The manuscript presents findings of a descriptive analysis of data from a cross-sectional study of adolescents aimed at identifying their family planning needs and the best approaches to addressing them in the Kintampo Districts of Ghana. Data for the paper were from the family planning module of a sexual and reproductive health survey carried out by the Kintampo Health and Demographic Surveillance System in 2011. Adolescents in this study recorded high marital (1.6% females and 0.4% males) and pregnancy rates (11.5% females and 1.5% males). Their knowledge of contraceptive methods was high (87.7% females and 82% males), but utilization was low (17.9% females and 6% males). Most study participants viewed family planning as important to their health and wellbeing (59.6% females and 58.6% males). A minority of adolescents were of the perception that contraceptive use was solely the responsibility of women (41.1% females and 32.4% males); and that the use of contraceptives could lead to promiscuity among women (43.8% females and 42.5% males). Those adolescents who previously had unwanted pregnancies would have accepted some help in preventing it (33.1% females and 9.1% males). Recommendations made by respondents included creating a friendly atmosphere by care providers for family planning services delivery to adolescents. Other suggestions were ensuring that family planning services are available and accessible to adolescents, and educating adolescents on the diverse methods available.
Adolescence is the period between the ages of 10 and 19 years when young individuals transition into adulthood [
Family planning (FP) aims at empowering persons to anticipate and attain the number of children they desire whilst spacing and timing their births appropriately [
The total fertility rate (TFR) in Ghana has risen to 4.3 in 2011 [
Pregnancies and births among adolescents are mostly unplanned and are associated with higher maternal and infant complications/mortality as compared with those in older women [
In the midst of such high levels of adolescent pregnancies, contraceptive use in Ghana remains low among this population. The knowledge of at least one type of contraceptive was generally low among adolescents aged 15 to 19 years [
The study’s objective was to identify the FP needs of the adolescent population in the Kintampo North and South Districts in Ghana and to define the best approach to satisfying these needs.
The Kintampo Health and Demographic Surveillance System (KHDSS), administered by the Kintampo Health Research Centre (KHRC), regularly collects information on the health and demographic needs of residents from the Kintampo North and South Districts in the Brong Ahafo Region of Ghana [
The study was cross-sectional, with a mixed methods design and data collected from multi-informant sources. Data collection included the use of structured questionnaires consisting of close-ended questions administered to study participants in the study area. The survey was designed to allow for a reliable estimation of SRH behavior, contraception knowledge and use, fertility preferences, and knowledge and prevalence of self-reported sexually transmitted infections (STIs) within the study population.
Data for this paper was extracted from the FP module of the SRH survey. Relevant information on adolescents’ FP needs and their views on FP with respect to personal health and wellbeing were collated.
The questions in the module were adapted from the 2008 Ghana Demographic and Health Survey (GDHS) [
A total of 2641 adolescents (10 to 19 years of age) were sampled based on a contraceptive prevalence of 23% [
Data was double entered into Microsoft FoxPro with verification and consistency checks applied. The data was then verified for accuracy and transferred to STATA 11.0 for analysis. The main themes analyzed were FP needs of adolescents and FP’s importance to their health and wellbeing. Means, medians and proportions were used to describe characteristics and responses of respondents.
The Kintampo Health Research Centre Institutional Ethics Committee (KHRC IEC) approved the study ahead of its implementation. Considering that FP research involves asking respondents about their sexual behaviors and practices, which may cause some level of embarrassment to respondents, we ensured that the respondents were primed and educated on the sensitive issues envisaged in the questionnaires. They were only interviewed after they had thoroughly understood the essence and content of the survey, asked questions that were answered to their satisfaction and assented or consented to be part of the study. For persons under 18 years of age who assented, a parent or guardian consented as well on their behalf. Confidentiality of data collected was maintained by storing them at the secured KHRC data bank.
After data cleaning, 2128 out of an estimated 2641 adolescents sampled (80.6% response rate) were included in the data analysis. These consisted of 1415 (66.5%) females and 713 (33.5%) males.
At the time of the study, 388 (27.4%) female and 63 (8.8%) male adolescents were sexually active; with a fifth of females’ [70 (18.0%)] and a fourth of males’ [16 (26.1%)] first sex occurring in early adolescence. The median age at first sex (the first time in their lives they ever performed a sexual act) and marriage was 16 for both genders. Median age at first birth was 17 for females and 16 for males. It is also worth noting that an overwhelming majority of early adolescents [407 (98.5%) females and 423 (98.6% males)] had not had sex at the time of the survey.
Females recorded more pregnancies [168 (11.9%) to 11 (1.5%)] and births (11% to 1.4%) than males, with most
Female n (%) | Male n (%) | |||||
---|---|---|---|---|---|---|
10 - 14 (n = 413) | 15 - 19 (n = 1002) | 10 - 19 (n = 1415) | 10 - 14 (n = 429) | 15 - 19 (n = 284) | 10 - 19 (n = 713) | |
Place of residence | ||||||
Rural | 285 (69.1) | 624 (62.3) | 910 (64.3) | 299 (69.8) | 196 (69.1) | 496 (69.5) |
Urban | 128 (30.9) | 378 (37.7) | 505 (35.7) | 130 (30.2) | 88 (30.9) | 217 (30.5) |
District of residence | ||||||
Kintampo North | 245 (59.3) | 623 (62.2) | 867 (61.3) | 262 (61.1) | 173 (60.9) | 435 (61.0) |
Kintampo South | 168 (40.7) | 379 (37.8) | 548 (38.7) | 167 (38.9) | 111 (39.1) | 278 (39.0) |
Current educational attainment | ||||||
No education | 142 (34.4) | 77 (7.7) | 219 (15.5) | 142 (33.1) | 19 (6.7) | 161 (22.6) |
Primary | 264 (63.9) | 580 (57.9) | 844 (59.6) | 274 (63.9) | 194 (68.3) | 468 (65.6) |
JHS & higher | 2 (0.5) | 334 (33.3) | 336 (23.7) | 8 (1.9) | 69 (24.3) | 77 (10.8) |
*Missing | 5 (1.2) | 11 (1.1) | 16 (1.2) | 5 (1.1) | 2 (0.7) | 7 (1.0) |
Marital status | ||||||
Married | 1 (0.2) | 22 (2.2) | 23 (1.6) | 0 (0.0) | 3 (1.1) | 3 (0.4) |
Living together | 1 (0.2) | 170 (17.0) | 171 (12.1) | 1 (0.2) | 16 (5.6) | 17 (2.4) |
Divorced | 0 (0.0) | 3 (0.3) | 3 (0.2) | 0 (0.0) | 1 (0.4) | 1 (0.1) |
Separated | 0 (0.0) | 20 (2.0) | 20 (1.4) | 0 (0.0) | 1 (0.4) | 1 (0.1) |
Never being in a relationship | 404 (97.8) | 776 (77.4) | 1180 (83.4) | 427 (99.5) | 262 (92.3) | 689 (96.6) |
Missing | 7 (1.7) | 11 (1.1) | 18 (1.3) | 1 (0.2) | 1 (0.4) | 2 (0.3) |
*Missing-missing values.
of them occurring in late adolescence [167 (16.7% to 8 (2.8%)]. A third [60 (35.5%)] of ever-pregnant females and about a fifth [2 (18.2%)] of males were not ready for a pregnancy (the pregnancy was unintended); most of those who were not ready for a pregnancy [56 (33.1% females) and 1 (9.1% males)] would have accepted help in the form of FP methods to prevent it (
Knowledge of any method and modern methods of contraception was the same across age ranges and marital status, whereas their utilization varied (
Both females and males (48.6% and 33.9% respectively) had less knowledge of traditional methods. Early adolescents knew and utilized less of all the forms of contraception. Adolescents who had been in a relationship had higher levels of knowledge and use of contraceptives than those who had never been in any relationships (and were not sexually active).
Sexually active adolescents in no relationships had the highest level of knowledge of FP methods. Contraceptive use was higher among males in relationships than their female counterparts.
Family planning method use was low for sexually active adolescents (9.1% currently and 10.9% at last sex). FP use by late adolescents was higher than that of early adolescents. Adolescents in relationships and those who were sexually active recently utilized FP methods more than those not in relationships.
At their last sexual activity, most females (41.1%) used no FP methods, 20.9% used the male condom, 16.6%
Female n (%) | Male n (%) | |||
---|---|---|---|---|
Not ready for pregnancy n = 168 | Accept help to prevent pregnancy n = 168 | Not ready for pregnancy n = 11 | Accept help to prevent pregnancy n = 11 | |
Age range | ||||
10 - 14 | 1 (50.0) | 1 (50.0) | 0 (0.0) | 0 (0.0) |
15 - 19 | 59 (35.3) | 55 (32.9) | 2 (25.0) | 1 (12.5) |
10 - 19 | 60 (35.5) | 56 (33.1) | 2 (18.2) | 1 (9.1) |
Marital status | ||||
Never being in a relationship | 17 (44.7) | 16 (42.1) | 0 (0.0) | 0 (0.0) |
Married/living together | 40 (34.5) | 36 (31.0) | 2 (40.0) | 1 (20.0) |
Widowed/divorced/separated | 3 (20.0) | 4 (26.7) | 0 (0.0) | 0 (0.0) |
Total | 60 (35.5) | 56 (33.1) | 2 (18.2) | 1 (9.1) |
Never being in a relationship but recently sexually active | 4 (50.0) | 3 (37.5) | 0 (0.0) | 0 (0.0) |
Note: Percentages are based on females who have ever been pregnant and males who have ever impregnated a woman.
Female n (%) | Male n (%) | |||||
---|---|---|---|---|---|---|
Heard of any method n = 1415 | Heard of any modern method n = 1415 | Heard of any traditional method n = 1415 | Heard of any method n = 713 | Heard of any modern method n = 713 | Heard of any traditional method n = 713 | |
Age range | ||||||
10 -14 | 300 (72.6) | 300 (72.6) | 71 (17.2) | 315 (73.4) | 315 (73.4) | 77 (17.9) |
15 - 19 | 941 (93.9) | 941 (93.9) | 617 (61.6) | 270 (95.1) | 270 (95.1) | 165 (58.1) |
10 - 19 | 1241 (87.7) | 1241 (87.7) | 688 (48.6) | 585 (82.0) | 585 (82.0) | 242 (33.9) |
Marital status | ||||||
Never being in a relationship | 1024 (86.8) | 1024 (86.8) | 517 (43.8) | 563 (81.7) | 563 (81.7) | 223 (32.4) |
Married/living together | 191 (99.0) | 191 (99.0) | 152 (78.8) | 19 (95.0) | 19 (95.0) | 17 (85.0) |
Widowed/divorced/separated | 23 (100.0) | 23 (100.0) | 18 (78.3) | 2 (100.0) | 2 (100.0) | 2 (100.0) |
NK/NA/Missing | 3 (15.8) | 3 (15.8) | 1 (5.3) | 1 (50.0) | 1 (50.0) | 0 (0.0) |
Total | 1241 (87.7) | 1241 (87.7) | 688 (48.6) | 585 (82.0) | 585 (82.0) | 242 (33.9) |
Never being in a relationship but recently sexually active | 86 (100.0) | 86 (100.0) | 73 (84.9) | 23 (100.0) | 23 (100.0) | 18 (78.3) |
used the rhythm method, 13.8% the pill and 3.6% the injectable. In contrast to what they used, females preferred the injectable (35.2%), followed by the pill (20.6%), and close to a fifth of them (19.4%) preferred no methods at all. Males at the last sexual act used the male condom (65.1%) and withdrawal method (2.3%), but a fourth (25.1%) of them used no method at all.
Majority of females (53.6%) were intent on using a method in the future, with late adolescents predominating (59.9%). Those who were in relationships (87%) were more intent on future use than those not in relationships (50.8%).
Male late adolescents (71.5%) were much more aware of places they could access condoms than the younger ones (40.8%) (
Female n (%) | Male n (%) | |||||
---|---|---|---|---|---|---|
Used any method n = 1415 | Used any modern method n = 1415 | Used any traditional method n = 1415 | Used any method n = 713 | Used any modern method n = 713 | Used any traditional method n = 713 | |
Age range | ||||||
10 -14 | 4 (1.0) | 3 (0.7) | 3 (0.7) | 3 (0.7) | 2 (0.5) | 1 (0.2) |
15 - 19 | 249 (24.9) | 191 (19.1) | 156 (15.6) | 40 (14.1) | 37 (13.0) | 18 (6.3) |
10 - 19 | 253 (17.9) | 194 (13.7) | 159 (11.2) | 43 (6.0) | 39 (5.5) | 19 (2.7) |
Marital status | ||||||
Never being in a relationship | 101 (8.6) | 70 (5.9) | 66 (5.6) | 26 (3.8) | 22 (3.2) | 11 (1.6) |
Married/living together | 139 (72.0) | 113 (58.5) | 86 (44.6) | 15 (75.0) | 15 (75.0) | 7 (35.0) |
Widowed/divorced/separated | 12 (52.2) | 10 (43.50 | 6 (26.1) | 2 (100.0) | 2 (100.0) | 1 (50.0) |
NK/NA/Missing | 1 (5.3) | 1 (5.3) | 1 (5.3) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Total | 253 (17.9) | 194 (13.7) | 159 (11.2) | 43 (6.0) | 39 (5.5) | 19 (2.7) |
Never being in a relationship but recently sexually active | 47 (54.7) | 38 (44.2) | 28 (32.6) | 13 (56.5) | 12 (52.2) | 6 (26.1) |
Female n (%) | Male n (%) | ||||
---|---|---|---|---|---|
Currently using a method n = 1415 | Used a method at last sex n = 1415 | Intention to use in the future n = 1415 | Knows where to get condoms n = 713 | Used a method at last sex n = 713 | |
Age range | |||||
10 -14 | 0 (0.0) | 1 (0.2) | 158 (38.3) | 175 (40.8) | 1 (0.2) |
15 - 19 | 129 (12.9) | 153 (15.3) | 600 (59.9) | 203 (71.5) | 24 (12.0) |
10 - 19 | 129 (9.1) | 154 (10.9) | 758 (53.6) | 378 (53.0) | 35 (4.9) |
Marital status | |||||
Never being in a relationship | 49 (4.2) | 65 (5.5) | 599 (50.8) | 359 (52.1) | 23 (3.3) |
Married/living together | 74 (38.2) | 82 (42.5) | 138 (71.5) | 17 (85.0) | 10 (50.0) |
Widowed/divorced/separated | 5 (21.7) | 6 (26.1) | 20 (87.0) | 2 (100.0) | 2 (100.0) |
NK/NA/Missing | 1 (5.3) | 1 (5.3) | 1 (5.3) | 0 (0.0) | 0 (0.0) |
Total | 129 (9.1) | 154 (10.9) | 758 (53.6) | 378 (53.0) | 35 (4.9) |
Never being in a relationship but recently sexually active | 27 (31.4) | 34 (39.5) | 65 (75.6) | 23 (100.0) | 14 (60.9) |
Radio was the main source of information on FP (29.1% for females and 30.1% for males), followed by television (19.9% females and 15.4% males) and socializing [Socializing is defined as taking part in activities such as fetching of water from outside the compound, going to farm or market, or visiting the hairdresser or the seamstress for females and for males included playing indigenous indoor games like draught, ludo and oware or visiting alcohol drinking spots in the community] (19.1% females and 10.7% males) in the 3 months preceding the survey.
With the exception of early adolescents and males who had never been in a relationship but were recently sexually active, a majority of each category of respondents agreed on the importance of FP in reducing unwanted pregnancies, reducing STI risk, improving maternal and child health, reducing maternal deaths, and ultimately improving the health and well-being of individuals (
Females n (%) | |||||
---|---|---|---|---|---|
Reduce unwanted pregnancies (n = 1415) | Reduce STI risk (n = 1415) | Improve MCH (n = 1415) | Reduce maternal deaths (n = 1415) | Improve health and well-being (n = 1415) | |
Age range | |||||
10 -14 | 162 (39.2) | 112 (27.1) | 167 (40.4) | 139 (33.7) | 173 (41.9) |
15 - 19 | 743 (74.2) | 489 (48.8) | 662 (66.1) | 598 (59.7) | 670 (66.9) |
10 - 19 | 905 (64.0) | 601 (42.5) | 829 (58.6) | 737 (52.1) | 843 (59.6) |
Marital status | |||||
Never being in a relationship | 719 (60.9) | 483 (40.9) | 670 (56.8) | 586 (49.7) | 674 (57.1) |
Married/living together | 163 (84.5) | 102 (52.8) | 138 (71.5) | 133 (68.9) | 147 (76.2) |
Widowed/divorced/separated | 20 (87.0) | 14 (60.9) | 19 (82.6) | 16 (69.6) | 20 (87.0) |
NK/NA/Missing | 3 (15.8) | 2 (10.5) | 2 (10.5) | 2 (10.5) | 2 (10.5) |
Total | 905 (64.0) | 601 (42.5) | 829 (58.6) | 737 (52.1) | 843 (59.6) |
Never being in a relationship but recently sexually active | 77 (89.5) | 56 (65.1) | 72 (83.70 | 65 (75.6) | 71 (82.6) |
Males n (%) | |||||
---|---|---|---|---|---|
Reduce unwanted pregnancies (n = 713) | Reduce STI risk (n = 713) | Improve MCH (n = 713) | Reduce maternal deaths (n = 713) | Improve health and well-being (n = 713) | |
Age range | |||||
10 -14 | 202 (47.1) | 150 (35.0) | 201 (46.9) | 181 (42.2) | 207 (48.3) |
15 - 19 | 212 (74.6) | 143 (50.4) | 204 (71.8) | 190 (66.9) | 211 (74.3) |
10 - 19 | 414 (58.1) | 293 (41.1) | 405 (56.8) | 371 (52.0) | 418 (58.6) |
Marital status | |||||
Never being in a relationship | 397 (57.6) | 283 (41.1) | 386 (56.0) | 760 (51.5) | 399 (57.9) |
Married/livingtogether | 15 (75.0) | 10 (50.0) | 17 (85.0) | 15 (75.0) | 17 (85.0) |
Widowed/divorced/separated | 2 (100.0) | 0 (0.0) | 2 (100.0) | 1 (50.0) | 2 (100.0) |
NK/NA/Missing | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Total | 414 (58.1) | 293 (41.1) | 405 (56.8) | 371 (52.0) | 418 (58.6) |
Never being in a relationship but recently sexually active | 22 (95.7) | 14 (60.9) | 20 (87.0) | 20 (87.0) | 22 (95.7) |
Females n (%) | |||||
---|---|---|---|---|---|
Women’s responsibility (n = 1415) | Makes women promiscuous (n = 1415) | Many children dangerous (n = 1415) | Better not to have more children (n = 1415) | Smaller families succeed (n = 1415) | |
Age range | |||||
10 -14 | 127 (30.8) | 119 (28.8) | 235 (56.9) | 286 (69.2) | 257 (62.2) |
15 - 19 | 455 (45.4) | 501 (50.0) | 773 (77.1) | 897 (89.5) | 823 (82.1) |
10 - 19 | 582 (41.1) | 620 (43.8) | 1008 (71.2) | 1183 (83.6) | 1080 (76.3) |
Marital status | |||||
Never being in a relationship | 458 (38.8) | 502 (42.5) | 829 (70.3) | 974 (82.5) | 886 (75.1) |
Married/living together | 111 (57.5) | 102 (53.0) | 157 (81.3) | 184 (95.3) | 171 (88.6) |
Widowed/divorced/separated | 10 (43.5) | 15 (65.2) | 19 (82.6) | 22 (95.7) | 20 (87.0) |
NK/NA/Missing | 3 (15.8) | 1 (5.3) | 3 (15.8) | 3 (15.8) | 3 (15.8) |
Total | 582 (41.1) | 620 (43.8) | 1008 (71.2) | 1183 (83.6) | 1080 (76.3) |
Never being in a relationship but recently sexually active | 38 (44.2) | 48 (55.8) | 75 (87.2) | 84 (97.7) | 76 (88.4) |
Males n (%) | |||||
---|---|---|---|---|---|
Women’s responsibility (n = 713) | Makes women promiscuous (n = 713) | Many children dangerous (n = 713) | Better not to have more children (n = 713) | Smaller families succeed (n = 713) | |
Age range | |||||
10 -14 | 130 (30.3) | 155 (36.1) | 247 (57.6) | 303 (70.6) | 278 (64.8) |
15 - 19 | 101 (35.6) | 148 (52.1) | 208 (73.2) | 246 (86.6) | 231 (81.3) |
10 - 19 | 231 (32.4) | 303 (42.5) | 455 (63.8) | 549 (77.0) | 509 (71.4) |
Marital status | |||||
Never being in a relationship | 224 (32.5) | 296 (43.0) | 436 (63.3) | 528 (76.6) | 493 (71.6) |
Married/living together | 7 (35.0) | 6 (30.0) | 17 (85.0) | 19 (95.0) | 14 (70.0) |
Widowed/divorced/separated | 0 (0.0) | 1 (50.0) | 2 (100.0) | 2 (100.0) | 2 (100.0) |
NK/NA/Missing | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Total | 231 (32.4) | 303 (42.5) | 455 (63.8) | 549 (77.0) | 509 (71.4) |
Never being in a relationship but recently sexually active | 9 (39.1) | 18 (78.3) | 18 (78.3) | 21 (91.3) | 15 (95.7) |
Most respondents viewed having many children as dangerous to a woman’s health; thought it was better not to have many children and that smaller families were more likely to succeed in life.
Marital rates among adolescents in the study population seem to be higher than observed in other parts of Ghana, Benin and Burundi, but lower than in Nigeria, Burkina Faso, Cameroon, Central African Republic, Congo, Cote D’Ivoire and Ethiopia among others [
Though a minority, some amount of sexual activity occurred in early adolescence as observed by this study. Cases of adolescents being sexually active before their 15th birthday were identified from surveys across sub-Saharan Africa and beyond [
Though it is known that most of the pregnancies among adolescents are unwanted like occurred in this study, an interesting observation made was that respondents would have accepted FP services to help prevent them. Several births to mothers below 20 years of age in sub-Saharan Africa are either not wanted at all or wanted later; unwanted pregnancies were as high as 80% in South Africa and as low as 11% in Niger [
The study population exhibited a higher knowledge of FP methods in contrast to their use [
Prominent sources of FP information in the study communities were the electronic media, radio and television as identified by other published works [
Adolescents in this study generally viewed FP as important to the health and wellbeing of individuals. Health and wellbeing programs could therefore serve as a window of opportunity for the introduction of FP programs. It is however important to address the less favourable concerns of some early adolescents and the never married with respect to them perceiving FP as being the responsibility of women and that it fuels promiscuity.
In spite of the sensitive nature of some information collected, there were no records of persons approached for interviews refusing participate in the study. This probably could be attributed to the study participants’ urge to bring out issues of importance to them that hitherto had remained unaddressed.
This was a cross-sectional study to access the situation on the ground to advise further investigations and action on FP care to adolescents.
1) Study findings point to the fact that adolescents in the study communities have FP needs that should be addressed―Pregnancy rates were high, contraceptive use was low, preferred methods such as injectables were not accessible to them and those with prior pregnancies would have accepted help to prevent them. The following recommendations are made to stakeholders involved in FP service delivery to adolescents:
2) Healthcare policy makers―Aside age appropriate sexual health education, FP education and services should be accessible to early adolescents at risk of engaging in sex and those in non-marital relationships. Encourage the training of peer educators in FP programs to enhance information dissemination among adolescents. Ensure policies and other measures to enhance access of adolescents to diverse FP methods including the injectable and pill so as to satisfy their preferences.
3) Healthcare providers―Providers should educate adolescents on diverse FP methods including the injectable and pills; and ensure their accessibility. Providers should take advantage of social gatherings of adolescents to deliver FP education messages. FP messages could be introduced when providing talks on overall health and wellness. Providers should have a friendly approach to adolescents (both early and late) who seek help, and be preemptive in providing FP methods to adolescents (early and late) who might require them but are not be bold to demand them.
4) The research community―Collaborate with service providers, educators, adolescents and the community in defining appropriate sex education programs to accommodate early adolescents at risk of pregnancy. Design studies that further investigate associations between these findings and others to provide evidence based approaches to facilitate FP programs uptake by adolescents.
We thank the Director and staff of KHRC for the support provided for the study. We also thank the study subjects without whom these findings would not have been possible and lastly the Sexual and Reproductive Health (SRH) Team of the KHRC that worked tirelessly to on the study to promote the health needs of the community.
This work was supported by the MEASURE Evaluation PRC, Chapel Hill, North Carolina under the USAID Cooperative agreement # GPO-A-00-09-00003-00. The main funding of the study was from the Kintampo Health and Demographic Surveillance System (KHDSS).