Healthcare seeking patterns of families of infants with circumcision-related morbidities from two population-based cohort studies in Ghana

BMJ Open, Volume 7, No. 8, Year 2017

Interpretation

Objective This study assessed healthcare seeking patterns of families of infants with circumcision-related morbidities and families of infants with acute illnesses in rural Ghana. Design Two population-based cohort studies. Setting Brong Ahafo Region of central rural Ghana. Participants A total of 22 955 infants enrolled in a large population-based trial (Neovita trial) from 16 August 2010 to 7 November 2011 and 3141 infants in a circumcision study from 21 May 2012 to 31 December 2012. Primary outcome Care seeking for circumcision-related morbidities and acute illnesses unrelated to circumcision. Results Two hundred and thirty (8.1%) infants from the circumcision study had circumcision-related morbidities and 6265 (27.3%) infants from the Neovita study had acute illnesses unrelated to circumcision. A much lower proportion (35, 15.2%) of families of infants with circumcision-related morbidities sought healthcare compared with families of infants with acute illnesses in the Neovita study (5520, 88.1%). More families sought care from formal providers (24, 69%) compared with informal providers (11, 31%) for circumcision-related morbidities. There were no obvious determinants of care seeking for acute illnesses or circumcision-related morbidities in the population. Conclusions Government and non-government organisations need to improve awareness about the complications and care seeking needed for circumcision-related morbidities. Data from two separate cohort studies in the same part of the Brong Ahafo Region of central Ghana were analysed separately and compared descriptively. The larger of the two cohorts includes data from a population-based trial of newborn vitamin A supplementation (Neovita trial), conducted between 16 August 2010 and 7 November 2011 and involving 22 955 mother–infant pairs; full details have been published previously.12 The smaller cohort was conducted between 21 May 2012 and 31 December 2012 and focused on circumcision. This was implemented to obtain additional observational data on births, cause-specific mortality and circumcision-related morbidity in the study area. Over the period from 2010 to 2012, 80% of the study population lived in rural settlements and 20% of mothers had no primary school education. Four major district hospitals and over 80 small health facilities provided healthcare services to the population. There were 30 doctors and 44 other formal health service providers (medical assistants and nurses) providing curative services in the four district hospitals at the time of the circumcision study. There were also approximately 120 informal care providers such as drug sellers, traditional healers and religious leaders in the study area. For the Neovita study, from August 2010 to November 2011, all births in the study area were reported to the trial team via a network of fieldworkers. Fieldworkers visited all families at home between 2 hours and 2 days after birth and interviewed the mother of the infant or the primary caregiver. Fieldworkers weighed the baby and asked the mother or the primary caregiver about: date of birth, site of birth, current address, distance to health facilities, sociodemographic characteristics and socioeconomic information (using an asset index). At the monthly surveillance visits, the families were asked by fieldworkers for detailed information on infant illness including start and end dates and healthcare seeking during infant illness. Due to time constraints, families were not asked exactly who they sought care from. The fieldworkers also asked the families who sought healthcare whether the infant was admitted to hospital. The fieldworkers next reviewed infant health records and checked for consistency with family’s report. The fieldworkers also collected data on the vital status of the baby (including if the baby was alive, dead or hospitalised). The circumcision study included all male live-born infants who were born in the study population from May to December 2012 and were aged under 12 weeks. Follow-up visits were scheduled between 8 to 11 weeks postbirth and trained senior fieldworkers asked for consent to collect additional detailed data on: age at circumcision, site of circumcision and type of circumcision provider. The fieldworkers asked about circumcision morbidities and whether these morbidities had been confirmed by a trained health professional. Families were also asked if they sought care for circumcision-related morbidities and if they had been given advice about potential problems or care seeking. The fieldworkers also asked detailed information on the following: site of healthcare, type of healthcare provider, medicines prescribed, admissions and surgery. Consent to access the baby’s Neovita data including socioeconomic, sociodemographic and care seeking was obtained. In both studies the fieldworkers were trained for 2 weeks in all study procedures prior to the commencement of the study. Inter-rater reliability was checked between all fieldworkers. We did not perform statistical evaluation of agreements between the fieldworkers and the study coordinator (GT). However, each fieldworker was supervised during two visits per month as part of the study scheduled and unscheduled supervisory visits. During these visits, GT and field supervisors observed the fieldworker interviewing mothers and examined infants and recorded findings independently. Recorded data were compared between the fieldworker and GT/field supervisor and used to provide feedback after the home visits and at weekly fieldworker meetings. The fieldworkers used standardised paper-based data collection tools (including a standardised list of closed-ended questions) for all interviews. We defined a formal healthcare service as medical care provided at hospitals, clinics or health posts by professionally trained, licensed and regulated providers of medical services including: doctors, medical assistants, nurses or pharmacists. An informal healthcare service was defined as care provided by untrained, unlicensed, unregulated private provider of care services including: drug sellers, traditional healers and religious leaders. Circumcision-related morbidities were defined as complications occurring during or after the circumcision procedure as reported by the primary caregiver including: excess skin removal or incision, excess bleeding, inadequate skin removal, infection, abnormal stream of urine, glans amputation, ulcer.1 Acute illnesses were defined as illnesses or injuries other than circumcision-related complications such as malaria, sepsis, acute respiratory tract infection or diarrhoea.13 14 A formal circumcision provider referred to professionally trained, licensed and regulated providers of medical services. This included: doctors, medical assistants or nurses. An informal circumcision provider was an untrained, unlicensed, unregulated private provider of medical services including: drug sellers, domestic staff, family members and Wanzams (village-based traditional circumcision providers). Our primary outcome was care seeking. In the circumcision study, we defined care seeking as the percentage of families of infants who sought care from either a formal healthcare provider or an informal care provider among families who reported of an infant having a circumcision-related morbidity after circumcision during the circumcision follow-up visits (occurred between 8 and 11 weeks postbirth). In the Neovita study, care seeking was defined as the percentage of families of infants with acute illnesses unrelated to circumcision who sought care outside the home of the infant as reported by caregivers during the Neovita infant follow-up visits (from 4 weeks up to 52 weeks of age). Two hundred and thirty (8.1%) infants had circumcision-related morbidities and of these, only 35 (15.2%) families sought care. Thus, we reported care seeking patterns in our circumcised cohort only using simple proportions and descriptive analyses. Statistical analyses were used to assess care seeking patterns in the larger Neovita cohort of 22 955 infants. Multivariable logistic regression models were constructed a priori to assess the association between care seeking patterns and morbidity risk and adjusted for the effect of important explanatory variables including: religion, maternal education level, maternal age, distance to health facility, site of delivery, sex, birth weight and income status. Adjusted ORs (aORs) and 95% CI were calculated. All analyses were conducted in STATA V.13. Ethical approvals were obtained from Ghana Health Service Ethical Review Committee, the institutional ethics committee of Kintampo Health Research Centre, the research ethics committee of London School of Hygiene and Tropical Medicine and the human research ethics committee of the University of Western Australia. Written informed consent was obtained from all the families of the circumcised male infants.

AI Digest

Study Justification:

– The study aimed to assess the healthcare seeking patterns of families of infants with circumcision-related morbidities and families of infants with acute illnesses in rural Ghana.
– The study aimed to identify the proportion of families seeking healthcare for circumcision-related morbidities and acute illnesses unrelated to circumcision.
– The study aimed to compare the care seeking patterns between the two groups and identify any determinants of care seeking.

Highlights:

– 8.1% of infants in the circumcision study had circumcision-related morbidities, while 27.3% of infants in the Neovita study had acute illnesses unrelated to circumcision.
– A lower proportion (15.2%) of families sought healthcare for circumcision-related morbidities compared to families seeking care for acute illnesses (88.1%).
– More families sought care from formal healthcare providers (69%) for circumcision-related morbidities compared to informal providers (31%).
– No obvious determinants of care seeking for acute illnesses or circumcision-related morbidities were found in the population.

Recommendations for Lay Reader and Policy Maker:

– Government and non-government organizations should improve awareness about the complications and care seeking needed for circumcision-related morbidities.
– Efforts should be made to educate families about the importance of seeking healthcare for circumcision-related complications.
– Policy makers should consider implementing strategies to increase access to formal healthcare providers for families of infants with circumcision-related morbidities.

Key Role Players:

– Government health agencies
– Non-government organizations
– Healthcare providers (doctors, medical assistants, nurses, pharmacists)
– Traditional healers
– Religious leaders
– Drug sellers

Cost Items for Planning Recommendations:

– Awareness campaigns and educational materials
– Training programs for healthcare providers
– Infrastructure development for healthcare facilities
– Outreach programs to reach rural communities
– Monitoring and evaluation of the implemented strategies

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is fairly strong, but there are some areas for improvement. The study design is described as two population-based cohort studies, which provides a solid foundation for the research. The sample sizes are also relatively large, which increases the reliability of the findings. The results are presented clearly, showing the proportions of families seeking healthcare for circumcision-related morbidities and acute illnesses. However, the abstract lacks information on the methods used to collect and analyze the data, as well as any statistical analysis performed. Including these details would strengthen the evidence. Additionally, the abstract does not mention any limitations of the study, which would be helpful for interpreting the results. To improve the evidence, the authors could provide more information on the data collection methods, statistical analysis, and limitations of the study.

Abstract

Data from two separate cohort studies in the same part of the Brong Ahafo Region of central Ghana were analysed separately and compared descriptively. The larger of the two cohorts includes data from a population-based trial of newborn vitamin A supplementation (Neovita trial), conducted between 16 August 2010 and 7 November 2011 and involving 22 955 mother–infant pairs; full details have been published previously.12 The smaller cohort was conducted between 21 May 2012 and 31 December 2012 and focused on circumcision. This was implemented to obtain additional observational data on births, cause-specific mortality and circumcision-related morbidity in the study area. Over the period from 2010 to 2012, 80% of the study population lived in rural settlements and 20% of mothers had no primary school education. Four major district hospitals and over 80 small health facilities provided healthcare services to the population. There were 30 doctors and 44 other formal health service providers (medical assistants and nurses) providing curative services in the four district hospitals at the time of the circumcision study. There were also approximately 120 informal care providers such as drug sellers, traditional healers and religious leaders in the study area. For the Neovita study, from August 2010 to November 2011, all births in the study area were reported to the trial team via a network of fieldworkers. Fieldworkers visited all families at home between 2 hours and 2 days after birth and interviewed the mother of the infant or the primary caregiver. Fieldworkers weighed the baby and asked the mother or the primary caregiver about: date of birth, site of birth, current address, distance to health facilities, sociodemographic characteristics and socioeconomic information (using an asset index). At the monthly surveillance visits, the families were asked by fieldworkers for detailed information on infant illness including start and end dates and healthcare seeking during infant illness. Due to time constraints, families were not asked exactly who they sought care from. The fieldworkers also asked the families who sought healthcare whether the infant was admitted to hospital. The fieldworkers next reviewed infant health records and checked for consistency with family’s report. The fieldworkers also collected data on the vital status of the baby (including if the baby was alive, dead or hospitalised). The circumcision study included all male live-born infants who were born in the study population from May to December 2012 and were aged under 12 weeks. Follow-up visits were scheduled between 8 to 11 weeks postbirth and trained senior fieldworkers asked for consent to collect additional detailed data on: age at circumcision, site of circumcision and type of circumcision provider. The fieldworkers asked about circumcision morbidities and whether these morbidities had been confirmed by a trained health professional. Families were also asked if they sought care for circumcision-related morbidities and if they had been given advice about potential problems or care seeking. The fieldworkers also asked detailed information on the following: site of healthcare, type of healthcare provider, medicines prescribed, admissions and surgery. Consent to access the baby’s Neovita data including socioeconomic, sociodemographic and care seeking was obtained. In both studies the fieldworkers were trained for 2 weeks in all study procedures prior to the commencement of the study. Inter-rater reliability was checked between all fieldworkers. We did not perform statistical evaluation of agreements between the fieldworkers and the study coordinator (GT). However, each fieldworker was supervised during two visits per month as part of the study scheduled and unscheduled supervisory visits. During these visits, GT and field supervisors observed the fieldworker interviewing mothers and examined infants and recorded findings independently. Recorded data were compared between the fieldworker and GT/field supervisor and used to provide feedback after the home visits and at weekly fieldworker meetings. The fieldworkers used standardised paper-based data collection tools (including a standardised list of closed-ended questions) for all interviews. We defined a formal healthcare service as medical care provided at hospitals, clinics or health posts by professionally trained, licensed and regulated providers of medical services including: doctors, medical assistants, nurses or pharmacists. An informal healthcare service was defined as care provided by untrained, unlicensed, unregulated private provider of care services including: drug sellers, traditional healers and religious leaders. Circumcision-related morbidities were defined as complications occurring during or after the circumcision procedure as reported by the primary caregiver including: excess skin removal or incision, excess bleeding, inadequate skin removal, infection, abnormal stream of urine, glans amputation, ulcer.1 Acute illnesses were defined as illnesses or injuries other than circumcision-related complications such as malaria, sepsis, acute respiratory tract infection or diarrhoea.13 14 A formal circumcision provider referred to professionally trained, licensed and regulated providers of medical services. This included: doctors, medical assistants or nurses. An informal circumcision provider was an untrained, unlicensed, unregulated private provider of medical services including: drug sellers, domestic staff, family members and Wanzams (village-based traditional circumcision providers). Our primary outcome was care seeking. In the circumcision study, we defined care seeking as the percentage of families of infants who sought care from either a formal healthcare provider or an informal care provider among families who reported of an infant having a circumcision-related morbidity after circumcision during the circumcision follow-up visits (occurred between 8 and 11 weeks postbirth). In the Neovita study, care seeking was defined as the percentage of families of infants with acute illnesses unrelated to circumcision who sought care outside the home of the infant as reported by caregivers during the Neovita infant follow-up visits (from 4 weeks up to 52 weeks of age). Two hundred and thirty (8.1%) infants had circumcision-related morbidities and of these, only 35 (15.2%) families sought care. Thus, we reported care seeking patterns in our circumcised cohort only using simple proportions and descriptive analyses. Statistical analyses were used to assess care seeking patterns in the larger Neovita cohort of 22 955 infants. Multivariable logistic regression models were constructed a priori to assess the association between care seeking patterns and morbidity risk and adjusted for the effect of important explanatory variables including: religion, maternal education level, maternal age, distance to health facility, site of delivery, sex, birth weight and income status. Adjusted ORs (aORs) and 95% CI were calculated. All analyses were conducted in STATA V.13. Ethical approvals were obtained from Ghana Health Service Ethical Review Committee, the institutional ethics committee of Kintampo Health Research Centre, the research ethics committee of London School of Hygiene and Tropical Medicine and the human research ethics committee of the University of Western Australia. Written informed consent was obtained from all the families of the circumcised male infants.

Materials

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Increase awareness: Government and non-government organizations can work together to improve awareness about the complications and care seeking needed for circumcision-related morbidities. This can be done through community education programs, health campaigns, and targeted messaging.

2. Strengthen healthcare infrastructure: There is a need to improve the availability and accessibility of healthcare facilities in rural areas. This can be achieved by increasing the number of doctors, nurses, and other healthcare providers in the district hospitals and small health facilities. Additionally, efforts can be made to improve the quality of care provided in these facilities.

3. Enhance training and capacity building: Training programs can be implemented to enhance the skills and knowledge of healthcare providers in managing circumcision-related morbidities. This can include training on proper circumcision techniques, identification and management of complications, and counseling families on potential problems and care seeking.

4. Improve coordination and referral systems: Efforts can be made to improve coordination and communication between formal and informal healthcare providers. This can include establishing referral systems to ensure that families of infants with circumcision-related morbidities are appropriately referred to formal healthcare providers when needed.

5. Address socioeconomic barriers: Socioeconomic factors, such as income status and maternal education level, can impact care seeking behaviors. Initiatives can be implemented to address these barriers, such as providing financial support for healthcare expenses and promoting girls’ education to improve maternal health knowledge and decision-making.

6. Utilize technology: Technology can be leveraged to improve access to maternal health services. This can include telemedicine initiatives to provide remote consultations and advice, mobile health applications to provide information and reminders, and electronic health records to improve continuity of care.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of the population in question.

AI Innovations Description

Based on the description provided, the recommendation to improve access to maternal health in rural Ghana is to increase awareness about the complications and care seeking needed for circumcision-related morbidities. This can be done through government and non-government organizations implementing educational campaigns to inform families about the potential risks and the importance of seeking healthcare for circumcision-related complications. Additionally, efforts can be made to improve access to formal healthcare providers in rural areas, such as increasing the number of doctors and other healthcare professionals in district hospitals and health facilities. This would ensure that families have access to trained and regulated providers who can properly address circumcision-related morbidities.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase awareness: Government and non-government organizations should focus on improving awareness about the complications and care-seeking needed for circumcision-related morbidities. This can be done through community education programs, workshops, and campaigns targeting families, healthcare providers, and community leaders.

2. Strengthen healthcare infrastructure: Efforts should be made to improve the availability and accessibility of healthcare facilities in rural areas. This can include building more health clinics, training and deploying healthcare professionals, and ensuring the availability of essential medical supplies and equipment.

3. Enhance healthcare seeking behavior: Strategies should be implemented to encourage families to seek healthcare for circumcision-related morbidities. This can involve providing information on the importance of seeking timely and appropriate care, addressing cultural beliefs and misconceptions, and promoting the use of formal healthcare providers.

4. Collaborate with informal care providers: Collaboration with informal care providers such as traditional healers and religious leaders can help improve access to maternal health. Training and educating these providers on recognizing and referring circumcision-related morbidities to formal healthcare providers can be beneficial.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of families seeking healthcare for circumcision-related morbidities, the number of healthcare facilities in rural areas, and the level of awareness among the target population.

2. Collect baseline data: Gather data on the current situation, including the healthcare seeking patterns of families, the availability and accessibility of healthcare facilities, and the level of awareness among the population.

3. Implement interventions: Implement the recommended interventions, such as awareness campaigns, infrastructure improvements, and collaboration with informal care providers.

4. Monitor and evaluate: Continuously monitor and evaluate the impact of the interventions. Collect data on the indicators identified in step 1 and compare them to the baseline data. This can be done through surveys, interviews, and data analysis.

5. Analyze and interpret results: Analyze the data collected and interpret the results to determine the effectiveness of the interventions. Assess whether the recommendations have led to an increase in healthcare seeking for circumcision-related morbidities, improved access to healthcare facilities, and increased awareness among the population.

6. Adjust and refine: Based on the results and analysis, make any necessary adjustments or refinements to the interventions. This could involve scaling up successful interventions, addressing any challenges or barriers identified, and continuously improving the strategies implemented.

7. Repeat the process: Continuously repeat the monitoring, evaluation, and adjustment process to ensure ongoing improvement in access to maternal health. This iterative approach allows for continuous learning and refinement of interventions to achieve the desired impact.

Author

Dima Health

Statistics:

Citations: 2

Identifiers:

DOI: 10.1136/bmjopen-2017-018185

Research Areas:

Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Violence and Injury, Workforce

Study Countries:

Ghana

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Male