health insurance. The three communities that formed the significant cluster in Ningo area council, however, fared well in almost all indicators. CONCLUSION: The identified significant clustering of under-five mortality demands further studies to investigate the causes of the clustering, especially the Ningo area council.

Gender in tuberculosis research.

Gender studies as an area of research have developed to address the social, cultural and contextual factors that disproportionately affect the ability of women to promote their health and treat disease. The importance of gender in health and disease is now clearly established and increasingly evident in mainstream public health as well as in clinical and social medicine. The inordinate focus on women in the research in this area, however, while justified, has had the effect of almost excluding the experiences of men. More importantly, it continues to limit our understanding of the dynamic interactive social processes that may provide the key to effective public health interventions for the management and control of communicable diseases. Using tuberculosis as a case study, we outline the contribution of gender studies in the control of disease and highlight the ongoing challenges that need to be addressed to enhance the understanding of the role of gender in public health.

Community-directed treatment: the way forward to eliminating lymphatic filariasis as a public-health problem in Ghana.

The elimination of lymphatic filariasis as a public-health problem is currently dependent on the delivery of annual drug treatments to at least 80% of the eligible members of endemic populations for at least 5 years. However, for various reasons, this goal may not be achievable by the health systems of most endemic countries in sub-Saharan Africa, particularly if treatment is not community-directed. In Ghana, community-directed ivermectin treatment involving the regular public-health services at the implementation level (ComDT/HS) has recently been compared with mass-treatment in which only the health services participated (HST). Health staff and the target communities appreciated the ComDT/HS approach more than the HST approach and were more willing to participate in the community-directed scheme. The treatment coverage achieved by ComDT/HS (74.5%) was not only much higher than that of HST (43.5%) but also probably adequate for filariasis elimination. HST coverage was particularly poor in villages located > 5 km from a health facility, but distance from such a facility had no significant effect on treatment coverage in the ComDT/HS arm. As virtually all the subjects who received drugs swallowed them, compliance with treatment was not a problem. The ComDT/HS approach is therefore recommended, especially for areas where access to health facilities is poor and the health workers are over-stretched. The implications of these findings for the global programme for filariasis elimination are discussed.

The burden of hydrocele on men in Northern Ghana.

The social and economic impact of lymphatic filariasis was studied in Northern Ghana. Qualitative methods of gathering information revealed that even though the disease was a problem to both men and women, men with hydrocele suffered a greater psychosocial burden. Particular attention was paid to them, distinguishing men with small hydroceles and men with large ones. Out of frustration men with small hydroceles sought health care from a wider range of places than men with larger ones. The pain associated with adenolymphangitis (ADL) renders them inactive for up to 5 days. Complications of lymph scrotum and ridicule from community members were a problem. Unmarried men in particular found it difficult to find a spouse with their condition, and various degrees of sexual dysfunction were reported amongst married men. The clinical significance and the value of time and attention for counseling to mitigate the effects of the disease on damaged male identity and the need for gender studies to address male issues and the need for including psychosocial issues in the calculating of disability adjusted life years (DALY's) is also discussed.

Filariasis in northern Ghana: some cultural beliefs and practices and their implications for disease control.

This article reports on how some endemic rural communities in northern Ghana perceive and manage lymphatic filariasis. The disease was mainly attributed to supernatural and spiritual factors. Except for a few instances of neglect, the community was generally caring towards people with the disease. Issues related to marriage, stigma, concealment and leadership are discussed. On the whole, the importance of social and cultural perceptions of a disease and its relevance to control cannot be over emphasized.

Introducing insecticide impregnated bednets in an area of low bednet usage: an exploratory study in north-east Ghana.

To find out the acceptability of the use of insecticide impregnated bednets before launching a large-scale trial to evaluate their impact on child mortality, 96 permethrin impregnated bednets were distributed in 4 communities within the Kassena Nankana district of the Upper East Region of Ghana, where previously only 4% of the people had owned a mosquito net. The nets were readily accepted and used by the recipients. The major benefit perceived by the users was the reduction of the nuisance effect of mosquitoes and other insects. The people in the study area normally sleep on mats in either an open courtyard or a sleeping room depending on the weather but this did not deter them from using the nets. The white nets distributed for this study became dirty with use, and users thought they needed to be washed. In order to discourage this, it is recommended that dark coloured nets be used in the main intervention trial. After having used the nets for a year, the community members expressed willingness to buy the nets if they were made available after the harvest season when they had sold their crops and had enough money to pay for them. The results of this study have been used to plan and conduct a large intervention trial.

The epidemiology of acute adenolymphangitis due to lymphatic filariasis in northern Ghana.

A study to investigate the socioeconomic impact of lymphatic filariasis was conducted in a rural community in northern Ghana. The incidence, severity, and duration of acute adenolymphangitis (ADL), as identified by local terminologies and confirmed using World Health Organization diagnostic criteria, were investigated. Local terminologies were found to be highly specific and sensitive for diagnosing ADL (sensitivity = 0.978, specificity = 0.980). The incidence of ADL was 95.9 per 1,000 per annum among adults more than 10 years of age, being much higher in females than in males. Among those with elephantiasis and other chronic filarial symptoms, there was no clear relationship between the stage of chronic lymphedema and the incidence of ADL. The incidence of ADL was found to be closely related to the rainfall pattern. The design of the study, its findings, and the public health implications of the findings are discussed in this paper.

Rapid community diagnosis of lymphatic filariasis.

We conducted a pilot study to test rapid assessment procedures for the community diagnosis of lymphatic filariasis in some rural communities in Ghana. The assessment criteria included direct key informant interviews, focus group discussions, routine reporting from health facilities, self-administered questionnaires, and a random examination of adult males for hydroceles. All the data collection methods were easy, convenient, non-invasive to use and acceptable to the community. The study provided reliable estimates of the burden of lymphatic filariasis in the community when compared with data from standard epidemiological surveys. The direct key informant interviews and focus group discussions gave a broad perspective of the burden of diseases in the community in general, and lymphatic filariasis in particular. The use of self-administered questionnaires provided data comparable with data on elephantiasis in the community from a case search. Examination of a random 30-40 adult males for hydroceles provided a good correlation with the community microfilaria prevalence, with a correlation coefficient of linear regression r = 0.79. These individual rapid assessment procedures of the burden of lymphatic filariasis, if further developed and tested could, be widely used in combination for the mapping of the distribution of lymphatic filariasis in Ghana and possibly, the African sub-region.

The economic burden of lymphatic filariasis in northern Ghana.

The socio-economic impact of lymphatic filariasis was investigated in a rural community in northern Ghana, as part of a multi-country study. The entire community was followed up for a period of one full calendar year, to document episodes of acute adenolymphangitis (ADL), treatment seeking and the cost of treatment. Cases of chronic filarial disease identified at the start of the study were also visited every 3 months to monitor treatment seeking and the costs of treatment. The subjects, who were mainly subsistence farmers, were found to be materially very poor. The incidence of ADL, which lasted an average of 5 days, was found to be very high. Most of those affected were unable to perform their normal activities for much of the ADL episode. In general, most subjects with long-standing chronic disease, such as elephantiasis of the leg and hydroceles, tended not to seek treatment except when there was superimposed ADL. Some aspects of treatment seeking, the cost of treatment, the burden of the disease on the community, and the public-health implications are discussed.

Risk factors for child mortality in northern Ghana: a case-control study.

BACKGROUND: A population-based case-control study was carried out to investigate potential risk factors for post-neonatal and child mortality in northern Ghana were child survival rates are among the lowest in Africa. METHOD: Cases were post-neonatal infant and child deaths identified within a large population under continuous demographic surveillance. For each case, one living control, matched for age, sex and locality, was selected from the demographic database. Mothers of each case and control were interviewed to obtain information on social, enconomic, demographic, environmental and other possible risk factors. Matched analyses of the 317 cases and their controls were performed using discordant pairs analysis and conditional logistic regression. RESULTS: The mortality rate for children aged 6 months to 4 years was estimated as 23.9/1000 children/year. An increased risk of death was observed where the delivery was not performed by a trained person (OR = 1.8, 95% CI: 1.0-3.2), if the preceding birth interval was < 24 months (OR = 2.2, 95% CI: 1.1-3.9), if the father beat the child's mother (OR = 4.3, 95% CI: 1.2-15.6) or if the water source was unprotected (OR = 1.6, 95% CI: 1.0-2.7). No association was found between weaning practices, parental education, or any of the socioeconomic or hygiene variables considered. CONCLUSIONS: Few strong risk factors for mortality were identified, perhaps because living conditions within the study population are relatively homogeneous. While mortality rates may be reduced by targeted interventions, such as increasing deliveries by trained people, more general improvements in the socioeconomic status in the region are essential.

PIP: A population-based case-control study was conducted in the Kassena-Nankana district of the Upper East Region of Ghana to investigate potential risk factors for post-neonatal and child mortality in northern Ghana where child survival rates are among the lowest in Africa. 317 cases of post-neonatal infant and child deaths were matched with controls, with matched analyzes subsequently conducted using discordant pairs analysis and conditional logistic regression. Mothers of each case and control were interviewed to obtain information on social, economic, demographic, environmental, and other possible risk factors. The mortality rate for children aged six months to four years was estimated as 23.9/1000 children/year. An increased risk of death was observed where the delivery was not performed by a trained person, if the preceding birth interval was less than 24 months, if the father beat the child's mother, or if the water source was unprotected. No association was found between weaning practices, parental education, or any of the socioeconomic or hygiene variables considered. The authors note that few strong risk factors for mortality were identified possibly due to the relatively homogeneous living conditions within the study area. While mortality rates can be reduced by targeted interventions, general improvement in the socioeconomic status in the region is needed.