Background In Sub-Saharan Africa (SSA), HIV infection is the main factor contributing to adult premature death. The prevalence of HIV in the region could also be associated with recent increases in Female Genital Schistosomiasis (FGS) globally. The fast-rising prevalence of FGS in SSA nations including Ghana, which has led to the emergence of dual HIV-FGS conditions, provides evidence of the trend. As such the WHO is advocating for integrated services of HIV and FGS care. This study explored stakeholders’ perspectives of the integration of prevention and control measures for Female Genital Schistosomiasis and HIV care in FGS endemic settings in Ghana. Methods The study was conducted in the Ga South Municipality in the Greater Accra region of Ghana. Using qualitative research methods, Focus Group Discussion was conducted with Community Health Officers (n=9) and Key Informant Interviews with stakeholders including health care professionals and providers at the Regional, District and community levels (n=13) to explore the feasibility, challenges, and opportunities of integrating FGS prevention and control package with HIV continuum of care in communities. In-depth interviews were also conducted among Persons with FGS and HIV (n=13), Female Households (n=10), Community Health Management Committee members and Community leader (n=7) to explore their views on the facilitators and barriers of the integration of FGS into HIV care into the Primary Health Care (PHC) in Ghana. All study participants were purposively sampled to achieve the study objective. All audio-recorded data were transcribed verbatim, a codebook developed, and the data was thematically analysed with the aid of NVivo software version 13.     Results The study identified a knowledge gap regarding Female Genital Schistosomiasis (FGS) compared to HIV. The majority of Community Health Officers (CHOs) exhibited limited knowledge about FGS. Additionally, health workers misconstrued FGS as sexually transmitted infections. Community members who expressed knowledge of FGS were about gynecological symptoms of FGS. Three main health outlets; health facilities, herbal centers, and spiritual centers are utilized either concurrently or in sequence. This health seeking behaviour negatively affected the early detection and management of FGS among HIV clients. Integration of HIV and FGS may be affected by the limited awareness and knowledge, resource constraints, stigma and discrimination, healthcare providers’ attitudes and practices, and cultural beliefs. Conclusions The study finds that knowledge of FGS was usually low among both community members and Community Health Officers. This was having a detrimental effect on regular screening of females for genital schistosomiasis. Integration of FGS and HIV has the potential to help Ghana achieve HIV eradication; however, before such a program is launched, implementation barriers such as stigma, knowledge gap, unavailability of needed logistics at health facilities, shortage of FGS and HIV drugs and issues of accessibility of drugs must be addressed. The results also imply that forming alliances and working together with various community health care professionals may help with early HIV and FGS diagnosis and treatment. Finally, there is the pressing need to develop a clinical protocol for FGS and HIV integration. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The protocol for the study was reviewed and approved by the Ghana Health Service Ethics Review Committee (GHS -ERC: 001/01/24). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data is available on request sent to the Administrator of Ghana Health Service Ethics Review Committee at ethics.research@ghs.gov.gh

Malaria remains a leading cause of illness and death especially among children and pregnant women in Ghana. Despite the efforts made by the National Malaria Elimination Programme (NMEP), including distribution of Long-Lasting Insecticide Nets (LLINs) to households through periodic Point Mass Distribution (PMD) campaigns and continuous channels (antenatal, schools and postnatal), there is a gap between access and use of LLINs in Ghana. An effective and functional community-based group that would seek to improve the effectiveness of LLIN distribution before, during, after PMD Campaigns and continuous distribution at the community level could help address this gap. This paper assesses the implementation outcomes and short-term effectiveness of the pilot implementation of co-created community health advocacy teams (CHAT) intervention in Ghanaian communities to plan and implement campaigns to increase LLIN use. The study employed a one-group pre-post study design and measured implementation outcomes (acceptability, appropriateness, and feasibility) and effectiveness outcomes (LLIN awareness, LLIN access, willingness to purchase LLIN, and LLIN use) among 800 community households. The CHAT intervention was implemented for four months across six districts in the Eastern and Volta regions of Ghana. The data were downloaded directly from REDCap and analyzed statistically (descriptive and McNemar test of association) using SPSS 22 software. After the implementation period, the majority of respondents in all six districts indicated that the CHAT intervention was acceptable (89.8%), appropriate (89.5%), and feasible (90%). Also, there was a significant association between baseline and end-line assessment on all four effectiveness outcome measures. Household members’ awareness of, access to, willingness to purchase, and use of LLINs increased significantly over the four-month period that the CHAT intervention was implemented. The study concludes that CHAT is an acceptable, appropriate, and feasible intervention for supporting the National Malaria Programme in LLIN PMD and for engaging in Social and Behaviour Change Communication activities through the continuous channels of distribution. Additionally, the CHAT demonstrates short-term effectiveness outcomes in terms of creating LLIN awareness, providing access to LLIN, and encouraging Ghanaian community members to be willing to purchase and use LLINs. Although the activities of CHAT members were largely voluntary, integration into the existing primary health care system will make it sustainable.

Studies have reported widespread disposable diaper (DD) consumption in parts of urban Africa, increasing municipal waste generation and with mismanaged DD waste impacting water quality. However, the DD manufacturing and distribution systems behind this trend are little studied, yet understanding these underlying systems is critical in informing efforts to promote extended producer responsibility. This study therefore aims to assess DD brand preferences and trends in international trade in absorbent hygiene products in two case study Sub-Saharan countries. A cross-sectional survey was undertaken of 440 carers of children aged 0-36 months attending health facilities in Greater Accra, Ghana and Kisumu, Kenya. Survey analysis was supplemented by analysis of international trade in absorbent hygiene products for both countries from 2000-2021. Trade data showed DD imports to Ghana and Kenya increased from 2000-17 particularly from China, but declined thereafter. This coincided with Chinese foreign direct investment establishing DD production facilities within both countries in 2018-19, and increased DD exports from Kenya and Ghana to surrounding countries. Meanwhile, 93.0% and 94.2% of survey respondents in Greater Accra and Kisumu respectively reported using DD. In Greater Accra and Kisumu respectively, 62.4% and 45.3% of survey participants reported using the brand produced by these new domestic manufacturing facilities, with 29.8% and 40.9% using imported brands. In Greater Accra, approximately half of reported imported brands were unregistered with the regulator. Given its market dominance, we therefore recommend engagement with the leading manufacturer to identify product or waste management innovations to address water pollution from DD waste. We also recommend similar engagement with imported brand manufacturers and greater DD import regulation in Ghana, given lack of imported brand registration.

Background The National Malaria Elimination Programme implements the mass LLIN Distribution Campaigns in Ghana. Implementation science promotes the systematic study of social contexts, individual experiences, real-world environments, partnerships, and stakeholder consultations regarding the implementation of evidence-informed interventions. In this paper, we assess the core elements of the mass LLIN distribution campaign in a resource constrained setting to learn best implementation practices. Three core domains were assessed through the application of Galbraith's taxonomy (i.e., implementation, content, and pedagogy) for evidence-informed intervention implementation.MethodsSix districts in two regions (Eastern and Volta) in Ghana participated in this study. Fourteen Focus Group Discussions (FGDs) were conducted across these communities. Eligible participants were purposively sampled considering age, occupation, gender, and care giving for children under 5 years and household head roles. All audio-recorded FGDs were transcribed verbatim, data was assessed and coded through deductive and inductive processes. NVivo software version 13 was used for the coding process. Themes were refined, legitimized, and the most compelling extracts selected to produce the results.ResultsSixty-nine (69) caregivers of children under 5 years and sixty (60) household heads participated in the FGDs. All caregivers were females (69), whilst household heads included more males (41). Core elements identified under implementation domain of the LLIN distribution campaign in Ghana include the registration and distribution processes, preceded by engagement with traditional authorities and continuous involvement of community health volunteers during implementation. For pedagogy domain, core elements include delivery of intervention through outreaches, illustrations, demonstrations, and the use of multiple communication channels. Core elements realized within the content domain include information on effective malaria prevention, and provision of information to enhance their self-efficacy. Yet, participants noted gaps (e.g., misuse) in the desired behavioural outcome of LLIN use and a heavy campaign focus on women.Conclusion and recommendationsAlthough the implementation of the mass LLIN distribution campaigns exhibit components of core elements of evidence informed interventions (implementation, content and pedagogy), it has not achieved its desired behavioural change intentions (i.e. continuous LLIN use). Future campaigns may consider use of continuous innovative pedagogical approaches at the community level and lessons learnt from this study to strengthen the implementation process of evidence-based health interventions. There is also the need for standardization of core elements to identify the number of core elements required within each domain to achieve efficacy.Ethical approvalEthical clearance was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC: 002/06/21) before the commencement of all data collection.

Introduction:In Ghana, the National Malaria Elimination Programme (NMEP) distributes long-lasting insecticide net (LLIN) to households for free through the periodic point mass distribution (PMD) campaign and continuous distribution to populations most vulnerable to malaria. It is known that the existence of effective and functional community-based groups could influence positive behaviours regarding health interventions promoted through health campaigns. However, there is no evidence of functional community-based groups that aim to improve the effectiveness of LLIN distribution campaigns by transitioning into primary healthcare delivery. This study aimed to explore the opportunities and barriers to the pilot implementation of co-created community health advocacy teams (CHATs) to improve the effectiveness of LLIN distribution through both campaigns and continuous channels in Ghana.Methods:A qualitative research approach was used among 43 CHAT members across six communities in the Eastern and Volta regions of Ghana. The CHAT constitutes significant community actors whose roles are centred on key elements of community/social mobilisation and capacity building, all nested in social and behaviour change communication (SBCC) strategies. The CHATs were pilot implemented in all study communities for 4 months after which we identified opportunities and barriers during implementation. CHAT members participated in six focus group discussions which were audio recorded, transcribed verbatim, and analysed thematically using the NVivo 13.Results:CHATs were instrumental in sensitising community members through SBCC strategies. Moreover, there were changes in the behaviour of community members who were receptive towards and participated in CHAT activities. Community members were accurately informed about malaria (e.g., causes and preventive measures). However, the CHAT experienced barriers during implementation, including a lack of financial support to aid in transportation, organisation of meetings, and outreach activities. Additionally, the level of participation by CHAT members in activities and the medium of communication among members were key areas of concern.Conclusion:The CHATs would be instrumental in promoting LLINs' use during and after PMD campaigns through community outreaches. It is therefore necessary to provide resources to support their operations and a good network to address communication barriers. Finally, continuous capacity strengthening of CHAT members by the NMCP is important.

Violence against women (VAW) is a global health problem, which leads to negative sexual, reproductive, mental and physical health outcomes, as well as death in extreme cases. Globally, over 35% of women are reported to have experienced some form of violence, while in Ghana, 37% of women have ever experienced physical violence. Considering that the sustainability of community-based VAW interventions is largely dependent on ownership, this study used the Theoretical Framework of Acceptability (TFA) to assess the COMBAT (Community Based Action Teams) intervention (for example, ethicality, self-efficacy, and intervention coherence) which was implemented to prevent violence against women in Ghana. This qualitative research study was conducted at baseline and end-line of the intervention, which used COMBAT as a vehicle to change social norms on gender and violence in the Central region, Ghana. Participants comprised of adult (women and men) who reside in the Agona District. We analyzed the transcripts from eight (8) Focus Group Discussions conducted within one of the two intervention recipient sites (4 female community FGDs and 4 male community FGDs). Data was analyzed thematically using the Nvivo software version 12. Through the application of the TFA, the findings show that community members perceive VAW as inappropriate at the individual and community levels (ethicality), have good knowledge of the COMBAT intervention and how it works (intervention coherence). Also, the study shows that participants have a positive attitude towards the intervention and its components (positive affective attitude), and could take up components of the intervention, by reporting and seeking for VAW support (positive self-efficacy). There was a perceived reduction in VAW practices in the various communities, as well as a reduction in the abuse of women, thereby improving their well-being (intervention effectiveness). The COMBAT strategy was accepted by the community members hence could be sustained as a culturally appropriate intervention for preventing VAW.

ObjectiveMass long-lasting insecticide net (LLIN) distribution campaigns are rolled out, as a part of the Ghana Malaria Strategic plan (2021–2025) which seeks to protect at least 80% of the population at risk with effective malaria prevention interventions. Although the mass LLIN distribution campaign indicates a comprehensive stakeholder engagement approach, it does not systematically transition into the basic primary healthcare structures within the Ghana Health Services. This paper presents the process and outcome of creating an innovative social intervention, which focuses on community mobilisation and capacity building of community health officers.MethodsThis study employed a concurrent triangulation mixed methods approach conducted across six districts in Eastern and Volta regions, Ghana. Findings were synthesised, grouped and further distilled to guide the participatory cocreation workshops. Cocreation involved participatory learning in action technique which is a practical, adaptive research strategy which enabled diverse groups and individuals to learn, work and act together in a cooperative manner.ResultsThe results suggest the establishment of a Community Health Advocacy Team (CHAT). This would be necessary in efforts aimed at transitioning LLIN distribution campaign in communities. The role of the CHAT would be centred on key elements of community/social mobilisation and capacity building, all nested in a social and behaviour change communication strategies.ConclusionThe research team is in the process of assessing the acceptability and feasibility of the CHAT intervention with all stakeholders in the various communities. Assessment of the effectiveness of the CHAT intervention would be done at a later time.