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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.
