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Title: A case study of reproductive health supplies in Ghana.
Author: Akitobi E; Leahy E; Nerquaye-Tetteh J
Source: Washington, D.C., Population Action International, 2009 Jun. 30 p.
Abstract: This paper, together with five additional case studies from other countries and information from other sources, provides an evidence base for national level advocacy. Each case study is written with generalist advocates in mind. These can include, but are not limited to, civic leaders, parliamentarians, faith-based leaders, and community leaders. This report provides overview of how RH supplies, specifically contraceptives and condoms, are programmed, managed and funded in Ghana. It presents a distillation of information on policies, systems, budgets and key actors to help raise awareness of experienced advocates -- who may lack technical knowledge about contraceptives -- so that they strategically choose advocacy actions and targets. This information should also facilitate collaboration and coordination with advocacy efforts at the global and regional levels. Information and issues from one country may be useful to other countries facing similar challenges. (Excerpt)
Language: English
Keywords:
GHANA | SUMMARY REPORT | CASE STUDIES | RESEARCH METHODOLOGY | REPRODUCTIVE HEALTH | EQUIPMENT AND SUPPLIES | CONTRACEPTIVE DISTRIBUTION | HEALTH POLICY | PUBLIC SECTOR | LOGISTICS | MANAGEMENT | FINANCIAL ACTIVITIES | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Studies | Health | Medical Procedures | Medicine | Health Services | Delivery of Health Care | Distributional Activities | Program Activities | Programs | Organization and Administration | Policy | Political Factors | Sociocultural Factors | Macroeconomic Factors | Economic Factors
Document Number: 331428

Peer Reviewed

Title: Examining the geographical heterogeneity associated with risk of mistimed and unwanted pregnancy in Ghana.
Author: Amoako Johnson F; Madise NJ
Source: Journal of Biosocial Science. 2009 Mar;41(2):249-67.
Abstract: After a decade of fertility decline, Ghana's fertility and the level of unmet need for contraception stalled in mid-transition in the late 1990s. Although the literature acknowledges this, the geographical patterns in unmet need have not been adequately documented. Spatial analysis of unmet need can reveal differences in usage and provision of contraceptive commodities, thereby pointing to geographical areas where contraceptive programmes should be strengthened. This study examines the geographical variation of the risk of mistimed and unwanted pregnancies between rural communities and also between urban communities of the three ecological zones of Ghana. The study also investigates if geographical differences in the risks of mistimed and unwanted pregnancies changed during the period when unmet need stalled at the national level. A multilevel regression model was applied to pooled data from the 1998 and 2003 Ghana Demographic and Health Surveys to examine the determinants of the risk of unintended pregnancies, while controlling for clustering of outcomes within communities. The results show that between the two surveys, there was no significant change in the levels of risk of mistimed and unwanted pregnancy. However, geographical heterogeneity in the risk of mistimed and unwanted pregnancy was observed, after controlling for relevant predictors. This showed concentration of mistimed pregnancies in some rural communities relative to others, and variation in the risk of unwanted pregnancies between urban communities. The results give a clear indication that bridging the inequality gap in contraceptive use requires programmes that are area-specific.
Language: English
Keywords:
GHANA | RESEARCH REPORT | NEEDS | HETEROGENEITY | FERTILITY DECLINE | GEOGRAPHIC FACTORS | PREGNANCY, UNPLANNED | CONTRACEPTIVE USAGE | INEQUALITIES | NEEDS ASSESSMENT | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Economic Factors | Population Characteristics | Demographic Factors | Population | Fertility Changes | Fertility | Population Dynamics | Reproductive Behavior | Contraception | Family Planning | Socioeconomic Factors | Evaluation
Document Number: 331181

Title: Does where you live influence what you know? Community effects on health knowledge in Ghana.
Author: Andrzejewski CS; Reed HE; White MJ
Source: Health and Place. 2009 Mar;15(1):228-38.
Abstract: This paper examines community effects on health knowledge in a developing country setting. We examine knowledge about the etiology and prevention of child illnesses using a unique 2002 representative survey of communities and households in Ghana. We find that community context matters appreciably, even after adjusting for the anticipated positive effects of an individual's education, literacy, media exposure and household socioeconomic status. The proportion of literate adults and the presence of a market in a community positively influence a person's health knowledge. In other words, even if a person herself is not literate, living in a community with high levels of literacy or a regular market can still positively affect her health knowledge. Our results suggest that social networks and diffusion play a key role in these community effects. In turn, these results offer policy implications for Ghana and sub-Saharan Africa.
Language: English
Keywords:
GHANA | RESEARCH REPORT | KAP SURVEYS | COMMUNITY | CHILDREN | SOCIAL NETWORKS | KNOWLEDGE | LOCALE | CHILD HEALTH | DISEASE PREVENTION | EDUCATIONAL STATUS | LITERACY | MASS MEDIA | SOCIOECONOMIC STATUS | SOCIAL POLICY | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Surveys | Sampling Studies | Studies | Research Methodology | Residence Characteristics | Population Distribution | Geographic Factors | Population | Youth | Age Factors | Population Characteristics | Demographic Factors | Friends and Relatives | Family and Household | Sociocultural Factors | Health | Prevention and Control | Diseases | Socioeconomic Factors | Economic Factors | Communication | Policy | Political Factors
Document Number: 330296

Title: Efficacy and acceptability of rapid, point-of-care HIV testing in two clinical settings in Ghana.
Author: Appiah LT; Havers F; Gibson J; Kay M; Sarfo F; Chadwick D
Source: AIDS Patient Care and STDs. 2009 May;23(5):365-9.
Abstract: This study assessed the efficacy and acceptability of two rapid point-of-care HIV assays used in a voluntary counseling and testing (VCT) and a tuberculosis (TB) clinic in Kumasi, Ghana. Over a 4-week period in 2007, 95 individuals attending the VCT clinic and 35 patients with newly diagnosed TB were offered a rapid HIV test. Rates of return for positive results and attendance at the HIV clinic were compared with 471 individuals (395 attending the VCT clinic and 76 patients with TB), tested during an 8-week period 6 months earlier using standard testing procedures. All patients offered a rapid test in each clinic underwent testing, compared to 93% of VCT clients and 40% of TB patients offered a test 6 months earlier. In the rapid testing period, 37%, 60%, and 3% of the VCT clients and 26%, 74% and 0% of the TB patients had positive, negative, or indeterminate serology, respectively. There were no discordant results following retesting of patients with a positive test. All patients attending either the VCT or TB clinics who tested positive for HIV with the point-of-care test returned to the HIV clinic for care, while only 64% and 95%, respectively, of the patients previously testing positive had returned for follow-up. Both clients and staff showed high levels of satisfaction with the rapid testing procedure. In conclusion, rapid point-of-care testing in both of these settings was successful in improving diagnosis of HIV infection and engaging those testing positive in a clinical care program.
Language: English
Keywords:
GHANA | RESEARCH REPORT | COMPARATIVE STUDIES | CLIENTS | HIV TESTING | PROGRAM ACCEPTABILITY | CLINIC ACTIVITIES | VOLUNTARY COUNSELING AND TESTING | TUBERCULOSIS | SATISFACTION | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Studies | Research Methodology | Program Activities | Programs | Organization and Administration | Laboratory Examinations and Diagnoses | Examinations and Diagnoses | Medical Procedures | Medicine | Health Services | Delivery of Health Care | Health | Program Evaluation | Infections | Diseases | Psychological Factors | Behavior
Document Number: 342184

Title: Demographic data for development in sub-Saharan Africa.
Author: Baldwin W; Diers J
Source: New York, New York, Population Council, 2009. 15 p. (Poverty, Gender, and Youth Working Paper No. 13)
Abstract: More demographic data are being collected throughout the developing world than ever before, but the effective use of that data to further development goals is often lacking. This paper summarizes case studies on the demand for data in four sub-Saharan African countries, namely Ethiopia, Ghana, Senegal, and Uganda. The project's objective was to create a detailed portrait of access and demand at the country level, and to determine whether policymakers are getting the data they need to develop sound policies. Common findings across the four countries include an increased external demand from international initiatives that has not necessarily translated into internal demand for data; a missing link between producers and users of data; and a need for data to be presented in user-friendly formats. One driver of internal demand for data is the decentralization and democratization process that is underway in all four countries; this demand highlighted the paucity of available data that can be disaggregated at the level to which policies were being devolved. Next steps are to support initiatives to establish data access as a right, encourage a culture of data-sharing among funders and producers of data, strengthen intermediaries between policymakers and data collectors, display data in accessible formats such as maps, and disaggregate available data to the most useful levels. (Author's abstract)
Language: English
Keywords:
ETHIOPIA | GHANA | SENEGAL | UGANDA | SUMMARY REPORT | DEMOGRAPHIC ANALYSIS | DATA COLLECTION | CASE STUDIES | DATA QUALITY | NEEDS | DECENTRALIZATION | DEMOCRACY | INFORMATION DISTRIBUTION | POVERTY | GENDER ISSUES | YOUTH | POLICY | PROGRAM ACCESSIBILITY | Africa, Eastern | Africa, Sub Saharan | Africa | Developing Countries | Africa, Western | Research Methodology | Studies | Data Analysis | Economic Factors | Political Factors | Sociocultural Factors | Political Systems | Communication | Socioeconomic Factors | Age Factors | Population Characteristics | Demographic Factors | Population | Program Evaluation | Programs | Organization and Administration
Document Number: 331433

Title: Role of parents in adolescent sexual activity and contraceptive use in four african countries.
Author: Biddlecom A; Awusabo-Asare K; Bankole A
Source: International Perspectives On Sexual and Reproductive Health. 2009 Jun;35(2):72-81.
Abstract: Data were collected in 2004 in nationally representative surveys of 12- to 19-year-olds in Burkina Faso, Ghana, Malawi, and Uganda. Bivariate analysis was used to compare gender differences for two outcomes among unmarried 15- to 19-year-olds having had sexual intercourse in the last 12 months and, among those who had had sex in this period, having used contraception at last sex. Unmarried adolescents reported moderate to high levels of parental monitoring and low levels of parent-child communication about sexual matters. In all countries, adolescent males who reported low monitoring were at elevated risk of having had sex in the last year, as were their female counterparts in three of the countries. Communication with parents was positively associated with sexual activity among Malawian males and Ugandan females. Parental monitoring was not associated with contraceptive use at last sex, whereas parent-child communication was associated with such use among Ghanaian females and among Ugandan adolescents of both genders. The authors conclude that programs to improve adolescent sexual and reproductive health should include dimensions of parental involvement.
Language: English
Keywords:
BURKINA FASO | GHANA | MALAWI | UGANDA | RESEARCH REPORT | SURVEYS | ADOLESCENTS | SEX BEHAVIOR | PARENTAL INVOLVEMENT | REPRODUCTIVE HEALTH | INTERPERSONAL COMMUNICATION | CONTRACEPTIVE USAGE | Africa, Western | Africa, Sub Saharan | Africa | Developing Countries | Africa, Southern | Africa, Eastern | Sampling Studies | Studies | Research Methodology | Youth | Age Factors | Population Characteristics | Demographic Factors | Population | Behavior | Child Rearing | Health | Communication | Contraception | Family Planning
Document Number: 342142

Peer Reviewed

Title: Sustained immunological responses to highly active antiretroviral therapy at 36 months in a Ghanaian HIV cohort.
Author: Collini P; Schwab U; Sarfo S; Obeng-Baah J; Norman B; Chadwick D; Bibby D; Bedu-Addo G
Source: Clinical Infectious Diseases. 2009 Apr 1;48(7):988-91.
Abstract: Two hundred thirty-seven Ghanaian human immunodeficiency virus-infected patients who were starting antiretroviral therapy underwent clinical and immunological monitoring for 3 years. Seventy-eight percent of patients had disease classified as World Health Organization stage III or IV. The mean increase in the CD4 cell count was 395 cells/mm(3), 13% of patients experienced immunological failure, and 8% of patients switched treatment to a second-line regimen. However, two-thirds of patients who experienced immunological failure did not switch treatment, and 31% of all patients were lost to follow-up.
Language: English
Keywords:
GHANA | RESEARCH REPORT | CLINICAL RESEARCH | COHORT ANALYSIS | LONGITUDINAL STUDIES | PERSONS LIVING WITH HIV/AIDS | ANTIRETROVIRAL THERAPY | IMMUNOLOGICAL EFFECTS | IMMUNITY, CELLULAR | TIME FACTORS | AIDS | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Research Methodology | Studies | HIV Infections | Viral Diseases | Diseases | HIV | Immunity | Immune System | Physiology | Biology | Population Dynamics | Demographic Factors | Population
Document Number: 330985

Peer Reviewed

Title: The influence of changes in women's religious affiliation on contraceptive use and fertility among the Kassena-Nankana of Northern Ghana.
Author: Doctor HV; Phillips JF; Sakeah E
Source: Studies in Family Planning. 2009 Jun;40(2):113-122.
Abstract: Religious affiliation is undergoing major changes in rural Sahelian Africa, with profound consequences for customs that are grounded in traditional belief systems. This study examines the influence of women's religious affiliation on contraceptive use and fertility among the Kassena-Nankana of northern Ghana. Analysis of longitudinal data for women in 1995 and 2003 shows that 61 percent of women changed their religion, with shifts from traditional beliefs to Christianity being dominant. Moreover, women were more likely than men to make such a change. Regression results show that, compared with those who did not change, switching from traditional religion to Christianity or Islam is associated with increased contraceptive use and decreased fertility. The more rapid change in religious affiliation among women than men may have social consequences for the status of women, signaling a trend toward greater autonomy in the family and new aspirations, values, and behavior as evidenced by the proportion of people adopting contraceptives.
Language: English
Keywords:
GHANA | RESEARCH REPORT | LONGITUDINAL STUDIES | SAMPLING STUDIES | ETHNIC GROUPS | WOMEN | RELIGIOUS ASPECTS | CONTRACEPTIVE USAGE | REPRODUCTIVE BEHAVIOR | BELIEFS | CHRISTIANITY | ISLAM | SOCIAL CHANGE | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Studies | Research Methodology | Cultural Background | Population Characteristics | Demographic Factors | Population | Religion | Sociocultural Factors | Contraception | Family Planning | Fertility | Population Dynamics | Culture
Document Number: 341895

10.
Peer Reviewed

Title: Adapting a multifaceted U.S. HIV prevention education program for girls in Ghana.
Author: Fiscian VS; Obeng EK; Goldstein K; Shea JA; Turner BJ
Source: AIDS Education and Prevention. 2009;21(1):67-79.
Abstract: A U.S. HIV prevention program was adapted to address knowledge gaps and cultural pressures that increase the risk of infection in adolescent Ghanaian girls. The theory-based nine-module HIV prevention program combines didactics and games, an interactive computer program about sugar daddies, and tie-and-dye training to demonstrate an economic alternative to transactional sex. The abstinence-based study was conducted in a church-affiliated junior secondary school in Nsawam, Ghana. Of 61 subjects aged 10-14 in the prevention program, over two thirds were very worried about becoming HIV infected. A pre-post evaluation of the intervention showed significant gains in three domains: HIV knowledge (p = .001) and self efficacy to discuss HIV and sex with men (p < .001) and with boys (p < .001). Responses to items about social norms of HIV risk behavior were also somewhat improved (p = .09). Subjects rated most program features highly. Although short-term knowledge and self-efficacy to address HIV improved significantly, longer term research is needed to address cultural and economic factors placing young women at risk of HIV infection. (author's)
Language: English
Keywords:
GHANA | UNITED STATES OF AMERICA | EVALUATION REPORT | THEORETICAL MODELS | KAP SURVEYS | ADOLESCENTS, FEMALE | WOMEN IN DEVELOPMENT | SEX WORKERS | HIV PREVENTION | SEX EDUCATION | KNOWLEDGE | COMPUTER PROGRAMS AND PROGRAMMING | SELF ESTEEM | RISK BEHAVIOR | PARTNER COMMUNICATION | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Developed Countries | North America | Americas | Evaluation | Research Methodology | Surveys | Sampling Studies | Studies | Adolescents | Youth | Age Factors | Population Characteristics | Demographic Factors | Population | Economic Development | Economic Factors | Sex Behavior | Behavior | HIV Infections | Viral Diseases | Diseases | Education | Sociocultural Factors | Information Processing | Information | Psychological Factors | Interpersonal Relations
Document Number: 325287

11.

Peer Reviewed

Title: Adapting a multifaceted U.S. HIV prevention education program for girls in Ghana.
Author: Fiscian VS; Obeng EK; Goldstein K; Shea JA; Turner BJ
Source: AIDS Education and Prevention. 2009 Feb;21(1):67-79.
Abstract: We adapted a U.S. HIV prevention program to address knowledge gaps and cultural pressures that increase the risk of infection in adolescent Ghanaian girls. The theory-based nine-module HIV prevention program combines didactics and games, an interactive computer program about sugar daddies, and tie-and-dye training to demonstrate an economic alternative to transactional sex. The abstinence-based study was conducted in a church-affiliated junior secondary school in Nsawam, Ghana. Of 61 subjects aged 10-14 in the prevention program, over two thirds were very worried about becoming HIV infected. A pre-post evaluation of the intervention showed significant gains in three domains: HIV knowledge (p = .001) and self efficacy to discuss HIV and sex with men (p < .001) and with boys (p < .001). Responses to items about social norms of HIV risk behavior were also somewhat improved (p = .09). Subjects rated most program features highly. Although short-term knowledge and self-efficacy to address HIV improved significantly, longer term research is needed to address cultural and economic factors placing young women at risk of HIV infection.
Language: English
Keywords:
UNITED STATES OF AMERICA | GHANA | EVALUATION REPORT | THEORETICAL MODELS | ADOLESCENTS, FEMALE | SUGAR DADDIES | SEX WORKERS | FAITH-BASED ORGANIZATION | HEALTH EDUCATION | SEX EDUCATION | HIV PREVENTION | CULTURE | COMPUTER PROGRAMS AND PROGRAMMING | ABSTINENCE | BEHAVIOR CHANGE COMMUNICATION | Developed Countries | North America | Americas | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Evaluation | Research Methodology | Adolescents | Youth | Age Factors | Population Characteristics | Demographic Factors | Population | Sex Behavior | Behavior | Organizations | Political Factors | Sociocultural Factors | Education | HIV Infections | Viral Diseases | Diseases | Information Processing | Information | Family Planning, Behavioral Methods | Family Planning | Communication Programs | Communication | Behavior Change
Document Number: 331081

12.

Title: Confidential inquiries into maternal deaths: Modifications and adaptations in Ghana and Indonesia.
Author: Hussein J; D'Ambruoso L; Armar-Klemesu M; Achadi E; Arhinful D; Izati Y; Ansong-Tornui J
Source: International Journal of Gynaecology and Obstetrics. 2009 May 8;
Abstract: OBJECTIVE: Factors contributing to the limited use of confidential inquiries into maternal deaths include the negative focus and demotivating effect of such inquiries, perceptions of unavailability of sufficient documentation of events, and lack of time and resources. To ascertain whether these problems can be overcome, variations to confidential inquiries into maternal deaths were introduced in Ghana and Indonesia. METHODS: Clinical review panels were set up as part of the usual process of confidential inquiries, and modifications to the confidential inquiries were introduced. In Ghana, the traditional confidential inquiry process focusing on health facility care was modified to introduce the assessment of positive factors. In addition to the assessment of positive factors, adaptations in Indonesia consisted of including cases of obstetric complications, as well as deaths, and the use of interview testimonials as data sources. Information about resource and time needs for conducting confidential inquiries was collected. RESULTS: The introduction of positive aspects to the process provided a balanced and more motivating setting for the inquiry. The data obtained from case notes in district hospitals and interview testimonials provided sufficient information to assess why maternal deaths and severe complications occurred. The costs of conducting the inquiries ranged from US $4000 to US $11000 (per study), and the estimated time required for a panel member to review each case was more than 3 hours. CONCLUSION: This study introduced practical ways to encourage the implementation of maternal death reviews, inquiries, and audits that are context specific and, therefore, acceptable to local practitioners.
Language: English
Keywords:
GHANA | INDONESIA | RESEARCH REPORT | EPIDEMIOLOGIC METHODS | CLINICAL RESEARCH | WOMEN IN DEVELOPMENT | PREGNANT WOMEN | CONFIDENTIAL INFORMATION | MATERNAL MORTALITY | PERCEPTION | MOTIVATION | TIME FACTORS | PREGNANCY COMPLICATIONS | ECONOMIC FACTORS | AUTOPSY | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Asia, Southeastern | Asia | Research Methodology | Economic Development | Population Characteristics | Demographic Factors | Population | Ethics | Sociocultural Factors | Mortality | Population Dynamics | Psychological Factors | Behavior | Diseases | Examinations and Diagnoses | Medical Procedures | Medicine | Health Services | Delivery of Health Care | Health
Document Number: 341454

13.

Title: On the spatial inequalities of institutional versus home births in Ghana: a multilevel analysis.
Author: Johnson FA; Padmadas SS; Brown JJ
Source: Journal of Community Health. 2009;34:64-72.
Abstract: Spatial inequalities related to the choice of delivery care have not been studied systematically in Sub-Saharan Africa where maternal and perinatal health outcomes continue to worsen despite a range of safe motherhood interventions. Using retrospective data from the 1998 and 2003 Demographic and Health Surveys, this paper investigates the extent of changes in spatial inequalities associated with type of delivery care in Ghana with a focus on rural-urban differentials within and across the three ecological zones (Savannah, Forest and Coastal). More than one-half of births in Ghana continue to occur outside health institutions without any skilled obstetric care. While this is already known, we present evidence from multilevel analyses that there exist considerable and growing inequalities, with regard to birth settings between communities, within rural and urban areas and across the ecological zones. The results show evidence of poor and disproportionate use of institutional care at birth; the inequalities remained high and unchanged in both urban and rural communities within the Savannah zone and widening in urban communities of the Forest and Coastal zones. The key policy challenges in Ghana, therefore, include both increasing the uptake of institutional delivery care and ensuring equity in access to both public and private health institutions.
Language: English
Keywords:
GHANA | RESEARCH REPORT | DEMOGRAPHIC AND HEALTH SURVEYS | CHILDBIRTH | HOME CARE | HOSPITALS | INEQUALITIES | DELIVERY OF HEALTH CARE | MATERNAL-CHILD HEALTH SERVICES | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Demographic Surveys | Population Dynamics | Demographic Factors | Population | Pregnancy Outcomes | Pregnancy | Reproduction | Care and Support | Health Services | Health | Health Facilities | Socioeconomic Factors | Economic Factors | Primary Health Care
Document Number: 340222

14.

15.

Peer Reviewed

Title: Impact of acyclovir on genital and plasma HIV-1 RNA, genital herpes simplex virus type 2 DNA, and ulcer healing among HIV-1-infected African women with herpes ulcers: a randomized placebo-controlled trial.
Author: Mayaud P; Legoff J; Weiss HA; Gresenguet G; Nzambi K; Bouhlal H; Frost E; Pepin J; Malkin JE; Hayes RJ; Mabey DC; Belec L
Author: ANRS 1212 Study Group
Source: Journal of Infectious Diseases. 2009 Jul 15;200(2):216-26.
Abstract: BACKGROUND: Little is known about the impact of episodic treatment of herpes on human immunodeficiency virus type 1 (HIV-1). METHODS: Women from Ghana and the Central African Republic who had genital ulcers were enrolled in a randomized, double-blind, placebo-controlled trial of acyclovir plus antibacterials and were monitored for 28 days. Ulcer etiologies and detection of lesional HIV-1 RNA were determined by polymerase chain reaction (PCR). Cervicovaginal HIV-1 RNA and herpes simplex virus type 2 (HSV-2) DNA and plasma HIV-1 RNA were quantitated by real-time PCR. Primary analyses included 118 HIV-1-infected women with HSV-2 ulcers (54 of whom were given acyclovir and 64 of whom were given placebo). RESULTS: Acyclovir had little impact on (1) detection of cervicovaginal HIV-1 RNA (risk ratio [RR], 0.96; 95% confidence interval [CI], 0.8-1.2) at day 7 of treatment, (2) the mean cervicovaginal HIV-1 RNA load (-0.06 log(10) copies/mL; 95% CI, -0.4 to 0.3 log(10) copies/mL) at day 7 of treatment, or (3) the plasma HIV-1 RNA load (+0.09 log(10) copies/mL; 95% CI, -0.1 to 0.3 log(10) copies/mL) at day 14 of treatment. At day 7, women receiving acyclovir were less likely to have detectable lesional HIV-1 RNA (RR, 0.70; 95% CI, 0.4-1.2) or cervicovaginal HSV-2 DNA (RR, 0.69; 95% CI, 0.4-1.3), had a lower quantity of HSV-2 DNA (-0.99 log(10) copies/mL; 95% CI, -1.8 to -0.2 log(10) copies/mL), and were more likely to have a healed ulcer (RR, 1.26; 95% CI, 0.9-1.9). CONCLUSION: Episodic therapy for herpes reduced the quantity of cervicovaginal HSV-2 DNA and slightly improved ulcer healing, but it did not decrease genital and plasma HIV-1 RNA loads. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT00158483 .
Language: English
Keywords:
GHANA | RESEARCH REPORT | CLINICAL TRIALS | WOMEN | PERSONS LIVING WITH HIV/AIDS | HERPES GENITALIS | HIV INFECTIONS | TREATMENT | LABORATORY PROCEDURES | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Clinical Research | Research Methodology | Demographic Factors | Population | Viral Diseases | Diseases | Sexually Transmitted Diseases | Reproductive Tract Infections | Infections | Medical Procedures | Medicine | Health Services | Delivery of Health Care | Health | Laboratory Examinations and Diagnoses | Examinations and Diagnoses
Document Number: 342690

16.

Title: Pregnancy after ureterosigmoidostomy for vesicovaginal fistula.
Author: Opare-Addo HS; Danso KA; Turpin CA
Source: International Journal of Gynaecology and Obstetrics. 2009 Mar 31;
Abstract: This report describes a pregnancy and subsequent preterm delivery in a patient who underwent ureterosigmoidostomy for incurable vesicovaginal fistula at the Komfo Anokye Teaching Hospital, Ghana. The patient presented in 1990 at the age of 14 years with a vesicovaginal fistula caused by prolonged obstructed labor. The fistula involved the bladder neck and the distal urethra. Although the defect was successfully closed, the patient remained incontinent from a scarred "drained pipe" distal urethra and damaged bladder neck. The patient subsequently underwent a sling procedure using synthetic material but this did not improve the incontinence. In 1994, bilateral ureterosigmoidostomy was performed; although the patient regained continence, bowel movements occurred 5-6 times a day. The patient was put on oral alkalinizing agents, remained healthy, and returned to work. Four years later the patient presented with amenorrhea that had been ongoing for 3.5 months. Ultrasound confirmed an intrauterine fetus at 15 weeks of gestation. The patient's pregnancy remained uneventful until premature rupture of membranes at 33 weeks of gestation. The patient received 24 mg of dexamethasone over 24 hours in 2 divided doses and was started on a course of antibiotics. Labor began 2 days after admission and a cesarean delivery was performed because of low birth weight. The outcomew as a healthy female neonate weighing 1600 g. Ten years later, in 2008, the patient remained healthy and continent. Her daughter is alive and healthy. Published data on pregnancy after urinary diversion, especially after incurable vesicovaginal fistula, are scarce. Reporting such pregnancies and their outcomes is important to allow accumulation of data to improve counseling and patient management. Our patient, unlike in earlier reports, did not develop dilatation or infection of the kidneys and upper urinary tract, nor was the continence mechanism compromised during pregnancy. However, the patient suffered preterm rupture of membranes and subsequent preterm labor, which is a common occurrence in pregnancy after obstetric fistula repair. The potential effect of metabolic sequelae on fetal growth and preterm labor in pregnancy following ureterosigmoidostomy needs further investigation. (full-text)
Language: English
Keywords:
GHANA | RESEARCH REPORT | CLINICAL RESEARCH | CASE STUDIES | WOMEN IN DEVELOPMENT | PREGNANT WOMEN | VESICOVAGINAL FISTULA | PREGNANCY COMPLICATIONS | OBSTETRICAL SURGERY | CHILDBIRTH | AMENORRHEA | ULTRASONICS | ADMINISTRATION AND DOSAGE | TIME FACTORS | LOW BIRTH WEIGHT | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Research Methodology | Studies | Economic Development | Economic Factors | Population Characteristics | Demographic Factors | Population | Urogenital Effects | Urogenital System | Physiology | Biology | Diseases | Surgery | Treatment | Medical Procedures | Medicine | Health Services | Delivery of Health Care | Health | Pregnancy Outcomes | Pregnancy | Reproduction | Menstruation Disorders | Drugs | Population Dynamics | Birth Weight | Body Weight
Document Number: 341467

17.

Title: Correlates of misperceptions in HIV knowledge and attitude towards people living with HIV/AIDS (PLWHAs) among in-school and out-of school adolescents in Ghana.
Author: Sallar AM
Source: African Health Sciences. 2009 Jun;9(2):82-91.
Abstract: A cross-sectional quantitative and qualitative study was conducted among adolescents ages 10-19 (n = 483; mean age, 16.6) in the Ashanti region of Ghana. When asked how to prevent acquiring AIDS, participants mentioned sexual abstinence (78.1%), condom use (72.7%), fidelity to partner (72.5%), not sharing needles (76.4%), and reducing sexual partners (56.7%). Statistically significant associations were found in high misperception scores and having negative attitudes toward PLWHAs (0.001 < p < 0.009). Out-of-school adolescents were less likely to be willing to take care of relatives with HIV/AIDS, allow PLWHAs to conceal their status, or allow PLWHAs to work with others. Out-of-school students were also more likely to provide PLWHAs with less healthcare, and they indicated that PLWHAs should be isolated. The author concludes that out-of-school adolescents constitute a hard-to-reach population, and mechanisms should be developed to help reduce their misperceptions that fuel stigma and discrimination.
Language: English
Keywords:
GHANA | RESEARCH REPORT | ADOLESCENTS | STUDENTS | OUT-OF-SCHOOL YOUTHS | PERSONS LIVING WITH HIV/AIDS | HIV TRANSMISSION | KNOWLEDGE | MISINFORMATION | ATTITUDES | STIGMA | SOCIAL DISCRIMINATION | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Youth | Age Factors | Population Characteristics | Demographic Factors | Population | Education | Educational Status | Socioeconomic Status | Socioeconomic Factors | Economic Factors | HIV Infections | Viral Diseases | Diseases | Sociocultural Factors | Communication | Psychological Factors | Behavior | Social Problems
Document Number: 339887

18.
Title: Correlates of misperceptions in HIV knowledge and attitude towards People Living With HIV/AIDS (PLWHAs) among in-school and out-of-school adolescents in Ghana.
Author: Sallar AM
Source: African Health Sciences. 2009 Jun;9(2):82-91.
Abstract: BACKGROUND: A quarter century into the HIV pandemic, knowledge about sexual transmission and sharing of needles remain high just as misperceptions relating to casual contact. OBJECTIVES: To assess HIV knowledge, misperceptions, and attitude towards people living with HIV/AIDS (PLWHAs) among adolescents. METHODS: A cross sectional quantitative and qualitative study was conducted among adolescents aged 10-19 (n = 483; mean age, 16.6) in the Ashanti region of Ghana. RESULTS: Knowledge score ranged 0 to 38 (mean = 26.64; sd +/- 6.74). To prevent AIDS, 78.1% mentioned sexual abstinence, condom use (72.7%), fidelity to partner (72.5%), not sharing needles (76.4%), and reducing sexual partners (56.7%). Statistically significant associations were found in high misperception scores and having negative attitude towards PLWHAs (0.001 < p < 0.009). Out-of-school adolescents were less likely to be willing to take care of HIV/AIDS relatives (p = 0.004); allow PLWHAs conceal their status (p < 0.001); allow PLWHAs to work with others (p = 0.007); more likely to let PLWHAs have less healthcare (p = 0.026); and indicate that PLWHAs should be isolated (p < 0.001). CONCLUSION: Out-of-school adolescents constitute hard-to-reach population and mechanisms should be developed to reach them to reduce misperceptions which may fuel stigma and discrimination.
Language: English
Keywords:
GHANA | RESEARCH REPORT | SAMPLING STUDIES | ADOLESCENTS | STUDENTS | OUT-OF-SCHOOL YOUTHS | PERSONS LIVING WITH HIV/AIDS | HIV PREVENTION | KNOWLEDGE | ATTITUDES | PERCEPTION | SOCIAL DISCRIMINATION | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Studies | Research Methodology | Youth | Age Factors | Population Characteristics | Demographic Factors | Population | Education | Educational Status | Socioeconomic Status | Socioeconomic Factors | Economic Factors | HIV Infections | Viral Diseases | Diseases | Sociocultural Factors | Psychological Factors | Behavior | Social Problems
Document Number: 342651

19.

Peer Reviewed

Title: Recent diarrhoeal illness and risk of lower respiratory infections in children under the age of 5 years.
Author: Schmidt WP; Cairncross S; Barreto ML; Clasen T; Genser B
Source: International Journal of Epidemiology. 2009 Jun;38(3):766-72.
Abstract: BACKGROUND: Children in low-income settings suffering from frequent diarrhoea episodes are also at a high risk of acute lower respiratory infections (ALRI). We explored whether this is due to common risk factors for both conditions or whether diarrhoea can increase the risk of ALRI directly. METHODS: We used a dynamic time-to-event analysis of data from two large child studies in low-income settings in Ghana and Brazil, with the cumulative diarrhoea prevalence over 2 weeks as the exposure and severe ALRI as outcome. The analysis was adjusted for baseline risk of ALRI and diarrhoea, seasonality and age. RESULTS: The child population from Ghana had a much higher risk of diarrhoea, malnutrition and death than the children in Brazil. In the data from Ghana, every additional day of diarrhoea within 2 weeks increased the risk of ALRI by a factor of 1.08 (95% CI 1.00-1.15). In addition, we found a roughly linear relationship between the number of diarrhoea days over the last 28 days and the risk of ALRI. In the Ghana data, 26% of ALRI episodes may be due to recent exposure to diarrhoea. The Brazilian data gave no evidence for an association between diarrhoea and ALRI. CONCLUSION: Diarrhoea may contribute substantially to the burden of ALRI in malnourished child populations.
Language: English
Keywords:
GHANA | BRAZIL | RESEARCH REPORT | EVENT HISTORY ANALYSIS | LOW INCOME POPULATION | CHILDREN | DIARRHEA | PNEUMONIA | MALNUTRITION | RESPIRATORY INFECTIONS | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | South America, Eastern | South America | Latin America | Americas | Demographic Analysis | Research Methodology | Social Class | Socioeconomic Status | Socioeconomic Factors | Economic Factors | Youth | Age Factors | Population Characteristics | Demographic Factors | Population | Diseases | Pulmonary Effects | Physiology | Biology | Nutrition Disorders | Infections
Document Number: 342510

20.

Peer Reviewed

Title: Obstetric ultrasonography in low-income countries.
Author: Seffah JD; Adanu RM
Source: Clinical Obstetrics and Gynecology. 2009 Jun;52(2):250-5.
Abstract: The major issues in obstetric practice in developing countries are the high rates of maternal and perinatal mortality. In most low-income countries health financing systems are not well established so most people pay for health services at the service delivery points. This causes cost-related issues to be of major concern. The main questions that therefore need to be addressed about obstetric ultrasonography in low-income countries is whether the practice improves maternal and neonatal outcomes and whether the service is within the means of most people in these countries. The indications for obstetric ultrasound, guidelines for the use of obstetric ultrasound and the benefits of obstetric ultrasound in low-income countries are discussed and the future of obstetric ultrasound in developing countries is also briefly considered.
Language: English
Keywords:
GHANA | RESEARCH REPORT | LOW INCOME POPULATION | WOMEN | MATERNAL MORTALITY | ULTRASONICS | OBSTETRICS | PERINATAL MORTALITY | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Social Class | Socioeconomic Status | Socioeconomic Factors | Economic Factors | Demographic Factors | Population | Mortality | Population Dynamics | Medical Procedures | Medicine | Health Services | Delivery of Health Care | Health
Document Number: 342242

21.

Peer Reviewed

Title: Initiating antiretroviral treatment in a resource-constrained setting: does clinical staging effectively identify patients in need?
Author: Torpey K; Lartey M; Amenyah R; Addo NA; Obeng-Baah J; Rahman Y; Suzuki C; Mukadi YD; Colebunders R
Source: International Journal of STD and AIDS. 2009 Jun;20(6):395-8.
Abstract: In industrialized countries, the initiation of antiretroviral therapy (ART) is based on virological, immunological and clinical markers. The objective of this study was to identify treatment gaps when ART initiation is based on clinical staging alone. The method employed was a retrospective study of 5784 patients enrolled in an HIV treatment programme in two urban and two rural sites in Ghana. Of the patients, 29.5% were in clinical Stages I and II and had a CD4+ T-lymphocyte count less than 200 cells/mm(3). Significantly more patients in clinical Stage I from urban sites (37.0%) had a CD4+ T-lymphocyte count less than 200 cells/mm(3) as compared with patients from rural sites (23.8%) (P value <0.05). In addition, more men (39.9%) in clinical Stage I had a CD4+ T-lymphocyte count less than 200 cells/mm(3) when compared with women (27.4%) (P value <0.05). In conclusion, clinical staging cannot identify a relatively large number of patients who need ART. A wider availability of CD4+ T-lymphocyte count testing will optimize the identification of patients eligible for ART.
Language: English
Keywords:
GHANA | RESEARCH REPORT | RETROSPECTIVE STUDIES | CLINICAL RESEARCH | CLIENTS | ANTIRETROVIRAL THERAPY | IMMUNOLOGIC FACTORS | GEOGRAPHIC FACTORS | SEX FACTORS | AIDS | HIV INFECTIONS | SIGNS AND SYMPTOMS | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Studies | Research Methodology | Program Activities | Programs | Organization and Administration | HIV | Viral Diseases | Diseases | Immunity | Immune System | Physiology | Biology | Population | Population Characteristics | Demographic Factors
Document Number: 342443

22.

Title: HIV/AIDS-related stigma in Kumasi, Ghana.
Author: Ulasi CI; Preko PO; Baidoo JA; Bayard B; Ehiri JE; Jolly CM; Jolly PE
Source: Health and Place. 2009 Mar;15(1):255-62.
Abstract: OBJECTIVE: To assess HIV/AIDS-related stigma and discrimination of people living with HIV/AIDS (PLWHA) in Kumasi, Ghana. METHODS: A cross-sectional survey of 104 adults from the four sub-districts in Kumasi was conducted. RESULTS: Four stigma constructs, employment-based discrimination, screening and identification of HIV positive people, revelation of HIV status and social contact stigma were determined based on reliability measures from responses to the questionnaire. Regression analysis showed that participants with higher educational attainment were more likely to favor policies denying employment to PLWHA (p<0.05), but disapproved of revealing HIV sero-status (p<0.05). Muslims were more likely than Christians to agree with identifying PLWHA (p<0.05) and more likely to advocate revealing HIV sero-status (p<0.05). Males were more likely to favor revealing HIV status (p<0.05). Employed persons were more likely to have social contact with PLWHA (p<0.05). CONCLUSIONS: These findings are useful in guiding the design of interventions against HIV/AIDS-related stigma in Kumasi.
Language: English
Keywords:
GHANA | RESEARCH REPORT | KAP SURVEYS | CROSS SECTIONAL ANALYSIS | STATISTICAL REGRESSION | PERSONS LIVING WITH HIV/AIDS | STIGMA | SOCIAL DISCRIMINATION | EMPLOYMENT | HIV TESTING | ISLAM | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Surveys | Sampling Studies | Studies | Research Methodology | Data Analysis | HIV Infections | Viral Diseases | Diseases | Social Problems | Sociocultural Factors | Macroeconomic Factors | Economic Factors | Laboratory Examinations and Diagnoses | Examinations and Diagnoses | Medical Procedures | Medicine | Health Services | Delivery of Health Care | Health | Religion
Document Number: 330295

23.
Peer Reviewed

Title: Malaria and intestinal helminth co-infection among pregnant women in Ghana: prevalence and risk factors.
Author: Yatich NJ; Yi J; Agbenyega T; Turpin A; Rayner JC; Stiles JK; Ellis WO; Funkhouser E; Ehiri JE; Williams JH; Jolly PE
Source: American Journal of Tropical Medicine and Hygiene. 2009 Jun;80(6):896-901.
Abstract: Both malaria and intestinal helminths are endemic in sub-Saharan Africa, and their co-infection occurs commonly. This cross-sectional study assessed the prevalence of malaria and intestinal helminth co-infection in a sample of > 700 pregnant women in Ghana and identified risk factors for co-infection. The prevalence of malaria infection, intestinal helminth infection(s), and co-infection was 36.3%, 25.7%, and 16.6%, respectively. Women with intestinal helminth infection(s) were 4.8 times more likely to have malaria infection. Young age, low income, being single, and being primigravid were each associated with increased odds of co-infection. These associations were present when assessed separately for primi- and multigravid women, but the strength of associations varied considerably for the two groups of women. Young age had the strongest association among both primigravid (odds ratio = 5.2) and multigravid (odds ratio = 3.2) women. This study shows relatively high prevalence rates of malaria, intestinal helminths, and co-infection in pregnant women in Ghana.
Language: English
Keywords:
GHANA | RESEARCH REPORT | CROSS SECTIONAL ANALYSIS | SAMPLING STUDIES | PREGNANT WOMEN | MALARIA | PARASITIC DISEASES | GASTROINTESTINAL EFFECTS | PREVALENCE | RISK FACTORS | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Research Methodology | Studies | Population Characteristics | Demographic Factors | Population | Diseases | Physiology | Biology | Measurement | Health
Document Number: 341763

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Title: Developing community-based intervention strategies to save newborn lives: lessons learned from formative research in five countries.
Author: Neonatal Mortality Formative Research Working Group
Source: Journal of Perinatology. 2008 Dec;28 Suppl 2:S2-8.
Abstract: This paper summarizes lessons learned from formative research conducted in Bangladesh, Ghana, India, Mali and Nepal to inform the development of newborn health interventions, mostly in the context of field trials. Current practices, constraints to the adoption of optimal practices and implications for implementing inventions to improve newborn survival are discussed for: optimal care during pregnancy; skilled care at birth; optimal delivery and newborn care practices; special care of low birth weight babies; and timely and appropriate care seeking for newborn illness. General lessons concerning target audiences and intervention strategy are also drawn. In brief, interventions to reduce neonatal mortality need to start during pregnancy not only to promote birth preparedness and institutional delivery, but also to start the process of change concerning early newborn care practices. Their target audience should not only be pregnant or recently delivered women, but also include the main gatekeepers, particularly traditional birth attendants, grandmothers and other family members. Health providers' opinions also matter as care practices are less likely to change if families receive conflicting messages from different sources. Interventions are more likely to succeed if they are not simply message based, but include problem solving approaches, and a behavior change component to address community norms. Although antenatal care (ANC) is theoretically a good channel for newborn interventions, capitalising on its potential is not straightforward, and will require considerable investment and intervention development in its own right in order to improve ANC counselling, which will need to extend beyond training and tackle the many working day constraints encountered by ANC providers. Removing or subsidising the cost of deliveries may be a necessary action to increase institutional deliveries, but it is unlikely to be sufficient; measures will need to be put in place to ensure the basic quality of institutional deliveries and newborn care, and to change staff attitudes and practices. Post-natal visits should include observation of the baby, referral and counselling of the mother concerning danger signs in addition to promoting optimal care practices. The lessons learned should guide the development of interventions in other contexts, and ensure that key essential elements are not overlooked. They do not, however, mean that formative research will not be needed in other contexts, although the list of questions to address should be considerably reduced; successful intervention strategies require adaptation to make them local, context-specific if they are to be effective, and ongoing process monitoring to ensure the quality of intervention delivery, to check that it is having its intended effect, and to respond to any concerns from its implementers, recipients or the community. Finally, major gaps in evidence are highlighted. These include: establishing levels of recognition of asphyxiated babies and effectiveness of local solutions for resuscitation; clarifying the extent of the overlap between community perceptions of 'at risk' babies and low birthweight babies; developing and evaluating effective interventions to enable ANC services to deliver effective behaviour change counselling for pregnant and newborn health; evaluating effectiveness of delivering community-based newborn interventions at scale through routine services.
Language: English
Keywords:
MALI | INDIA | BANGLADESH | NEPAL | GHANA | RESEARCH REPORT | FORMATIVE RESEARCH | INFANT | CHILD SURVIVAL | PREGNANCY | CHILDBIRTH | BIRTH WEIGHT | NEONATAL MORTALITY | INFANT HEALTH | PRIMARY HEALTH CARE | PREVENTION AND CONTROL | PROGRAM EVALUATION | Developing Countries | Africa, Western | Africa, Sub Saharan | Africa | Asia, Southern | Asia | Research Methodology | Youth | Age Factors | Population Characteristics | Demographic Factors | Population | Survivorship | Length of Life | Mortality | Population Dynamics | Reproduction | Pregnancy Outcomes | Body Weight | Physiology | Biology | Infant Mortality | Child Health | Health | Health Services | Delivery of Health Care | Diseases | Programs | Organization and Administration
Document Number: 331049

28.

Peer Reviewed

Title: Clinical signs that predict severe illness in children under age 2 months: A multicentre study.
Author: Young Infants Clinical Signs Study Group
Source: Lancet. 2008 Jan 12;371(9607):135-142.
Abstract: Neonatal illness, particularly in the first week of life, is a leading cause of death worldwide. Improving identification of young infants who require referral for severe illness is of major public-health importance. Infants under 2 months of age brought with illness to health facilities in Bangladesh, Bolivia, Ghana, India, Pakistan, and South Africa were recruited in two age-groups: 0-6 days and 7-59 days. A trained health worker recorded 31 symptoms and clinical signs. An expert paediatrician assessed each case independently for severe illness that required hospital admission. We examined the sensitivity, specificity, and odds ratio (OR) for each symptom and sign individually and combined into algorithms to assess their value for predicting severe illness, excluding jaundice. 3177 children aged 0-6 days and 5712 infants aged 7-59 days were enrolled. 12 symptoms or signs predicted severe illness in the first week of life: history of difficulty feeding (OR 10.0, 95% CI, 6.9-14.5), history of convulsions (15.4, 6.4-37.2), lethargy (3.5, 1.7-7.1), movement only when stimulated (6.9, 3.0-15.5), respiratory rate of 60 breaths per minute or more (2.7, 1.9-3.8), grunting (2.9, 1.1-7.5), severe chest indrawing (8.9, 4.0-20.1), temperature of 37.5degreeC or more (3.4, 2.4-4.9) or below 35.5degreeC (9.2, 4.6-18.6), prolonged capillary refill (10.5, 5.1-21.7), cyanosis (13.7, 1.6-116.5), and stiff limbs (15.1, 2.2-105.9). A decision rule requiring the presence of any one sign had high sensitivity (87%) and specificity (74%). After we reduced the algorithm to seven signs (history of difficulty feeding, history of convulsions, movement only when stimulated, respiratory rate of 60 breaths per minute or more, severe chest indrawing, temperature of 37.5degreeC or more or below 35.5degreeC), mainly on the basis of prevalence of each sign or symptom, sensitivity (85%) and specificity (75%) were much the same. These seven signs also did well in 7-59-day-old infants (sensitivity 74%, specificity 79%). A single simple algorithm could be recommended for identifying severe illness in infants aged 0-2 months who are brought to health facilities. Further research is needed on screening newborn children for illness in the community during routine home visits. (author's)
Language: English
Keywords:
BANGLADESH | BOLIVIA | GHANA | INDIA | PAKISTAN | SOUTH AFRICA | RESEARCH REPORT | INFANT | INFANT HEALTH | SIGNS AND SYMPTOMS | SCREENING | Developing Countries | Asia, Southern | Asia | South America, Central | South America | Latin America | Americas | Africa, Western | Africa, Sub Saharan | Africa | Africa, Southern | Youth | Age Factors | Population Characteristics | Demographic Factors | Population | Child Health | Health | Diseases | Examinations and Diagnoses | Medical Procedures | Medicine | Health Services | Delivery of Health Care
Document Number: 308620

29.