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Low- and middle-income countries (LMICs) face the highest burden of maternal and neonatal deaths. Concurrently, they have the lowest number of physicians. Innovative methods such as the exchange of health-related information using mobile devices (mHealth) may support health care workers in the provision of antenatal, delivery, and postnatal care to improve maternal and neonatal outcomes in LMICs. We conducted a systematic review evaluating the effectiveness of mHealth interventions targeting health care workers to improve maternal and neonatal outcomes in LMIC. The Cochrane Library, PubMed, EMBASE, Global Health Library, and Popline were searched using predetermined search and indexing terms. Quality assessment was performed using an adapted Cochrane Risk of Bias Tool. A strength, weakness, opportunity, and threat analysis was performed for each included paper. A total of 19 studies were included for this systematic review, 10 intervention and 9 descriptive studies. mHealth interventions were used as communication, data collection, or educational tool by health care providers primarily at the community level in the provision of antenatal, delivery, and postnatal care. Interventions were used to track pregnant women to improve antenatal and delivery care, as well as facilitate referrals. None of the studies directly assessed the effect of mHealth on maternal and neonatal mortality. Challenges of mHealth interventions to assist health care workers consisted mainly of technical problems, such as mobile network coverage, internet access, electricity access, and maintenance of mobile phones. mHealth interventions targeting health care workers have the potential to improve maternal and neonatal health services in LMICs. However, there is a gap in the knowledge whether mHealth interventions directly affect maternal and neonatal outcomes and future research should employ experimental designs with relevant outcome measures to address this gap.

Coronavirus disease 2019 (COVID-19) has already claimed over four million lives globally and over 800 deaths in Ghana. The COVID-19 vaccine is a key intervention towards containing the pandemic. Over three billion doses of the vaccine have already been administered globally and over 800,000 doses administered in Ghana, representing less than 5% vaccination coverage. Fear, uncertainty, conspiracy theories and safety concerns remain important threats to, a successful rollout of the vaccine if not managed well. Ascertain the predictors of citizens' probability of participating in a COVID-19 vaccine trial and subsequently accept the vaccine when given the opportunity. The study was an online nation-wide survey among community members (n = 1556) from 18th September to 23rd October, 2020 in the 16 regions in Ghana. Binary probit regression analysis with marginal effect estimations was employed to ascertain the predictors of community members' willingness to participate in a COVID-19 vaccine trial and uptake the vaccine. Approximately 60% of respondents said they will not participate in a COVID-19 vaccine trial; 65% will take the vaccine, while 69% will recommend it to others. Willingness to voluntarily participate in COVID-19 vaccine trial, uptake the vaccine and advise others to do same was higher among adults aged 18-48 years, the unmarried and males (p < 0.05). Significant predictors of unwillingness to participate in the COVID-19 vaccine trial and uptake of the vaccine are: married persons, females, Muslims, older persons, residents of less urbanised regions and persons with lower or no formal education (p < 0.05). Predominant reasons cited for unwillingness to participate in a COVID-19 vaccine trial and take the vaccine included fear, safety concerns, lack of trust in state institutions, uncertainty, political connotations, spiritual and religious beliefs. The probability of accepting COVID-19 vaccine among the adult population in Ghana is high but the country should not get complacent because fear, safety and mistrust are important concerns that have the potential to entrench vaccine hesitancy. COVID-19 vaccine rollout campaigns should be targeted and cognisant of the key predictors of citizens' perceptions of the vaccine. These lessons when considered will promote Ghana's efforts towards vaccinating at least 20 million people to attain herd immunity.

Intermittent preventive treatment of malaria among pregnant women with sulfadoxine-pyrimethamine (IPTp-SP), is one of the three recommended interventions for the prevention of malaria in pregnancy (MiP) in sub-Sahara Africa. The World Health Organisation recommended in 2012 that SP be given at each scheduled ANC visit except during the first trimester and can be given a dose every month until the time of delivery, to ensure that a high proportion of women receive at least three doses of SP during pregnancy. Despite implementation of this policy, Ghana did not attain the target of 100% access to IPTp-SP by 2015. Additionally, negative outcomes of malaria infection in pregnancy are still recurring. This ethnographic study explored how health system, individual and socio-cultural factors influence IPTp-SP uptake in two Ghanaian regions. The study design was ethnographic, employing non-participant observation, case studies and in depth interviews in 8 health facilities and 8 communities, from April 2018 to March 2019, in two Ghanaian regions. Recommended ethical procedures were observed. Health system factors such as organization of antenatal care (ANC) services and strategies employed by health workers to administer SP contributed to initial uptake. Women's trust in the health care system contributed to continued uptake. Inadequate information provided to women accessing ANC, stock-outs and fees charged for ANC services reduced access to IPTp-SP. Socio-cultural factor such as encouragement from social networks influenced utilization of ANC services and IPTp-SP uptake. Individual factors such as refusing to take SP, skipping ANC appointments and initiating ANC attendance late affected uptake. Health system, socio-cultural and individual factors influence uptake of optimum doses of IPTp-SP. Consequently, interventions that aim at addressing IPTp-SP uptake should focus on regular and sufficient supply of SP to health facilities, effective implementation of free ANC, provision of appropriate and adequate information to women and community outreach programmes to encourage early and regular ANC visits.

The novel coronavirus (COVID-19) is characterised by loads of fake news and misinformation, which can influence vaccine acceptance. Implementing a harmonized public health strategy during an outbreak necessitates effective community engagement and communication, which facilitates public trust and decision-making. This study explored the role of community engagement in the acceptance of COVID-19 vaccine amid fake news and misinformation in two municipalities in Ghana. A case study design was employed using in-depth interviews with government officials from the Ghana Health Service, Municipal Assembly, Information Services Department and the National Commission on Civic Education and community gatekeepers. Additionally, focus group discussions were conducted with a cross-section of women, men and migrants' community members to understand the role of community engagement in vaccine acceptance. Qualitative analysis software Nvivo 12 was used to support thematic coding and analysis. All ethical procedures and COVID-19 preventive protocols were observed. Study participants reported the sources of fake news and misinformation about the COVID-19 vaccines from interpersonal communication, the radio, and a popular anti-vaccine song. Some of the factors contributing to vaccine hesitancy were community members believed in the fake news and misinformation, low trust in the government and public institutions, and the lack of extensive education on COVID-19 vaccines. The Ghana Health Service was the most successful in engaging communities to promote vaccine acceptance amid fake news and misinformation. It leveraged on its existing community-based health planning and services (CHPS) programme, which engaged the communities frequently through routine programmes such as durbars, antenatal clinics, child welfare clinics, and other community programmes to carry out engagement. Misinformation and fake news about COVID-19 vaccines were widespread in the study communities, with significant implications for vaccine hesitancy. The sources of misinformation ranged from social media platforms and radio broadcasts to personal interactions within communities. While government efforts at community engagement were noted, these efforts were often inadequate to counteract the deeply ingrained fears and misconceptions.

Background The aim of the study was to determine the coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) and its relationship with delivery outcomes among obstetric referral cases at the district level of healthcare. Methods An implementation research within three districts of the Greater Accra region was conducted from May 2017 to February 2018, to assess the role of an enhanced inter-facility communication system on processes and outcomes of obstetric referrals. A cross-sectional analysis of the data on IPTp coverage as well as delivery outcomes for the period of study was conducted, for all the referrals ending up in deliveries. Primary outcomes were maternal and neonatal complications at delivery. IPTp coverage was determined as percentages and classified as adequate or inadequate. Associated factors were determined using Chi square. Odds ratios (OR, 95% CI) were estimated for predictors of adequate IPTp dose coverage for associations with delivery outcomes, with statistical significance set at p = 0.05. Results From a total of 460 obstetric referrals from 16 lower level facilities who delivered at the three district hospitals, only 223 (48.5%) received adequate (at least 3) doses of IPTp. The district, type of facility where ANC is attended, insurance status, marital status and number of antenatal clinic visits significantly affected IPTp doses received. Adjusted ORs show that adequate IPTp coverage was significantly associated with new-born complication [0.80 (0.65–0.98); p = 0.03], low birth weight [0.51 (0.38–0.68); p < 0.01], preterm delivery [0.71 (0.55–0.90); p = 0.01] and malaria as indication for referral [0.70 (0.56–0.87); p < 0.01]. Positive association with maternal complication at delivery was seen but was not significant. Conclusion IPTp coverage remains low in the study setting and is affected by type of health facility that ANC is received at, access to health insurance and number of times a woman attends ANC during pregnancy. This study also confirmed earlier findings that, as an intervention IPTp prevents bad outcomes of pregnancy, even among women with obstetric referrals. It is important to facilitate IPTp service delivery to pregnant women across the country, improve coverage of required doses and maximize the benefits to both mothers and newborns.

Slow progress has been made in achieving the Millennium Development Goals 4 and 5 in Ghana. Ensuring continuum of care (at least four antenatal visits; skilled birth attendance; postnatal care within 48 hours, at two weeks, and six weeks) for mother and newborn is crucial in helping Ghana achieve these goals and beyond. This study examined the levels and factors associated with continuum of care (CoC) completion among Ghanaian women aged 15-49. A retrospective cross-sectional survey was conducted among women who experienced live births between January 2011 and April 2013 in three regions of Ghana. In a two-stage random sampling method, 1,500 women with infants were selected and interviewed about maternal and newborn service usage in line with CoC. Multiple logistic regression models were used to assess factors associated with CoC completion. Only 8.0% had CoC completion; the greatest gap and contributor to the low CoC was detected between delivery and postnatal care within 48 hours postpartum. About 95% of women had a minimum of four antenatal visits and postnatal care at six weeks postpartum. A total of 75% had skilled assisted delivery and 25% received postnatal care within 48 hours. Factors associated with CoC completion at 95% CI were geographical location (OR = 0.35, CI 0.13-0.39), marital status (OR = 0.45; CI 0.22-0.95), education (OR = 2.71; CI 1.11-6.57), transportation (OR = 1.97; CI 1.07-3.62), and beliefs about childhood illnesses (OR = 0.34; CI0.21-0.61). The continuum of care completion rate is low in the study site. Efforts should focus on increasing postnatal care within 48 hours and overcoming the known obstacles to increasing the continuum of care completion rate.

The first antenatal clinic (ANC) visit helps to distinguish pregnant women who require standard care, from those with specific problems and so require special attention. There are protocols to guide care providers to provide optimal care to women during ANC. Our objectives were to determine the level of provider adherence to first antenatal visit guidelines in the Safe Motherhood Protocol (SMP), and assess patient factors that determine complete provider adherence. This cross-sectional study is part of a cohort study that recruited women who delivered in eleven health facilities and who had utilized antenatal care services during their pregnancy in the Greater Accra region of Ghana. A record review of the first antenatal visit of participants was carried out to assess the level of adherence to the SMP, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected using a questionnaire. Percentages of adherence levels and baseline characteristics were estimated and cluster-adjusted odds ratios (OR) calculated to identify determinants. A total of 948 women who had delivered in eleven public facilities were recruited with a mean age (SD) of 28.2 (5.4) years. Overall, complete adherence to guidelines pertained to only 48.1% of pregnant women. Providers were significantly more likely to completely adhere to guidelines when caring for multiparous women [OR = 5.43 (1.69-17.44), p<0.01] but less likely to do so when attending to women with history of previous pregnancy complications [OR = 0.50 (0.33-0.75), p<0.01]. Complete provider adherence to first antenatal visit guidelines is low across different facility types in the Greater Accra region of Ghana and is determined by parity and history of previous pregnancy complication. Providers should be trained and supported to adhere to the guidelines during provision of care to all pregnant women.

Objective To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present, with the aim of reducing current massive overdiagnosis and overtreatment of malaria.Design Cluster randomized trial of 24 clusters of shops.Setting Dangme West, a poor rural district of Ghana.Participants Shops and their clients, both adults and children.Interventions Providing rapid diagnostic tests with realistic training.Main outcome measures The primary outcome was the proportion of clients testing negative for malaria by a double-read research blood slide who received an artemisinin combination therapy or other antimalarial. Secondary outcomes were use of antibiotics and antipyretics, and safety.Results Of 4603 clients, 3424 (74.4%) tested negative by double-read research slides. The proportion of slide-negative clients who received any antimalarial was 590/1854 (32%) in the intervention arm and 1378/1570 (88%) in the control arm (adjusted risk ratio 0.41 (95% CI 0.29 to 0.58), P<0.0001). Treatment was in high agreement with rapid diagnostic test result. Of those who were slide-positive, 690/787 (87.8%) in the intervention arm and 347/392 (88.5%) in the control arm received an artemisinin combination therapy (adjusted risk ratio 0.96 (0.84 to 1.09)). There was no evidence of antibiotics being substituted for antimalarials. Overall, 1954/2641 (74%) clients in the intervention arm and 539/1962 (27%) in the control arm received appropriate treatment (adjusted risk ratio 2.39 (1.69 to 3.39), P<0.0001). No safety concerns were identified.Conclusions Most patients with fever in Africa present to the private sector. In this trial, providing rapid diagnostic tests for malaria in the private drug retail sector significantly reduced dispensing of antimalarials to patients without malaria, did not reduce prescribing of antimalarials to true malaria cases, and appeared safe. Rapid diagnostic tests should be considered for the informal private drug retail sector.Registration Clinicaltrials.gov NCT01907672

Many patients with malaria-like symptoms seek treatment in private medicine retail outlets (PMR) that distribute malaria medicines but do not traditionally provide diagnostic services, potentially leading to overtreatment with antimalarial drugs. To achieve universal access to prompt parasite-based diagnosis, many malaria-endemic countries are considering scaling up malaria rapid diagnostic tests (RDTs) in these outlets, an intervention that may require legislative changes and major investments in supporting programs and infrastructures. This review identifies studies that introduced malaria RDTs in PMRs and examines study outcomes and success factors to inform scale up decisions. Published and unpublished studies that introduced malaria RDTs in PMRs were systematically identified and reviewed. Literature published before November 2016 was searched in six electronic databases, and unpublished studies were identified through personal contacts and stakeholder meetings. Outcomes were extracted from publications or provided by principal investigators. Six published and six unpublished studies were found. Most studies took place in sub-Saharan Africa and were small-scale pilots of RDT introduction in drug shops or pharmacies. None of the studies assessed large-scale implementation in PMRs. RDT uptake varied widely from 8%-100%. Provision of artemisinin-based combination therapy (ACT) for patients testing positive ranged from 30%-99%, and was more than 85% in five studies. Of those testing negative, provision of antimalarials varied from 2%-83% and was less than 20% in eight studies. Longer provider training, lower RDT retail prices and frequent supervision appeared to have a positive effect on RDT uptake and provider adherence to test results. Performance of RDTs by PMR vendors was generally good, but disposal of medical waste and referral of patients to public facilities were common challenges. Expanding services of PMRs to include malaria diagnostic services may hold great promise to improve malaria case management and curb overtreatment with antimalarials. However, doing so will require careful planning, investment and additional research to develop and sustain effective training, supervision, waste-management, referral and surveillance programs beyond the public sector.

ObjectivesHypertension is one of the most prevalent non-communicable diseases in West Africa, which responds to effective primary care. This scoping review explored factors influencing primary care access, utilisation and quality for patients with hypertension in West Africa.DesignScoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews.Data sourcesPublished literature from PubMed, Embase, Scopus, Cairn Info and Google Scholar, between 1 January 2000 and 31 December 2023.Eligibility criteriaSystematic reviews, observational studies and reports involving participants aged 18 years and above, written in English, French or Portuguese, were included. Clinical case series/case reports, short communications, books, grey literature, randomised control trials, clinical trials, quasi-experiments, conference proceedings and papers on gestational hypertension and pre-eclampsia were excluded.Data extraction and synthesisData from included studies were extracted onto an Excel spreadsheet and synthesised qualitatively using thematic analysis structured by the components of the overall review question.ResultsThe search yielded a total of 5846 studies, 45 papers were selected for full review and 16 papers were eventually included. Macro (contextual) barriers included economic, funding and geographical barriers. Meso (health system) factors include access to medications, tools, equipment and other supplies, out-of-pocket payments, availability of health insurance, health workers numbers, capacity and distribution. Micro (community and patient factors) barriers included financial barriers and limited knowledge, whereas facilitators included the availability of alternative providers and community and household support. These factors are interconnected and complex and should be addressed as a whole to reduce the burden of hypertension in West Africa.ConclusionMultiple complex and interrelated factors at contextual, health systems, community and patient levels act as barriers and enablers to access, utilisation and quality of primary care for hypertension in West Africa. Improving primary care and outcomes will, therefore, require multilevel multifaceted interventions.