Objectives
To assess the extent of socio‐economic inequity in coverage and timeliness of key childhood immunisations in Ghana.
Methods
Secondary analysis of vaccination card data collected from ...babies born between January 2008 and January 2010 who were registered in the surveillance system supporting the ObaapaVita and Newhints Trials was carried out. 20 251 babies had 6 weeks' follow‐up, 16 652 had 26 weeks' follow‐up, and 5568 had 1 year's follow‐up. We performed a descriptive analysis of coverage and timeliness of vaccinations by indicators for urban/rural status, wealth and educational attainment. The association of coverage with socio‐economic indicators was tested using a chi‐square‐test and the association with timeliness using Cox regression.
Results
Overall coverage at 1 year of age was high (>95%) for Bacillus Calmette–Guérin (BCG), all three pentavalent diphtheria‐pertussis‐tetanus‐haemophilus influenzae B‐hepatitis B (DPTHH) doses and all polio doses except polio at birth (63%). Coverage against measles and yellow fever was 85%. Median delay for BCG was 1.7 weeks. For polio at birth, the median delay was 5 days; all other vaccine doses had median delays of 2–4 weeks. We found substantial health inequity across all socio‐economic indicators for all vaccines in terms of timeliness, but not coverage at 1 year. For example, for the last DPTHH dose, the proportion of children delayed more than 8 weeks were 27% for urban children and 31% for rural children (P < 0.001), 21% in the wealthiest quintile and 41% in the poorest quintile (P < 0.001), and 9% in the most educated group and 39% in the least educated group (P < 0.001). However, 1‐year coverage of the same dose remained above 90% for all levels of all socio‐economic indicators.
Conclusions
Ghana has substantial health inequity across urban/rural, socio‐economic and educational divides. While overall coverage was high, most vaccines suffered from poor timeliness. We suggest that countries achieving high coverage should include timeliness indicators in their surveillance systems.
Objectifs
Evaluer l'ampleur de l'inégalité socioéconomique dans la couverture et la ponctualité de l'immunisation de l'enfance au Ghana.
Méthodes
Analyse secondaire des données de vaccination recueillies sur des cartes pour des bébés nés entre janvier 2008 et janvier 2010, qui ont été enregistrés dans le système de surveillance à l'appui des études ObaapaaVita et Newhints. 20251 bébés avaient six semaines de suivi, 16 652 avaient 26 semaines de suivi et 5568 avaient un an de suivi. Nous avons effectué une analyse descriptive de la couverture et de la ponctualité des vaccinations par des indicateurs de statut urbain/rural, la richesse et le niveau de scolarité. L'association entre la couverture et les indicateurs socioéconomiques a été analysée en utilisant le test X2 et l'association avec la ponctualité en utilisant la régression de Cox.
Résultats
La couverture globale à un an de l’âge était élevée (> 95%) pour le bacille de Calmette‐Guérin (BCG), toutes les trois doses du pentavalent diphtérie‐coqueluche‐tétanos‐Haemophilus influenzae B‐ hépatite B (DPTHH) et toutes les doses de polio, à l'exception de la poliomyélite à la naissance (63%). La couverture contre la rougeole et la fièvre jaune était de 85%. Le retard médian pour le BCG était de 1,7 semaine. Pour la poliomyélite à la naissance, le retard médian était de cinq jours; toutes les autres doses de vaccin avaient les retards moyens de deux à quatre semaines. Nous avons trouvé des inégalités de santé importantes pour tous les indicateurs socioéconomiques pour tous les vaccins en termes de ponctualité, mais pas en termes de couverture à un an. Par exemple, pour la dernière dose de DPTHH la proportion d'enfants avec un retard de plus de huit semaines était de 27% pour les enfants en zone urbaine et 31% pour les enfants en zone rurale (p < 0,001), 21% dans le quantile le plus riche et 41% dans le quantile le plus pauvre (p < 0,001), 9% dans le groupe avec une scolarité plus élevée et 39% dans le groupe le moins instruit (p <0,001). Toutefois, la couverture à un an de la même dose est restée supérieure à 90% pour tous les niveaux de tous les indicateurs socioéconomiques.
Conclusions
Le Ghana a des inégalités de santé important dans les échelons urbain/rural, socio‐économiques et éducatifs. Alors que la couverture globale était élevée, la plupart des vaccins souffraient d'une ponctualité insuffisante. Nous suggérons que les pays ayant atteint une couverture élevée devraient inclure des indicateurs de ponctualité dans leurs systèmes de surveillance.
Objetivos
Evaluar la extensión de la inequidad socioeconómica en la cobertura y temporalidad de las principales vacunas infantiles en Ghana.
Métodos
Análisis secundario de datos del carnet vacunal, recogidos para bebés nacidos entre Enero del 2008 y Enero del 2010 y que fueron registrados en el sistema de vigilancia que servía de apoyo a los ensayos de ObaapaaVita y Newhints. 20,251 bebes tenían seis semanas de seguimiento, 16,652 tenían 26 semanas de seguimiento y 5,568 tenían un año de seguimiento. Realizamos un análisis descriptivo de la cobertura y la temporalidad de las vacunaciones mediante indicadores del estatus urbano/rural, riqueza y nivel educativo. La asociación de la cobertura con los indicadores socioeconómicos se evaluó mediante una prueba de X2 y la asociación con la temporalidad utilizando una regresión de Cox.
Resultados
La cobertura total con un año de edad era alta (>95%) para Bacillus Calmette–Guérin (BCG), las tres dosis de la vacuna pentavalente Difteria‐Pertussis‐Tétanos‐Haemophilus Influenzae tipo B‐ y el virus de la Hepatitis B (DPTHH) y todas las dosis de Polio excepto la del Polio en el momento de nacer (63%). La cobertura frente a sarampión y fiebre amarilla era del 85%. El retraso medio para BCG era de 1.7 semanas. Para el Polio en el momento de nacer, el retraso medio era de cinco días; todas las otras dosis de vacunas tenían retrasos medios de dos a cuatro semanas. Encontramos una inequidad sanitaria sustancial en todos los indicadores socioeconómicos y para todas las vacunas en términos de la temporalidad, pero no en la cobertura a un año. Por ejemplo, para la última dosis de DPTHH, la proporción de niños con un retraso de más de ocho semanas era del 27% para niños urbanitas y del 31% para niños rurales (p<0.001), 21% en el quintil más rico y 41% en el quintil más pobre (p<0.001), 9% entre el grupo con más educación y 39% en el grupo con un menor nivel de educación (p<0.001). Sin embargo, la cobertura a un año de la misma dosis estaba sobre el 90% en todos los niveles de indicadores socioeconómicos.
Conclusiones
Ghana tiene una inequidad sustancial en salud a lo largo de los estratos urbano/rural, socioeconómicos y educacionales. Mientras que la cobertura general era alta, para la mayoría de las vacunas había una mala temporalidad. Sugerimos que los países con una alta cobertura deberían incluir indicadores de temporalidad en sus sistemas de vigilancia.
Counselling for Alcohol Problems (CAP), a brief intervention delivered by lay counsellors, enhanced remission and abstinence over 3 months among male primary care attendees with harmful drinking in a ...setting in India. We evaluated the sustainability of the effects after treatment termination, the cost-effectiveness of CAP over 12 months, and the effects of the hypothesized mediator 'readiness to change' on clinical outcomes.
Male primary care attendees aged 18-65 years screening with harmful drinking on the Alcohol Use Disorders Identification Test (AUDIT) were randomised to either CAP plus enhanced usual care (EUC) (n = 188) or EUC alone (n = 189), of whom 89% completed assessments at 3 months, and 84% at 12 months. Primary outcomes were remission and mean standard ethanol consumed in the past 14 days, and the proposed mediating variable was readiness to change at 3 months. CAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up, with the proportion with remission (AUDIT score < 8: 54.3% versus 31.9%; adjusted prevalence ratio aPR 1.71 95% CI 1.32, 2.22; p < 0.001) and abstinence in the past 14 days (45.1% versus 26.4%; adjusted odds ratio 1.92 95% CI 1.19, 3.10; p = 0.008) being significantly higher in the CAP plus EUC arm than in the EUC alone arm. CAP participants also fared better on secondary outcomes including recovery (AUDIT score < 8 at 3 and 12 months: 27.4% versus 15.1%; aPR 1.90 95% CI 1.21, 3.00; p = 0.006) and percent of days abstinent (mean percent SD 71.0% 38.2 versus 55.0% 39.8; adjusted mean difference 16.1 95% CI 7.1, 25.0; p = 0.001). The intervention effect for remission was higher at 12 months than at 3 months (aPR 1.50 95% CI 1.09, 2.07). There was no evidence of an intervention effect on Patient Health Questionnaire 9 score, suicidal behaviour, percentage of days of heavy drinking, Short Inventory of Problems score, WHO Disability Assessment Schedule 2.0 score, days unable to work, or perpetration of intimate partner violence. Economic analyses indicated that CAP plus EUC was dominant over EUC alone, with lower costs and better outcomes; uncertainty analysis showed a 99% chance of CAP being cost-effective per remission achieved from a health system perspective, using a willingness to pay threshold equivalent to 1 month's wages for an unskilled manual worker in Goa. Readiness to change level at 3 months mediated the effect of CAP on mean standard ethanol consumption at 12 months (indirect effect -6.014 95% CI -13.99, -0.046). Serious adverse events were infrequent, and prevalence was similar by arm. The methodological limitations of this trial are the susceptibility of self-reported drinking to social desirability bias, the modest participation rates of eligible patients, and the examination of mediation effects of only 1 mediator and in only half of our sample.
CAP's superiority over EUC at the end of treatment was largely stable over time and was mediated by readiness to change. CAP provides better outcomes at lower costs from a societal perspective.
ISRCTN registry ISRCTN76465238.
Background
Risk factors for postnatal depression (PND), one of the most pervasive complications of child bearing, are poorly understood in Africa. A recent systematic review of 31 studies found that ...the strongest predictors are social and economic disadvantage and gender‐based factors; only six of these studies were community based, and almost all were in South Asia.
Methods
Cohort study nested within 4 weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for depression during pregnancy and after birth using the Patient Health Questionnaire to ascertain DSM‐IV major or minor depression. Information was collected on determinants relating to the mother, birth, and baby, which were examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals.
Results
Thirteen thousand nine hundred and twenty nine women were screened both during pregnancy and after birth, of whom 13,360 (95.9%) had complete data on potential determinants. Two hundred and fifty five (3.8%, 95% CI: 3.5%, 4.1%) had PND. Antenatal depression (AND) was the strongest determinant accounting for 34.4% of PND cases. Other determinants were season of delivery, peripartum/postpartum complications, newborn ill health, still birth, or neonatal death. Common determinants were observed for onset and persistent depression.
Conclusions
Although most AND resolves in this setting, more than a third of women with PND also had AND. Adverse birth‐ and baby‐related outcomes are the other main determinants. We recommend that programs detect and treat depression during pregnancy and provide support to women with adverse birth outcomes.
Community health workers (CHWs) are an increasingly important component of health systems and programs. Despite the recognized role of supervision in ensuring CHWs are effective, supervision is often ...weak and under-supported. Little is known about what constitutes adequate supervision and how different supervision strategies influence performance, motivation, and retention.
To determine the impact of supervision strategies used in low- and middle-income countries and discuss implementation and feasibility issues with a focus on CHWs.
A search of peer-reviewed, English language articles evaluating health provider supervision strategies was conducted through November 2013. Included articles evaluated the impact of supervision in low- or middle-income countries using a controlled, pre-/post- or observational design. Implementation and feasibility literature included both peer-reviewed and gray literature.
A total of 22 impact papers were identified. Papers were from a range of low- and middle-income countries addressing the supervision of a variety of health care providers. We classified interventions as testing supervision frequency, the supportive/facilitative supervision package, supervision mode (peer, group, and community), tools (self-assessment and checklists), focus (quality assurance/problem solving), and training. Outcomes included coverage, performance, and perception of quality but were not uniform across studies. Evidence suggests that improving supervision quality has a greater impact than increasing frequency of supervision alone. Supportive supervision packages, community monitoring, and quality improvement/problem-solving approaches show the most promise; however, evaluation of all strategies was weak.
Few supervision strategies have been rigorously tested and data on CHW supervision is particularly sparse. This review highlights the diversity of supervision approaches that policy makers have to choose from and, while choices should be context specific, our findings suggest that high-quality supervision that focuses on supportive approaches, community monitoring, and/or quality assurance/problem solving may be most effective.
In most low-income countries, several child-survival interventions are being implemented. We assessed how these interventions are clustered at the level of the individual child.
We analysed data from ...Bangladesh, Benin, Brazil, Cambodia, Eritrea, Haiti, Malawi, Nepal, and Nicaragua. A co-coverage score was obtained by adding the number of interventions received by each child (including BCG, diphtheria-pertussis-tetanus, and measles vaccines), tetanus toxoid for the mother, vitamin A supplementation, antenatal care, skilled delivery, and safe water. Socioeconomic status was assessed through principal components analysis of household assets, and concentration indices were calculated.
The percentage of children who did not receive a single intervention ranged from 0·3% (14/5495) in Nicaragua to 18·8% (1154/6144) in Cambodia. The proportions receiving all available interventions varied from 0·8% (48/6144) in Cambodia to 13·3% (733/5495) in Nicaragua. There were substantial inequities within all countries. In the poorest wealth quintile, 31% of Cambodian children received no interventions and 17% only one intervention; in Haiti, these figures were 15% and 17%, respectively. Inequities were inversely related to coverage levels. Countries with higher coverage rates tended to show bottom inequity patterns, with the poorest lagging behind all other groups, whereas low-coverage countries showed top inequities with the rich substantially above the rest.
The inequitable clustering of interventions at the level of the child raises the possibility that the introduction of new technologies might primarily benefit children who are already covered by existing interventions. Packaging several interventions through a single delivery strategy, while making economic sense, could contribute to increased inequities unless population coverage is very high. Co-coverage analyses of child-health surveys provide a way to assess these issues.
Maternal morbidity occurs several times more frequently than mortality, yet data on morbidity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and middle-income ...countries. We aimed to generate prospective, reliable population-based data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and postnatal periods and its association with maternal, foetal, and neonatal death in South Asia and sub-Saharan Africa.
This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia and sub-Saharan Africa. We conducted population-based surveillance of women of reproductive age (15 to 49 years) to identify pregnancies. Pregnant women who gave consent were include in the study and followed up to birth and 42 days postpartum from 2012 to 2015. We used standard operating procedures, data collection tools, and training to harmonise study implementation across sites. Three home visits during pregnancy and 2 home visits after birth were conducted to collect maternal morbidity information and maternal, foetal, and newborn outcomes. We measured blood pressure and proteinuria to define hypertensive disorders of pregnancy and woman's self-report to identify obstetric haemorrhage, pregnancy-related infection, and prolonged or obstructed labour. Enrolled women whose pregnancy lasted at least 28 weeks or those who died during pregnancy were included in the analysis. We used meta-analysis to combine site-specific estimates of burden, and regression analysis combining all data from all sites to examine associations between the maternal morbidities and adverse outcomes. Among approximately 735,000 women of reproductive age in the study population, and 133,238 pregnancies during the study period, only 1.6% refused consent. Of these, 114,927 pregnancies had morbidity data collected at least once in both antenatal and in postnatal period, and 114,050 of them were included in the analysis. Overall, 32.7% of included pregnancies had at least one major direct maternal morbidity; South Asia had almost double the burden compared to sub-Saharan Africa (43.9%, 95% CI 27.8% to 60.0% in South Asia; 23.7%, 95% CI 19.8% to 27.6% in sub-Saharan Africa). Antepartum haemorrhage was reported in 2.2% (95% CI 1.5% to 2.9%) pregnancies and severe postpartum in 1.7% (95% CI 1.2% to 2.2%) pregnancies. Preeclampsia or eclampsia was reported in 1.4% (95% CI 0.9% to 2.0%) pregnancies, and gestational hypertension alone was reported in 7.4% (95% CI 4.6% to 10.1%) pregnancies. Prolonged or obstructed labour was reported in about 11.1% (95% CI 5.4% to 16.8%) pregnancies. Clinical features of late third trimester antepartum infection were present in 9.1% (95% CI 5.6% to 12.6%) pregnancies and those of postpartum infection in 8.6% (95% CI 4.4% to 12.8%) pregnancies. There were 187 pregnancy-related deaths per 100,000 births, 27 stillbirths per 1,000 births, and 28 neonatal deaths per 1,000 live births with variation by country and region. Direct maternal morbidities were associated with each of these outcomes.
Our findings imply that health programmes in sub-Saharan Africa and South Asia must intensify their efforts to identify and treat maternal morbidities, which affected about one-third of all pregnancies and to prevent associated maternal and neonatal deaths and stillbirths.
The study is not a clinical trial.
No studies have examined the effect of socioeconomic deprivation on antepartum and intrapartum stillbirths in the poorest women in low income countries.
This study used data from a prospective ...population based surveillance system involving all women of childbearing age and their babies in rural Ghana. The primary objective was to evaluate associations between household wealth and risk of antepartum and intrapartum stillbirth. The secondary objective was to assess whether any differences in risk were mediated by utilisation of health services during pregnancy. Data were analysed using multivariable logistic regression. Random effect models adjusted for clustering of women who delivered more than one infant. There were 80267 babies delivered from 1 July 2003 to 30 September 2008: 77666 live births and 2601 stillbirths. Of the stillbirths 1367 (52.6%) were antepartum, 989 (38.0%) were intrapartum and 245 (9.4%) had no data on the timing of death. 94.8% of the babies born in the study (76129/80267) had complete data on all covariates and outcomes. 36 878 (48.4%) of babies were born to women in the two poorest quintiles and 3697 (4.9%) had no pregnancy care. There was no association between wealth and antepartum stillbirths. There was a marked 'dose response' of increasing risk of intrapartum stillbirth with increasing levels of socioeconomic deprivation (adjOR 1.09 1.03-1.16 p value 0.002). Women in the poorest two quintiles had greater risk of intrapartum stillbirth (adjOR 1.19 1.02-1.38 p value 0.023) compared to the richest women. Adjusting for heath service utilisation and other variables did not alter results.
Poor women had a high risk of intrapartum stillbirth and this risk was not influenced by health service utilisation. Health system strengthening is required to meet the needs of poor women in our study population.
Access to skilled attendance at childbirth is crucial to reduce maternal and newborn mortality. Several different measures of geographic access are used concurrently in public health research, with ...the assumption that sophisticated methods are generally better. Most of the evidence for this assumption comes from methodological comparisons in high-income countries. We compare different measures of travel impedance in a case study in Ghana's Brong Ahafo region to determine if straight-line distance can be an adequate proxy for access to delivery care in certain low- and middle-income country (LMIC) settings.
We created a geospatial database, mapping population location in both compounds and village centroids, service locations for all health facilities offering delivery care, land-cover and a detailed road network. Six different measures were used to calculate travel impedance to health facilities (straight-line distance, network distance, network travel time and raster travel time, the latter two both mechanized and non-mechanized). The measures were compared using Spearman rank correlation coefficients, absolute differences, and the percentage of the same facilities identified as closest. We used logistic regression with robust standard errors to model the association of the different measures with health facility use for delivery in 9,306 births.
Non-mechanized measures were highly correlated with each other, and identified the same facilities as closest for approximately 80% of villages. Measures calculated from compounds identified the same closest facility as measures from village centroids for over 85% of births. For 90% of births, the aggregation error from using village centroids instead of compound locations was less than 35 minutes and less than 1.12 km. All non-mechanized measures showed an inverse association with facility use of similar magnitude, an approximately 67% reduction in odds of facility delivery per standard deviation increase in each measure (OR = 0.33).
Different data models and population locations produced comparable results in our case study, thus demonstrating that straight-line distance can be reasonably used as a proxy for potential spatial access in certain LMIC settings. The cost of obtaining individually geocoded population location and sophisticated measures of travel impedance should be weighed against the gain in accuracy.
Abstract Background While depression during pregnancy is one of the strongest risk factors for postnatal depression, it has been comparatively little studied, particularly in sub-Saharan Africa. ...Methods Cohort study nested within 4-weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for depression during pregnancy using the P atient H ealth Qu estionnaire to ascertain DSM-IV major or minor depression. Information on demographic factors, indicators of social and economic disadvantage, and previous obstetric history were also collected which were examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals. Results 21,135 pregnant women were screened of whom 20,920 (98.9%) had complete data on potential determinants. 2086 (9.9%, 95% CI: 9.5%–10.3%) had AND. Determinants of AND were: maternal age 30+ years (relative risk RR, 1.16 (1.06–1.27); never married (RR 1.34, (1.14–1.58); lower wealth quintile (RR, 1.30 (1.13–1.50); unplanned pregnancy (RR, 1.55 (1.43–1.69); previous pregnancy loss (RR, 1.30 (1.18–1.43). Limitations We did not assess women for physical health during pregnancy, and lacked information on some potentially relevant psychosocial factors. Conclusion Prevalence of antenatal depression, applying clinical criteria, is similar to that seen in high income countries. Factors related to chronic social and economic disadvantage are among the most important co-determinants. Population-level interventions that address these problems among women of reproductive age may be the most effective strategy for reducing the prevalence and impact of depression in pregnancy.
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