Prevalence and associated factors of depression among persons with Tuberculosis in Ghana: A cross-sectional study

Abstract

Background

Tuberculosis remains a significant global public health challenge, with the African region accounting for one-quarter of global incident cases. In Ghana, TB prevalence reaches 356 cases per 100,000 population. Depression is prevalent among persons with tuberculosis, potentially worsening treatment outcomes and patient prognosis. This study aimed to investigate the prevalence and predictors of depression among persons with TB in Ghana.

Methods

A cross-sectional study was conducted across 20 randomly selected healthcare facilities providing TB care in eight administrative regions of Ghana. The study included 1,103 participants aged 18 years and older. Depression was assessed using the Patient Health Questionnaire (PHQ-9), with depression defined as a score ≥5. Data collection utilized systematic random sampling and a structured questionnaire implemented through the Research Electronic Data Capture (REDCap) platform. Modified Poisson regression with robust standard error was used for statistical analysis with STATA version 17.

Results

The study revealed a depression prevalence of 40.98% among PWTB. Among the predictors of depression, Females had a 28% higher likelihood of depression (Adjusted Relative Risk = 1.28 [1.06-1.56]). Participants with poor health had 2.19 times higher depression risk (Adjusted Relative Risk = 2.19[1.64-2.92]). Additionally, stigmatized participants showed 52% higher depression risk (Adjusted Relative Risk = 1.52 [1.22-1.89]).

Conclusions

The high prevalence of depression among TB patients in Ghana underscores the need for integrated mental health services in TB care. The study highlights the importance of addressing factors such as gender, health status, and stigma to improve mental health outcomes for persons with tuberculosis.

Keywords

tuberculosis depression mental health Ghana prevalence predictors

Introduction

Tuberculosis (TB) has been a major public health concern globally, and its co-occurrence with depression poses a significant challenge for healthcare systems.¹ The African region accounted for one-quarter of the global 131 incident cases per 100 000 population.¹ In Ghana, TB incidence reaches 126 cases per 100,000 population, positioning the country tenth among African nations surveyed.¹ The relationship between TB and depression is multifaceted and bidirectional,² revealing intricate immunological mechanisms underscoring both physiological and psychological connections.³ There is evidence of comorbidity between depression and TB, with 10-52% of TB patients experiencing depressive symptoms.^4–6 This relation between depression and TB worsens prognosis. Studies demonstrate depression among persons with TB (PWTB) leads to poorer adherence, higher likelihood of treatment failure, increased antimicrobial resistance, and elevated mortality risk.^2,7,8

Despite the intersection and burden, the depression among PWTB in Ghana has not been extensively studied. Existing research has primarily focused on the prevalence of TB and its associated factors, with less attention given to assessing the prevalence and predictors of depression among PWTB in Ghana.⁶ There is a noticeable gap in literature on the association between social and clinical factors and depression among TB patients in Ghana, which is essential for developing tailored interventions. The findings of this study will contribute to the existing body of knowledge on the intersection of depression and TB, which could advance the development of targeted interventions to improve the health and mental well-being of persons with TB in Ghana.

Methods

Study design and setting

This was a facility-based cross-sectional study conducted across randomly selected 20 healthcare facilities providing TB care in eight administrative regions of Ghana from 5th to 22nd February 2023. The study design was selected to provide insight on depression prevalence and associated factors among PWTB at a single point in time. The selected healthcare facilities represented a diverse geographical and healthcare system landscape, including primary, secondary, and tertiary level institutions across urban and rural settings.

Participants

The study population comprised PWTB accessing healthcare services at the selected facilities. Participants were carefully selected based on specific criteria designed to ensure meaningful and representative data collection. Individuals were eligible for inclusion if they were 18 years or older, had a confirmed tuberculosis diagnosis, were currently receiving TB treatment at the selected healthcare facilities, and were mentally competent to provide informed consent. To maintain data integrity and participant welfare, the study excluded individuals who were severely ill or hospitalized, as well as those unable to provide meaningful responses or consent to participate in the research.

Sample size

The sample size was calculated using a finite population of 44,000, representing the total number of persons with tuberculosis registered on treatment across the 20 ramdomly selected healthcare facilities at the time of study planning (February 2023), obtained directly from the Ghana National Tuberculosis Control Programme registry and district health information management system records. Using the formula for sample size determination in finite populations:

n = \frac{z^{2} \times p \times (1 - p) \times N}{z^{2} \times p \times (1 - p) + (N - 1) \times e^{2}} \times \frac{D E F F}{(1 - N R)}

Where: Z = 1.96 (95% confidence level), p = 0.50 (expected prevalence), N = 44,000 (finite population), e = 0.05 (margin of error), DEFF = 2 (design effect), and NR = 0.30 (non-response rate). The estimated sample size was 1,098 participants. The sample was allocated to each facility using a proportion-to-size technique (see Table 1), ensuring representative sampling across different healthcare settings.

Table 1.

List of healthcare facilities with PWTB population and sample allocation.

Facility no.	Region	Total PWTB on treatment	Proportional sample size
1	Greater Accra	2,207	55
2	Greater Accra	3,136	78
3	Greater Accra	1,565	39
4	Ashanti	1,032	26
5	Ashanti	1,328	33
6	Ashanti	3,612	90
7	Ashanti	2,631	66
8	Central	2,691	67
9	Central	2,426	61
10	Central	1,894	47
11	Central	1943	48
12	Eastern	3,115	78
13	Eastern	3,759	94
14	Eastern	2,145	54
15	Bono	2,272	57
16	Bono	1,874	47
17	Bono	2,351	59
18	Bono East	1,377	34
19	Northern	1,237	31
20	Upper West	1,405	35
Total		44,000	1,098

Sampling technique

The study utilized a systematic sampling technique designed to minimize selection bias and ensure randomized participant selection. Data collectors visited each of the 20 selected facilities from 5th to 22nd February 2023, calculating specific sampling intervals based on each facility’s TB patient volume on each visits. The initial participant in each facility was selected using a computer-generated random number, with subsequent participants chosen at predetermined intervals. In instances where a selected individual declined participation or did not meet inclusion criteria, they were replaced by the next eligible participant, maintaining the study’s sampling integrity and representativeness.

Data collection

Data collection was conducted using a structured questionnaire (see supplementary file 1) implemented through the Research Electronic Data Capture (REDCap) platform, a secure and robust data management system. The primary outcome variable was depression status, assessed using the Patient Health Questionnaire (PHQ-9).^9,10 The total score for the PHQ-9 is 27, with depression severity classified as 0-4 (None depression), 5-9 (Mild depression), 10-14 (Moderate depression), 15-19 (Moderately severe depression) and 20-27 (Severe depression). For this study, any depressive symptoms were defined as a PHQ-9 score ≥5, encompassing mild, moderate, moderately severe, and severe depression categories. This threshold was chosen to capture the full spectrum of depressive symptom burden relevant to TB care and treatment adherence, consistent with screening approaches in high-burden settings where early identification of psychological distress is critical. Independent variables included age, place of residence, gender, marital status, educational level, ethnicity, religion, accommodation, health status, treatment support, occupation, and stigmatized status.

Bias

To minimize potential sources of bias, the study implemented multiple methodological safeguards. Proportional sampling across facilities ensured representative participant selection, while systematic random selection techniques reduced selection bias. Standardized data collection protocols were developed and rigorously implemented, and all data collectors underwent comprehensive training to ensure consistency and reliability. The use of validated assessment tools like the PHQ-9 further enhanced the study’s methodological rigor, helping to minimize measurement bias and ensuring the comparability of results across different healthcare settings.¹⁰

Statistical analysis

Statistical analysis was conducted using Stata version 17.0,¹¹ employing a comprehensive and sophisticated analytical approach. Descriptive statistics were used to characterize the study population, with frequencies and proportions calculated for categorical variables and means with standard deviations computed for continuous variables. Bivariate associations were assessed using Pearson’s chi-square test of independence (or Fisher’s exact test where expected cell counts were <5) to identify potential associations between depression and independent variables. All variables with a bivariate p-value <0.20 or of known clinical/epidemiological importance were entered into a multivariate modified Poisson regression model. Because the outcome prevalence exceeded 10%, violating the rare-disease assumption, modified Poisson regression with robust standard errors was used to obtain unbiased relative risks (RRs) and adjusted relative risks (ARRs), while accounting for within-facility clustering and potential heteroskedasticity.^12,13 A two-sided p-value <0.05 was considered statistically significant.

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki. The study protocol received ethical approval from the Ghana Health Service Ethics Review Committee (Project ID: GHS-ERC 001/11/22). Written informed consent was obtained from all participants prior to data collection, ensuring voluntary participation and full understanding of the study’s purposes and procedures. For participants with no formal education, the consent form was read aloud in the participant’s preferred language by a trained research assistant. Consent was documented via a thumbprint or witnessed mark in the presence of an independent literate witness, as approved by the Ghana Health Service Ethics Review Committee. Participant confidentiality was maintained through secure data management protocols, with all personal identifiers protected and data anonymized during analysis.

Result

Socio-demographics

The total respondents from 20 participating 20 health facilities was 1,103/1,098 representing 100.5% response rate. Of the 1,103 participants the male participants presented 61.56%, with females represented 38.44%. The mean age was 41.56 years (sd=13.01), with participants aged 31-40 years constituting the largest age group (29.28%). Residential distribution showed a sub-urban majority of 40.25%, followed by rural (31.37%) and urban (28.38%) participants. Regarding educational levels, 31.28% of the participants have completed JSS/JHS education. The ethnic composition is majorly Akan, making up 40.71% of the participants, and the majority religion is Christian, with 76.07% adherence. Additionally, 44.06% of the participants live in family houses. A significant portion, 63.37%, report having good health, and 60.86% receive treatment support from family members. The occupational distribution shows 25.57% of the participants are traders, and 10.24% of them have reported experiencing stigma (see Table 2).

Table 2.

Socio-demographic characteristics of study participants.

Variable	Frequency (n=1,103)	Percentage (%)
Age group (years)	41.56 (13.01) *
≤20	27	2.45
21-30	212	19.22
31-40	323	29.28
41-50	271	24.57
≥51	270	24.48
Place of residence
Rural	346	31.37
Sub-urban	444	40.25
Urban	313	28.38
Gender
Male	679	61.56
Female	424	38.44
Marital status
Cohabiting	70	6.35
Married	91	8.25
Separated/divorced	554	50.23
Never married	292	26.47
Widowed	96	8.70
Educational level
No formal education	207	18.77
Primary	202	18.31
JSS/JHS	345	31.28
SHS/Voc-tech	283	25.66
Tertiary	66	5.98
Ethnicity
Akan	449	40.71
Ewe	269	24.39
Ga-Adangbe	91	8.25
Gruma	25	2.27
Grusi	36	3.26
Guan	11	1.00
Mande-Busanga	12	1.09
Mole-Dagbani	143	12.96
Others	67	6.07
Religion
Christian	839	76.07
Muslim	227	20.58
Traditionalist	34	3.08
Atheist	3	0.27
Accommodation
Family House	486	44.06
Kiosk/container	12	1.09
Rented apartment	243	22.03
Single house	346	31.37
Other	16	1.45
Health status
Good	699	63.37
Moderate	348	31.55
Poor	56	5.08
Treatment support
Family member	412	60.86
Friend	35	5.17
Spouse	105	15.51
TB coordinator	83	12.26
TB Cadre	42	6.20
Occupation
Government employee	49	4.44
Private employee	62	5.62
Student/apprentice	92	8.34
Trader	282	25.57
Unemployed	167	15.14
Artisan	223	20.22
Fishing/farming	228	20.67
Stigmatized
Yes	113	10.24
No	990	89.76
Depression
Normal	651	59.02
Depressed	452	40.98

^*Mean (Standard Deviation).

Prevalence of depression

The study revealed a depression prevalence of 40.98% among PWTB. To explore further, the analysis revealed statistically significant associations across multiple demographic factors as shown in Table 3. Specifically, depression was significantly associated with place of residence (p = 0.02), marital status (p = 0.01), ethnicity (p = 0.01), accommodation (p < 0.01), health status (p < 0.01), treatment support (p < 0.01), occupation (p = 0.01), and stigma (p < 0.01).

Table 3.

Chi-square test of independence between depression and independent variables.

Variable	Frequency
	Normal (%)	Depressed (%)	X²(P-value)
	n=651(59.02)	n=452(40.98)
Age [years] (n=1,103)			6.73(0.15)
≤20	13 (1.18)	14 (1.27)
21-30	129 (11.70)	83 (7.52)
31-40	200 (18.13)	123 (11.15)
41-50	165 (14.96)	106 (9.61)
≥51	144 (13.06)	126 (11.42)
Place of residence (n=1,103)			8.41(0.02)*
Rural	195 (17.68)	151 (13.69)
Sub-urban	285 (25.84)	159 (14.42)
Urban	171 (15.50)	142 (12.87)
Gender (n=1,103)			3.68(0.06)
Male	416 (37.72)	263 (23.84)
Female	235 (21.31)	189 (17.14)
Marital status (n=1,103)			13.70(0.01)*
Cohabiting	45 (4.08)	25 (2.27)
Divorced/Separated	44 (3.99)	47 (4.26)
Married	331 (30.01)	223 (20.22)
Never married	186 (16.86)	106 (9.61)
Widowed	45 (4.08)	51(4.62)
Educational level (n=1,103)			6.1284(0.19)
No formal education	120 (10.88)	87 (7.89)
Primary	128 (11.60)	74 (6.71)
JSS/JHS	194 (17.59)	151 (13.69)
SHS/Voc-tech	163 (14.78)	120 (10.88)
Tertiary	46 (4.17)	20 (1.81)
Ethnicity (n=1,103)			19.6434(0.01)* ^†
Akan	255 (23.12)	194 (17.59)
Ewe	158 (14.32)	111 (10.06)
Ga-Adangbe	61 (5.53)	30 (2.72)
Gruma	14 (1.27)	11 (1.00)
Grusi	29 (2.63)	7 (0.63)
Guan	3 (0.27)	8 (0.73)
Mande-Busanga	6 (0.54)	6 (0.54)
Mole-Dagbani	92 (8.34)	51 (4.62)
Others	33 (2.99)	34 (3.08)
Religion (n=1,103)			0.2924(1.0)^†
Christian	494 (44.79)	345 (31.28)
Moslem	136 (12.33)	91 (8.25)
Traditionalist	19 (1.72)	15 (1.36)
Atheist	2 (0.18)	1 (0.09)
Accommodation (n=1,103)			15.3095 (<0.01)* ^†
Family House	311 (28.20)	175 (15.87)
Kiosk/container	4 (0.36)	8 (0.73)
Rented apartment	144 (13.06)	99 (8.98)
Single house	181 (16.41)	165 (14.96)
Other	11 (1.00)	5 (0.45)
Health status (n=1,103)			77.8808(<0.01)*
Good	476 (43.16)	223 (20.22)
Moderate	163 (14.78)	185 (16.77)
Poor	12 (1.09)	44 (3.99)
Treatment support (n=677)			46.9866(<0.01)*
Family member	237 (35.01)	175 (25.85)
Friend	8 (1.18)	27 (3.99)
pouse	57 (8.42)	48 (7.09)
TB coordinator	69 (10.19)	14 (2.07)
TB Cadre	33 (4.87)	9 (1.33)
Occupation (n=1,103)			18.7306(0.01)*
Government employee	21(1.90)	28 (2.54)
Private employee	33 (2.99)	29 (2.63)
Student/apprentice	60 (5.44)	32 (2.90)
Trader	170 (15.41)	112 (10.15)
Unemployed	83 (7.52)	84 (7.62)
Artisan	133 (12.06)	90 (8.16)
Fishing/farming	151 (13.69)	77 (6.98)
Stigmatized (n=1,103)			19.1847(<0.01)*
No	606 (54.94)	384 (34.81)
Yes	45 (4.08)	68 (6.17)

^*Significant at 95% confidence interval.

^†Fisher’s exact test.

Predictors of depression

Multivariate analysis using modified Poisson regression with robust standard error identified several significant predictors of depression as shown in Table 4. Females demonstrated a 28% higher likelihood of depression compared to males (ARR = 1.28 [ 1.06-1.56]). Health status emerged as a critical factor, with participants reporting poor and moderate health experiencing 2.19 (ARR = 2.19 [1.64-2.92]) and 1.65 (ARR = 1.65 1.65 [1.36,2]) times higher depression risk respectively compared to those with good health. Stigma significantly influenced depression risk, with stigmatized participants showing a 52% higher likelihood of depression (ARR=1.52 [1.22-1.89]). Notably, ethnic and occupational variations revealed interesting patterns: the Grussi ethnic group demonstrated a 66% reduced depression risk (ARR=0.44 [0.2-0.99]), while traders exhibited a 25% lower depression risk compared to artisans (ARR=0.75 [0.57-0.99]). Treatment support sources revealed associations with depression risk. Friends (ARR 4.22, 95% CI 2.53-7.04), spouses (ARR=2.43 [1.47-4.03]), and family members (ARR=2.31 [1.44-3.70]) were associated with significantly higher depression risks.

Table 4.

Generalized modified poison regression models.

Independent variables	Model I						Model II
	RR	95%			Sig		ARR	95%		Sig
	RR	Lower C.I		Upper C.I	Sig		ARR	Lower C.I	Upper C.I	Sig
Age group (years)
≤20 (ref)	1	.		.			1	.	.
21-30	.76	.51		1.13			.89	.54	1.48
31-40	.73	.5		1.08			.8	.46	1.37
41-50	.75	.51		1.12			.82	.47	1.43
≥51	.9	.61		1.32			.94	.53	1.68
Gender
Male (ref)	1	.		.			1	.	.
Female	1.15	1		1.33			1.28	1.06	1.56	*
Place of residence
Rural(ref)	1	.		.			1	.	.
Sub-urban	.82	.69		.98	*		.79	.63	1.01
Urban	1.04	.88		1.23			.97	.79	1.18
Marital status
Cohabiting(ref)	1	.		.			1	.	.
Divorced/Separated	1.45	1		2.1			1.05	.54	2.01
Married	1.13	.81		1.57			.92	.51	1.66
Never married	1.02	.72		1.44			.77	.41	1.46
Widowed	1.49	1.03		2.15	*		1.11	.56	2.17
Educational level
No formal education(ref)	1	.		.			1	.	.
Primary	.87	.68		1.11			1.02	.73	1.43
JSS/JHS	1.04	.85		1.27			1.31	.99	1.74
SHS/Voc-tech	1.01	.82		1.24			1.26	.92	1.74
Tertiary	.72	.48		1.08			.72	.39	1.31
Occupation
Artisan(ref)	1	.		.			1	.	.
Fishing/farming	.84	.66		1.07			.78	.57	1.06
Government employe	1.42	1.06		1.89	*		1.56	.99	2.45
Private employee	1.16	.85		1.58			.9	.59	1.38
Student/apprentice	.86	.62		1.19			.76	.5	1.17
Trader	.98	.79		1.22			.75	.57	.99	*
Unemployed	1.25	1		1.55			.85	.62	1.17
Ethnicity
Others (ref)	1	.		.			1	.	.
Akan	.85	.66		1.1			.85	.59	1.23
Ewe	.81	.62		1.07			.93	.62	1.38
Ga/Dangme	.65	.45		.95	*		.76	.48	1.2
Gruma	.87	.53		1.43			1.07	.61	1.89
Grussi	.38	.19		.78	*		.44	.2	.99	*
Guan	1.43	.93		2.21			1.34	.82	2.2
Mande	.99	.53		1.82			.76	.38	1.52
Mole-Dagbani	.7	.51		.97	*		.82	.56	1.2
Religion
Atheist(ref)	1	.		.			1	.	.
Christian	1.23	.25		6.13			.89	.34	2.31
Muslem	1.2	.24		6.01			.91	.34	2.48
Traditionalist	1.32	.26		6.86			1	.36	2.74
Accommodation
Others (ref)	1	.		.			1	.	.
Family Compound House	1.15	.55		2.41			1.38	.67	2.82
Kiosk/container	2.13	.93		4.89	*		NC	NC	NC
Rented Flat/apartment	1.3	.62		2.74			1.33	.63	2.77
Single family home	1.53	.73		3.18			1.7	.83	3.48
Health status
Good (ref)	1	.		.			1	.	.
Moderate	1.67	1.44		1.93	*		1.65	1.36	2	*
Poor	2.46	2.07		2.93	*		2.19	1.64	2.92	*
Treatment Supporter
TB Coordinator (ref)	1	.		.			1	.	.
Family member other than Spouse	2.52	1.54		4.11	*		2.31	1.44	3.7	*
Friend	4.57	2.74		7.62	*		4.22	2.53	7.04	*
Spouse	2.71	1.61		4.57	*		2.43	1.47	4.03	*
TB Cader	1.27	.6		2.69			1.37	.65	2.91
Stigmatized
No (ref)	1	.	.			1		.	.
Yes	1.55	1.31	1.84		*	1.52		1.22	1.89	*

CI: Confidence Interval, RR: Relative Risk, ARR: Adjusted Relative Risk, NC: Non-Calculable.

^*Significant at 95% CI.

Discussion

The study aimed to investigate the prevalence and predictors of depression among PWTB in Ghana, revealing a significant depression prevalence of 41% using the PHQ-9 ≥5 threshold. This prevalence falls within the upper range of pooled estimate reported in systematic review of depression among PWTB in Ghana.⁶ The study’s outcome captures any depressive symptoms (mild through severe) rather than clinical depression alone, which is appropriate for screening in TB care settings where early identification of psychological distress can inform integrated mental health interventions and prevent progression to severe disease.

The gender dimension of depression emerged as a critical finding, with females demonstrating a 28% higher likelihood of experiencing depression compared to males. This disparity aligns with existing literature that suggests complex interactions between biological, psychological, and social factors contribute to female vulnerability to depression.¹⁴ The relationship between gender and mental health underscores the need for more gender-sensitive approaches in TB and mental health care.¹ Additionally, health status proved to be a crucial predictor of depression risk. Patients with poor health were 2.19 times more likely to experience depression, while those with moderate health status showed a 1.65 times higher depression risk compared to patients with good health. This bidirectional relationship highlights the intricate connection between physical and mental well-being.^2,3 Poor health can significantly impact mental health by limiting daily activities, reducing quality of life, and creating additional psychological stressors for PWTB.¹⁵

Stigma emerged as a particularly significant factor, with stigmatized patients experiencing a 52% higher risk of depression. This finding underscores the profound psychological impact of social marginalization and discrimination. TB-related stigma can induce feelings of shame, isolation, hopelessness, and worthlessness, creating additional mental health challenges for patients already dealing with a complex medical condition.¹⁶ Contrary to the study findingd of Gariépy and Co,¹⁷ receiving support from friends, spouses, and family members was associated with higher depression risks. This unexpected finding challenges existing assumptions about social support and suggests a more complex dynamic in how support is perceived and experienced by PWTB.

Lastly, cultural and occupational factors also played a significant role in depression risk. The Grussi ethnic group showed a 66% reduced depression risk, while traders exhibited a 25% lower depression risk compared to artisans. These variations suggest that cultural context, economic opportunities, and occupational characteristics can significantly influence psychological resilience and mental health outcomes.¹⁸

Study limitations and strengths

The study’s cross-sectional design presents limitations in establishing causal relationships between depression and identified predictors. Self-reported data may introduce recall and social desirability biases. However, the research’s strengths include a large sample size, systematic random sampling, and robust statistical analysis using modified Poisson regression, providing valuable insights into the complex landscape of depression among PWTB.

Implication for research and practice

The findings of this study carry significant implications for healthcare providers and policymakers. They highlight the urgent need to improve the integration of mental health screening into TB care services, develop targeted interventions to reduce TB-related stigma, provide comprehensive support addressing both physical and mental health needs, and create socioeconomic support programs to improve PWTBs’ overall well-being.

Conclusion and recommendation

This study highlights the high prevalence of depression among PWTB in Ghana and the need to improve gender and culturally sensitive approaches with targeted interventions to reduce TB-related stigma. Screening for depression should be a routine part of TB care, and patients with depression should be provided with appropriate counselling and support.

Supplemental material

Supplemental material - Prevalence and associated factors of depression among persons with tuberculosis in Ghana: A cross-sectional study

Supplemental material for Prevalence and associated factors of depression among persons with tuberculosis in Ghana: A cross-sectional study by Jacob Solomon Idan, Enock Ko-mati-oo Yentariba, Benjamin Spears Ngmekpele Cheabu, Jerry Amoah-Larbi, Francis Adjei Osei, Georgina Benyah, and Aliyu Mohammed in Sage Open Medicine.

Footnotes

ORCID iD

Jacob Solomon Idan

Ethical considerations

Consent to participate

Written informed consent was obtained from all participants prior to data collection, ensuring voluntary participation and full understanding of the study’s purposes and procedures. For participants with no formal education, the consent form was read aloud in the participant’s preferred language by a trained research assistant. Consent was documented via a thumbprint or witnessed mark in the presence of an independent literate witness, as approved by the Ghana Health Service Ethics Review Committee. Participant confidentiality was maintained through secure data management protocols, with all personal identifiers protected and data anonymized during analysis.

Author contributions

J.S.I and E.K.Y wrote the draft manuscript. J.S.I., E.K.Y., and B.S.N.C. played a role in the conceptualization and data analysis. J.A.-L. and F.A.O. contributed to the literature review. A.M, G.B. and J.S.I provided critical insights and contributed to manuscript revisions. All authors reviewed and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.*

Supplemental material

Supplemental material for this article is available online.

Appendix

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