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The Impact of Malaria Control Interventions on Malaria and Anaemia in Children under Five after Ten Years of Implementation in the Hohoe Municipality of Ghana  [PDF]
Margaret Kweku, Eric Kwaku Appiah, Yeetey Enuameh, Martin Adjuik, Wisdom Takramah, Elvis Tarkang, John Gyapong
Advances in Infectious Diseases (AID) , 2017, DOI: 10.4236/aid.2017.73010
Abstract: Background: Malaria remains a dominant health issue among children in Ghana. We monitored the trend of long lasting insecticide net (LLIN) ownership and use and its impact on malaria and anaemia among children under five over the past decade in an area of intense, prolonged and seasonal malaria transmission. Methods: A total of 1717, 2155 and 1915 children were surveyed in June and 1717, 2155 and 1697 in November in 30 communities of the Hohoe Municipality in 2006, 2010 and 2015 respectively. The primary outcomes monitored were the trend of LLIN ownership, use and prevalence of malaria and anaemia through cross-sectional surveys. Findings: Results showed a significantly positive trend (p < 0.001) in ownership of LLIN at 20.8%, 64.8% and 83.2% for 2006, 2010 and 2016 respectively. The sharp increase in ownership between 2006 and 2010 accounted for a highly significant departure from trend (p < 0.001). Similarly, the prevalence of LLIN use was 15.1%, 42.2% and 68.3% for 2006, 2010 and 2016 respectively with a significant positive trend (p < 0.001). The prevalence of malaria parasitaemia in June showed no significant drop over the three years studied. Anaemia prevalence was 7.9%, 5.3% and 11.1% for 2006, 2010 and 2015 respectively—Anaemia significantly increased (p < 0.001) between 2010 and 2015 accounting for a significant departure from the initially decreasing trend (p < 0.001). Malaria parasitaemia over the November surveys was 40.4%, 33.2% and 26.6% for 2006, 2010 and 2016 respectively, depicting a significant decline over the years of the study (p < 0.001). A significant decrease (p = 0.006) in anaemia was observed at 12.0%, 4.3% and 8.9% for 2006, 2010 and 2015 respectively. A significant departure from the decreasing trend (p < 0.001) was noted with increasing anaemia between 2010 and 2016. Interpretation: Ownership of LLIN and its use together with other indicators of malaria prevalence generally improved five years after the implementation of a malaria control programme. Ten years after programme implementation, consistent improvement was only in LLIN ownership and use. Also malaria prevalence indicators improved in the post as compared to the pre-rainy season in the study communities.
Using data envelopment analysis to measure the extent of technical efficiency of public health centres in Ghana
James Akazili, Martin Adjuik, Caroline Jehu-Appiah, Eyob Zere
BMC International Health and Human Rights , 2008, DOI: 10.1186/1472-698x-8-11
Abstract: This study uses the DEA method, to calculate the technical efficiency of 89 randomly sampled health centers in Ghana. The aim was to determine the degree of efficiency of health centers and recommend performance targets for the inefficient facilities.The findings showed that 65% of health centers were technically inefficient and so were using resources that they did not actually need.The results broadly point to grave inefficiency in the health care delivery system of public health centers and that significant amounts of resources could be saved if measures were put in place to curb the waste.A recent critical review of the Health Sector Reforms in Sub-Saharan Africa points to the fact that besides the issue of ever diminishing financial inflows to the health sector, poor quality of health care, mainly occasioned by a variety of inefficiencies at all levels of health care delivery is one of the most important concerns which has precipitated a number of reform initiatives and strategies in nearly all the developing countries [1]There is also a growing concern among policy makers and planners that health services are not being delivered with utmost efficiency. In 2002, government in about 65% of the 46 countries in the WHO Africa Region spent less than US$ 10 per capita per year [2]. Evidence from the Africa Region indicates that the problem of scarcity of resources is also compounded with technical inefficiency that leads to wastage of the available meager resources [2]. In 2006, cognizant of the technical inefficiency plaguing the African health systems, Ministers of Health of the African Union Member States undertook to institutionalize efficiency monitoring within the national health information systems [3].Coupled with this recognition, there is a realization among policy makers that increased funding alone will not and cannot solve the problem. From a strict sustainability perspective, it can be argued that most African countries are approaching or have already
Clustering of under-five mortality in the Navrongo HDSS in the Kassena-Nankana District of northern Ghana
Martin Adjuik,Ernest Kanyomse,Felix Kondayire,George Wak
Global Health Action , 2010, DOI: 10.3402/gha.v3i0.5233
Abstract: Background: Under-five mortality is a major public health problem and one of the health indicators of health care in sub-Saharan Africa. In order to address inefficient health systems, there is a need to identify the spatial distribution of under-five mortality, especially areas of high mortality clustering. This study aimed to explore spatial and temporal clustering in under-five mortality in the Kassena-Nankana District of the Upper East region. Methods: We used data from the Navrongo Health and Demographic Surveillance System in the Kassena- Nankana District of northern Ghana, which had an average population of 140,000 of which about 18,400 were under five years of age. We analysed under-five mortality in 49 villages during the period 1997–2006. We calculated total under-five mortality rates and investigated their geographical distributions. A spatial scan statistic was used to test for clustering of the mortality in both space and time. Results: Under-five mortality has been declining during the period. However, the data show a persistently higher than average clustering of mortality over the period among villages mainly in the north-eastern parts of the district. Conclusion: There is a higher than average under-five mortality clustering in the villages in the north-east of the district and this may suggest a relatively poor health care system despite the many health interventions that took place over time in the district, including the Community Health and Family Planning Project, whose impact may not have been felt in these parts of the district between 1995 and 2004.
Cause-specific mortality rates in sub-Saharan Africa and Bangladesh
Adjuik Martin,Smith Tom,Clark Sam,Todd Jim
Bulletin of the World Health Organization , 2006,
Abstract: OBJECTIVE: To provide internationally comparable data on the frequencies of different causes of death. METHODS: We analysed verbal autopsies obtained during 1999 -2002 from 12 demographic surveillance sites in sub-Saharan Africa and Bangladesh to find cause-specific and age-specific mortality rates. The cause-of-death codes used by the sites were harmonized to conform to the ICD-10 system, and summarized with the classification system of the Global Burden of Disease 2000 (Version 2). FINDINGS: Causes of death in the African sites differ strongly from those in Bangladesh, where there is some evidence of a health transition from communicable to noncommunicable diseases, and little malaria. HIV dominates in causes of mortality in the South African sites, which contrast with those in highly malaria endemic sites elsewhere in sub-Saharan Africa (even in neighbouring Mozambique). The contributions of measles and diarrhoeal diseases to mortality in sub-Saharan Africa are lower than has been previously suggested, while malaria is of relatively greater importance. CONCLUSION: The different patterns of mortality we identified may be a result of recent changes in the availability and effectiveness of health interventions against childhood cluster diseases.
Options for the Delivery of Intermittent Preventive Treatment for Malaria to Children: A Community Randomised Trial
Margaret Kweku, Jayne Webster, Martin Adjuik, Samuel Abudey, Brian Greenwood, Daniel Chandramohan
PLOS ONE , 2009, DOI: 10.1371/journal.pone.0007256
Abstract: Background Intermittent preventive treatment for malaria in children (IPTc) is a promising new intervention for the prevention of malaria but its delivery is a challenge. We have evaluated the coverage of IPTc that can be achieved by two different delivery systems in Ghana. Methods IPTc was delivered by volunteers in six villages (community-based arm) and by health workers at health centres or at Expanded Programme on Immunisation outreach clinics (facility based) in another six communities. The villages were selected randomly and drugs were administered in May, June, September and October 2006. The first dose of a three-dose regimen of amodiaquine plus sulphadoxine-pyrimethamine was administered under supervision to 3–59 month-old children (n = 964) in the 12 study villages; doses for days 2 and 3 were given to parents/guardians to administer at home. Results The proportion of children who received at least the first dose of 3 or more courses of IPTc was slightly higher in the community based arm (90.5% vs 86.6%; p = 0.059). Completion of the three dose regimen was high and similar with both delivery systems (91.6% and 91.7% respectively). Conclusion Seasonal IPTc delivered through community-based or facility-based systems can achieve a high coverage rate with the support and supervision of the district health management team. However, in order to maximise the impact of IPTc, both delivery systems may be needed in some settings. Trial Registration ClinicalTrials.gov NCT00119132
Seasonal Intermittent Preventive Treatment for the Prevention of Anaemia and Malaria in Ghanaian Children: A Randomized, Placebo Controlled Trial
Margaret Kweku, Dongmei Liu, Martin Adjuik, Fred Binka, Mahmood Seidu, Brian Greenwood, Daniel Chandramohan
PLOS ONE , 2008, DOI: 10.1371/journal.pone.0004000
Abstract: Background Malaria and anaemia are the leading causes of morbidity and mortality in children in sub-Saharan Africa. We have investigated the effect of intermittent preventive treatment with sulphadoxine-pyrimethamine or artesunate plus amodiaquine on anaemia and malaria in children in an area of intense, prolonged, seasonal malaria transmission in Ghana. Methods 2451 children aged 3–59 months from 30 villages were individually randomised to receive placebo or artesunate plus amodiaquine (AS+AQ) monthly or bimonthly, or sulphadoxine-pyrimethamine (SP) bimonthly over a period of six months. The primary outcome measures were episodes of anaemia (Hb<8.0 g/dl) or malaria detected through passive surveillance. Findings Monthly artesunate plus amodiaquine reduced the incidence of malaria by 69% (95% CI: 63%, 74%) and anaemia by 45% (95% CI: 25%,60%), bimonthly sulphadoxine-pyrimethamine reduced the incidence of malaria by 24% (95% CI: 14%,33%) and anaemia by 30% (95% CI: 6%, 49%) and bimonthly artesunate plus amodiaquine reduced the incidence of malaria by 17% (95% CI: 6%, 27%) and anaemia by 32% (95% CI: 7%, 50%) compared to placebo. There were no statistically significant reductions in the episodes of all cause or malaria specific hospital admissions in any of the intervention groups compared to the placebo group. There was no significant increase in the incidence of clinical malaria in the post intervention period in children who were >1 year old when they received IPTc compared to the placebo group. However the incidence of malaria in the post intervention period was higher in children who were <1 year old when they received AS+AQ monthly compared to the placebo group. Interpretation IPTc is safe and efficacious in reducing the burden of malaria in an area of Ghana with a prolonged, intense malaria transmission season. Trial Registration ClinicalTrials.gov NCT00119132
Insecticide resistance profiles for malaria vectors in the Kassena-Nankana district of Ghana
Francis Anto, Victor Asoala, Thomas Anyorigiya, Abraham Oduro, Martin Adjuik, Seth Owusu-Agyei, Dominic Dery, Langbong Bimi, Abraham Hodgson
Malaria Journal , 2009, DOI: 10.1186/1475-2875-8-81
Abstract: Indoor resting Anopheles mosquitoes were collected. Blood-fed and gravid females were allowed to oviposit, eggs hatched and larvae reared to 1–3 days old adults and tested against permethrin 0.75%, deltamethrin 0.05%, cyfluthrin 0.15%, lambdacyhalothrin 0.1% and DDT 4%, based on WHO methodology. PCR analyses were carried out on a sub-sample of 192 of the An. gambiae for sibling species complex determination. Resistance to pyrethroids and DDT was determined by genotyping the knock-down resistance kdr gene mutations in the study area.A total of 9,749 1–3 days-old F1 female Anopheles mosquitoes were exposed to the insecticides. Among the pyrethroids, permethrin, 0.75% had the least knockdown effect, whilst cyfluthrin 0.15%, had the highest knock-down effect. Overall, no difference in susceptibility between An. gambiae 93.3% (95% CI: 92.5–94.1) and An. funestus 94.5% (95% CI: 93.7–95.3) was observed when exposed to the pyrethroids. Similarly, there was no difference in susceptibility between the two vector species (An. gambiae = 79.1% (95% CI: 76.6–81.8) and An. funestus = 83.5% (95% CI: 80.2–86.4) when exposed to DDT. Overall susceptibility to the insecticides was between 80% and 98%, suggesting that there is some level of resistance, except for cyfluthrin 0.15%. The kdr PCR assay however, did not reveal any kdr mutations. The analysis also revealed only the molecular M (Mopti) form.The findings in this study show that An. gambiae and An. funestus, the main malaria vector mosquitoes in the Kassena-Nankana district are susceptible to the insecticides being used in the treatment of bed nets in the malaria control programme. There is however, the need for continuous monitoring of the pyrethroids as the efficacy is not very high.Malaria is a major public health problem in Ghana. The strategy of the National Malaria Control Programme is based on effective case management and the use of insecticide treated bed nets among vulnerable groups, such as children under five years o
Assessing malaria control in the Kassena-Nankana district of northern Ghana through repeated surveys using the RBM tools
Seth Owusu-Agyei, Elizabeth Awini, Francis Anto, Thomas Mensah-Afful, Martin Adjuik, Abraham Hodgson, Edwin Afari, Fred Binka
Malaria Journal , 2007, DOI: 10.1186/1475-2875-6-103
Abstract: Data were collected from mothers/caretakers on signs/symptoms of the most recent malaria attack for their under five year old children; the management actions that they took and their perception of health services provided at the health facilities, bednet use, antenatal attendance and place of delivery for the most recent pregnancy, malaria prophylaxis during their last pregnancy. Community health workers and herbalist/traditional healers were also interviewed about the types of health services they provide to community members.The results revealed a significant improvement in knowledge among mothers/caretakers over the three-year period; this affected caretakers' initial management of illnesses of their young children. The management in terms of the type and dosage of drugs used also improved significantly (p < 0.0001) over the period. Reported insecticide-treated bed net use among children under-five years and pregnant women significantly increased between 2000 and 2003 (p < 0.0001). Health professionals had improved on adoption of their quality of care roles.The intensification of malaria control activities and awareness creation in this district over a three year period had started demonstrating positive results towards reducing malaria disease burden.Periodic performance assessments through surveys as described and prompt feedback of results to stakeholders in the locality serves as a catalyst to improving malaria control in malaria-endemic countries.Malaria is the world's most important tropical parasitic disease; killing more people than any other communicable disease, except tuberculosis. Prevention is the best protection from malaria. It includes individual protection, such as the use of insecticide-treated bed nets, mosquito repellants and drug prophylaxis for pregnant women; community measures, such as the control of mosquito breading sites, insecticide spraying and drainage.Morbidity and mortality are particularly high among pregnant women, young childre
An Open Label, Randomised Trial of Artesunate+Amodiaquine, Artesunate+Chlorproguanil-Dapsone and Artemether-Lumefantrine for the Treatment of Uncomplicated Malaria
Seth Owusu-Agyei, Kwaku Poku Asante, Ruth Owusu, Martin Adjuik, Stephen Amenga-Etego, David Kwame Dosoo, John Gyapong, Brian Greenwood, Daniel Chandramohan
PLOS ONE , 2008, DOI: 10.1371/journal.pone.0002530
Abstract: Background Artesunate+amodiaquine (AS+AQ) and artemether-lumefantrine (AL) are now the most frequently recommended first line treatments for uncomplicated malaria in Africa. Artesunate+chlorproguanil-dapsone (AS+CD) was a potential alternative for treatment of uncomplicated malaria. A comparison of the efficacy and safety of these three drug combinations was necessary to make evidence based drug treatment policies. Methods Five hundred and thirty-four, glucose-6-phosphate dehydrogenase (G6PD) normal children were randomised in blocks of 15 to the AS+AQ, AL or AS+CD groups. Administration of study drugs was supervised by project staff and the children were followed up at r home on days 1,2,3,7,14 and 28 post treatment. Parasitological and clinical failures and adverse events were compared between the study groups. Main Findings In a per-protocol analysis, the parasitological and clinical failure rate at day 28 post treatment (PCF28) was lower in the AS+AQ group compared to the AL or AS+CD groups (corrected for re-infections: 6.6% vs 13.8% and 13.8% respectively, p = 0.08; uncorrected: 14.6% vs 27.6% and 28.1% respectively, p = 0.005). In the intention to treat analysis, the rate of early treatment failure was high in all three groups (AS+AQ 13.3%; AL 15.2%; and AS+CD 9.3%, p = 0.2) primarily due to vomiting. However, the PCF28 corrected for re-infection was lower, though not significantly, in the AS+AQ group compared to the AL or the AS+CD groups (AS+AQ 18.3%; AL 24.2%; AS+CD 20.8%, p = 0.4) The incidence of adverse events was comparable between the groups. Conclusions AS+AQ is an appropriate first line treatment for uncomplicated malaria in Ghana and possibly in the neighbouring countries in West Africa. The effectiveness of AL in routine programme conditions needs to be studied further in West Africa. Trial Registration ClinicalTrials.gov NCT00119145
Epidemiology of malaria in the forest-savanna transitional zone of Ghana
Seth Owusu-Agyei, Kwaku Asante, Martin Adjuik, George Adjei, Elizabeth Awini, Mohammed Adams, Sam Newton, David Dosoo, Dominic Dery, Akua Agyeman-Budu, John Gyapong, Brian Greenwood, Daniel Chandramohan
Malaria Journal , 2009, DOI: 10.1186/1475-2875-8-220
Abstract: Active surveillance of clinical malaria was carried out in a cohort of children below five years of age (n = 335) and the prevalence of malaria was estimated in a cohort of subjects of all ages (n = 1484) over a 12-month period. Participants were sampled from clusters drawn around sixteen index houses randomly selected from a total of about 22,000 houses within the study area. The child cohort was visited thrice weekly to screen for any illness and a blood slide was taken if a child had a history of fever or a temperature greater than or equal to 37.5 degree Celsius. The all-age cohort was screened for malaria once every eight weeks over a 12-month period. Estimation of Entomological Inoculation Rate (EIR) and characterization of Anopheline malaria vectors in the study area were also carried out.The average parasite prevalence in the all age cohort was 58% (95% CI: 56.9, 59.4). In children below five years of age, the average prevalence was 64% (95% CI: 61.9, 66.0). Geometric mean parasite densities decreased significantly with increasing age. More than 50% of all children less than 10 years of age were anaemic. Children less than 5 years of age had as many as seven malaria attacks per child per year. The attack rates decreased significantly with increasing cut-offs of parasite density. The average Multiplicity of Infection (MOI) was of 6.1. All three pyrimethamine resistance mutant alleles of the Plasmodium falciparum dhfr gene were prevalent in this population and 25% of infections had a fourth mutant of pfdhps-A437G. The main vectors were Anopheles funestus and Anopheles gambiae and the EIR was 269 infective bites per person per year.The transmission of malaria in the forest-savanna region of central Ghana is high and perennial and this is an appropriate site for conducting clinical trials of anti-malarial drugs and vaccines.Over 500 million episodes of malaria occur yearly, predominantly in sub-Saharan African children under five years of age, resulting in the d
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