Malnutrition could be defined as an imbalance between nutrients and energy supply to the cells and the bodys requirement for growth, maintenance and specific functions (1). That is, malnutrition could be over nutrition, in which case the body’s nutrients and energy supply exceeds what the body requires, or undernutrition, in which case the nutrients and energy supply does not meet the body’s demand. An example of over nutrition is obesity whiles and example of undernutrition is marasmus or kwashiorkor.
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Malnutrition is responsible for about 5.6 to 10 million child mortality annually, 1.5million of these deaths is as a results of severe malnutrition (). Nutritional status of an individual reflects the balance between the nutrients consumption and its utilization in the processes of growth, health maintenance and reproduction (). Thus, it extends from nutrient levels in the body, the end products of metabolism to the functional activities that they control ().
Undernutrition is disturbing because it is responsible for more than a third of all child deaths in developing countries (1). It blunts the mind, affects the productivity of its victims and brings about poverty (24). It is important to address the issue of undernutrition if there is any hope of achieving the Millennium Development Goals (MDGs), especially MDG 1 which is to eradicate extreme poverty and hunger. Proper nutrition helps give every child the best start in life. Beside every child has a right to adequate nutrition. However, there are a significant proportion of children who are denied this right for reasons that could easily be prevented. An estimated 13 million children under 5years globally are severely undernourished and 50% of them die from preventable causes (1). Interestingly, 99% of the child deaths occur in the developing countries (24). Up to date studies point out that, one in three children less than five years in the developing world are undernourished with sub-Saharan Africa and Asia having high rates, of 40 per cent and 35 per cent respectively (24).
Currently, it is estimated that one-third of children less than five years of age in developing countries are stunted (low height-for-age), whiles significant proportion of them, are also deficient in one or more micronutrients (24). Studies shows that, a child with severe undernutrition enrolls late in school and also affects his or her performance in school (26).This contributes significantly to the increased rates of school drop- out and undoubtedly contributing to the issue of meaningful access and educational outcome (25). This could be attributed to the fact that, the harm caused by undernutrition to children during the first two years, especially between 6 months and 24months is irreversible because it is the period of rapid brain development (25).
In order to ensure that all children achieve optimal nutrition as well as low incidence of infectious disease and infant mortality from malnutrition, it is important that we understand the factors that contributes to undernutrition (23).
CONCEPTUAL FRAME WORK OF CHILD UNDERNUTRITION.
According to the United Nations Children’s Emergency Fund (UNICEF), the theoretical outline of child malnutrition shows numerous interventions that can decrease morbidity and mortality associated with malnutrition (23). To prevent or manage malnutrition, the factors implicated needs evaluation. In addition, the various causes of malnutrition overlap, that is: immediate causes, underlying causes and basic causes (23).
Figure 1: conceptual framework of childhood undernutrition
1.2.1 IMMEDIATE CAUSES
The immediate causes of childhood malnutrition is classified as, insufficient diet as well as stress, trauma, diseases (such as HIV, TB etc) and poor psychosocial care. Poor dietary ingestion may refer to poor breastfeeding practices, early weaning, delayed introduction of complementary feed.
It is known that the stage from birth to two years of age is the significant period for the promotion of good growth, health, behavioral and cognitive development (24). Therefore, optimal infant and young child feeding is crucial during this period. Regrettably, this period (especially between 6 to 24months after birth), is often marked by growth faltering, micronutrient deficiencies as well as common childhood illnesses such as diarrhoea and acute respiratory infections (ARI) (24). The WHO therefore recommends Optimal feeding practices during this period, which involves early initiation of breastfeeding, exclusive breastfeeding during the first 6 months of life, continued breastfeeding for up to two years of age and beyond, timely introduction of complementary feeding at 6 months of age, frequency of feeding, solid/semisolid foods, and the diversity of food groups fed to children between 6 and 24months of age (1).
Exclusive breastfeeding is an excellent way of providing adequate food for a baby’s first six months of life (21). An estimated 1.4 million deaths occurs globally among under five children every year because of inadequate or suboptimum breastfeeding (22). The most recent data suggest that, in the developing world, 36 per cent of 0-5 month olds are exclusively breastfed, whiles 60 per cent of 6-8 month olds are breastfed and given complementary foods and 55 per cent of 20-23 month olds are provided with continued breastfeeding (22). Also among newborns, 43 per cent started breastfeeding within the first hour after birth (22).
Adequate complementary feeding of children from 6 months to two years is critical in preventing undernutrition. Proper timing of complementary feed introduction also helps prevent undernutrition. Early beginning of complementary food is found to be associated increased risk of acute respiratory tract infections, eye infections and high malaria morbidity. This is because, when complementary feeding is initiated, it results in reduced breastmilk consumption which could results in the loss of passive immunity from the mother to the child (23). Thus causing higher morbidity especially when unhygienic foods are used, as a results of development of diarrhoea (23). This is supported by a study done in India, which shows that growth curves weaken by 4months of life as a consequence of early initiation of complementary feeding (23). Evidence further shows that, complementary feeding practices are generally poor among developing countries, thus children continue to be vulnerable to permanent outcomes like stunting and impaired cognitive development (24).
Currently in Ghana, there is widespread child malnutrition, contributing to the continuous high child mortality (25). About 39% of all Ghanaian 2 year olds are moderately or severely stunted with the incidence rising in the Northern regions (25). Studies show that undernutrition is more prevalent in the rural than the urban areas of the country (3). Almost one in five children under age five in Ghana are underweight (18 percent) and 3% are classified as severely underweight (25). Nearly a quarter of children (22%) are stunted or too short for their age and 5 percent are wasted or too thin for their height (1).
1.2.2. UNDERLYING CAUSES:
It include inadequate levels of household food security, inadequate care of infant and children, low levels of education of mother/caregivers, inadequate health care and insanitary environment (23).
1.2.3. BASIC CAUSES OF MALNUTRITION
This is also called the root causes of malnutrition and it include deprived and control of resources (such as political, social, ideological and economic), degradation, of the environment, poor agriculture, war, political instability, urbanization, population growth and seize, distribution, conflicts, trade agreements and natural disasters, religious and cultural factors (23).
PROBLEM STATEMENT.
Globally it is estimated that 60 million children have moderate acute and 13 million have severe acute malnutrition(SAM) (23) . 50% of 10 to 11 children below five years die from preventable causes such as undernutrition (23). Studies have also shown that 9% of children in the sub-saharan Africa have moderate acute malnutrition whiles 2% of them are severely malnuhrised (23). One of the identified factors contributing to high mortality rates from undernutrition is because, only severe cases of malnutrition are reported with most of them reporting late.
According to a press released by the Central Regional Nutrition Officer on 20th September 2011, Four hundred and twenty seven (427) severe malnutrition cases among children were recorded (from January to June, last year) by the Central Region Health Administration, with Agona West having the highest of 113 followed by Upper Denkyira East with 83 cases. Eighty two percent (82%) of the cases were children from zero to two years. Fifty four per cent (54%) are females with forty six percent (46%) being males (4). According to the Ghana demographic and health survey report released in 2008, out of a total number of 246 children from the central region involved in the study, 47.8% of them had height for age below -3SD (indicating severe stunting), 22.6% had weight for age below -3SD (indicating severe wasting) and 13.7% had weight for height below -3SD (indicating severe undernutrition) (19). According to the report, out of 292 children born in the region over the period of the research, 99.3% were breastfed (19). Out of this, 55.5% of them breastfeeding was started within an hour after birth whiles 79.1% of them were breastfeed within 24hours after birth (19). The burden of undernutrition cannot be ignored when considering the health of a country, most importantly in a developing country like Ghana. Although Ghana recently attained a lower middle income country status, the prevalence of undernutrition has been persistently high. More needs to be done in terms of childhood nutrition if the millennium goals 4 is to be achieved. Undernutrition reduces an increased susceptibility to infections, slow recovery from illness and poor outcomes from simple medical conditions.
The ” critical window ” , which is the period of birth up to two years (24 months) of life, is an important period of preventing undernutrition . If undernutrition is not taken care of during this critical period, it may lead to irreversible damage for future development towards adulthood such as low intellect which may eventually affect productivity.
RATIONAL OF STUDY.
Infant and child morbidity and mortality as well as the economic ability of the country will always continue to be a problem if the nutritional status of young children(6 to24months) is overlooked.
If infant and child mortalities goes high, the government spends huge sums of money to reduce or prevent them. This could be avoided by just identifying and addressing the factors that are associated with undernutrition. For example, an inexpensive way of ensuring good child nutrition is to educate mothers to engage themselves in good child feeding practices such as exclusive breastfeeding for 6months and timely introduction of quality complementary feeding.
This study seeks to assess the nutritional status of children 6months to 24months in order to identify those who have any form of undernutrition which is indicated by stunting, wasting and underweight.
This will help identify the common factors that contributes to undernutrition so that programmes could be geared towards children 6 months to 24 months as a whole.
STUDY HYPOTHESIS:
Childhood undernutrition is influenced by socio-demographic factors, child feeding practices and the health history of child and mother/caregiver pair.
GENERAL OBJECTIVE
To assess the nutritional status of children 6months to 24months attending child welfare clinic in the cape coast metropolis and examine the factors associated with it.
SPECIFIC OBJECTIVES
The specific objectives are to:
Determine the socio demographic background of mother/caregiver and child (6 to 24 months old) pair.
Determine the nutritional status of children between the ages of 6months and 24months.
Determine the child feeding practices of mothers/ caregivers and its association with child nutritional status.
Identify the common food items used in complementary feeding of children 6 to 24months.
Determine the health history including acute (diarrhoea, respiratory tract infection, anemia and malaria) and chronic illnesses such as TB and HIV) of children between 6months and 24months and their association with undernutrition.
CHAPTER 2
2.1. INTRODUCTION
Worldwide, hunger and malnutrition are the two most significant public health challenges (23). Malnutrition increases the risk for illness and death with millions of both children and women being affected as a results of infections, poor and inadequate diet (23). Reports suggest that infants and young children are the most venerable to malnutrition because of their increased nutritional needs to support growth (23).
Nutritional disorders arise from imbalance between supply of protein-energy and the body’s demand for them to ensure optimal growth and function (23). This imbalance includes both inadequate and excessive nutrient intake; the former leading to malnutrition in the form of wasting, stunting and underweight whilst the latter results in overweight and obesity (23).
Malnutrition is often used to in place of PEM (protein energy malnutrition), which is commonly regarded and its severe forms are called marasmus, kwashiorkor and miasmic kwashiorkor (23). SAM is a term used to describe a combination of all the different forms of PEM, it refers to weight for height < 70% (which is wasted or pitting edema present in both feet) (23).
2.2. PREVALENCE OF MALNUTRITION
Globally, the nutritional status of children is improving with the exception of sub-Saharan Africa. This progress is however hindered by poverty, infection and inefficient governance (22). In a study conducted among developing countries, was second to Asia in terms of the number of children who are stunted, underweight and wasted (23).
Table 2.1. Prevalence of PEM among children under 5years in developing countries, 1995.
REGION
WASTING /%
STUNTING /%
UNDERWEIGHT /%
Africa
39
28
8
Asia
41
35
10
Latin America and Caribbean
18
10
3
Oceania
31
23
5
(Muller and krawntel, 2005). In the state of the world’s children report released in 1998, malnutrition resulted in about seven million deaths which are about 55% of all child deaths (23). Of these, three quarters are mild to moderately malnourished without obvious signs of problems (23).
According to a press released by the Central Regional Nutrition Officer on 20th September 2011, Four hundred and twenty seven (427) severe malnutrition cases among children were recorded (from January to June, last year) by the Central Region Health Administration, with Agona West having the highest of 113 followed by Upper Denkyira East with 83 cases. Eighty two percent (82%) of the cases were children from zero to two years. Fifty four per cent (54%) are females with forty six percent (46%) being males (4). In the 2008 Ghana demographic and health survey, out of a total number of 246 children from the central region involved in the study, 47.8% of them had height for age below -3SD (indicating severe stunting), 22.6% had weight for age below -3SD (indicating severe wasting) and 13.7% had weight for height below -3SD (indicating severe undernutrition) (19). In the report, out of 292 children born in the region over the period of the research, 99.3% were breastfed (19). Out of this, 55.5% of them breastfeeding was started within an hour after birth whiles 79.1% of them were breastfeed within 24hours after birth (19).
2.3. CLASSIFICATION OF MALNUTRITION
Malnutrition, defined in this context as nutritional deficiency, is a serious public health problem that has been linked to a substantial increase in the risk of mortality and morbidity. It is normally used to describe protein energy malnutrition.
Protein energy malnutrition (PEM) refers to a group of related disorders which include marasmus, kwashiorkor and marasmus-kwashiorkor (2). Marasmus involves inadequate intake of protein and calories and is characterized by emaciation or wasting (2). Kwashiorkor refers to an inadequate protein intake with reasonable caloric (energy) intake and it is characterized by edema (2). Therefore the major clinical difference between marasmus and kwashiorkor is the wasting which is seen in marasmus but absent in kwashiorkor and edema which is present in kwashiorkor but absent in marasmus. Moreover, in the intermediate state of marasmus – kwashiorkor, there is both wasting and edema. Studies suggest that marasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation (2). Children, usually present with a mixed picture of marasmus and kwashiorkor, hence the term protein- energy malnutrition is commonly used in child malnutrition (2). Patients with protein-energy malnutrition may also have deficiencies of vitamins, essential fatty acids, and trace elements (2).
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In marasmus the insufficient energy intake to match the body’s requirements causes the body draw on its own stores thus resulting in emaciation (2). In kwashiorkor, because there is adequate carbohydrate ( caloric) consumption but inadequate protein intake leads to decreased synthesis of visceral proteins (2).This result in hypoalbuminemia (low albumen in blood) which contributes to extravascular fluid accumulation as a result of reduced intravascular oncotic pressure (2). Another effect is the impaired synthesis of B-lipoprotein thus leading to a fatty liver (2). Marasmus and kwashiorkor could both be associated with impaired glucose clearance that relates to dysfunction of pancreatic β-cells (2). Protein-energy malnutrition also involves an inadequate intake of many essential nutrients such as zinc, vitamins e.t.c (2).
The WHO classifies malnutrition into moderate and severe malnutrition (23). Malnutrition is classified as severe when there is the presence of symmetrical edema (malnutrition edema), weight-for-height SD-score < -3(severe wasting), height-for- age SD-score<-3(severe stunting). Moderate malnutrition is when weight-for-height -3≤SD-score<-2 and height-for-age -3≤SD-score<-2 (23). This study uses the standard criteria for determining the nutritional status of the respondents.
2.4. ASSESSMENT OF NUTRITIONAL STATUS
The severity of malnutrition varies in terms of its clinical, biochemical and physiologic features. These features are also affected by the age of the child, nutritional deficits and infections. Diagnosis of child malnutrition is made by taking a detailed dietary history and demonstrating the presence of clinical features, which are weight loss, slow growth/ growth retardation, child’s physical activity and energy levels, the recent history of diarrhoea, immune-suppression and many other features.
The assessment of nutritional status according to weight-for-height, height-for-age and presence of nutritional edema is the WHO standard criteria for diagnosing undernutrition (1). Whilst the child with edematous malnutrition could easily be identified by most clinicians, wasting as a form of malnutrition could easily be missed if anthropometric measurements are not done. Growth assessment in terms of anthropometry is routinely done at child welfare clinics and at the end of all physical examination of a child during all hospital visits (1).
2.5. COMPLICATIONS / EFFECTS OF UNDERNUTRITION
In 2000, the WHO estimated that malnourished children numbered 181.9 million (32%) in developing countries. In addition, an estimated 149.6 million children under 5 years are malnourished when measured in terms of weight for age (2). Approximately 50% of the 10 million deaths each year in developing countries occur because of malnutrition in children under 5 years (2). In kwashiorkor, mortality tends to decrease as the age of onset increases (2). Marasmus usually occurs in children under 5years; this may be due to the fact that this period is characterized by increased energy requirements and increased susceptibility to viral and bacterial infections (2). Also weaning (the gradual withdrawal of breast milk and the commencement of nourishment with other food) occurs during this high-risk period (2). Weaning is usually complicated by geography, socio-economy, hygiene, public health, culture, and dietetics (2). Due to the complex nature of weaning, it could become ineffective when the foods introduced provide inadequate nutrients, when the food and water are contaminated, when the access to health care is inadequate, and/or when the patient cannot access or purchase proper nourishment (2).
Since low intake of calories or an inability to absorb calories is the key factor in the development of kwashiorkor, variety of syndromes could be associated with kwashiorkor (2). Clinically children would have poor weight gain or weight loss (slowing of linear growth) and behavioral changes such as, irritability, apathy (characteristically, the child is apathetic when undisturbed but irritable when picked up), decreased social responsiveness, anxiety, and attention deficit (2). In marasmus, the child appears emaciated with significant loss of subcutaneous fat and muscle wasting. Other features include; xerotic, wrinkled, and loose skin; loss of buccal fat pads given rise to what is called monkey face (2). In protein-energy malnutrition, more hairs are in the telogen (resting) phase than in the anagen (active) phase, a reverse of normal (2). Kwashiorkor typically presents with failure to thrive, edema, moon face, a swollen abdomen (potbelly), and a fatty liver (2). Skin changes are characteristic and could progress over few days, thus the skin becomes dark, dry, and then splits open when stretched, revealing pale areas between the cracks(2).
Globally, the most common cause of malnutrition is inadequate food intake (2). Preschool-aged children in developing countries are often at risk for malnutrition because of the following factors: their dependence on others for food; increased protein and energy requirements; immature immune systems causing a greater susceptibility to infection; and exposure to non-hygienic conditions (2).Another important factor is ineffective weaning as a result of ignorance, poor hygiene, socio-economic factors, and cultural factors (2). Diseases such as gastrointestinal infections can and often do precipitate clinical protein-energy malnutrition because of associated diarrhea, anorexia, vomiting, increased metabolic needs, and decreased intestinal absorption (2).
2.6. TREATMENT AND MANAGEMENT OF SEVERE UNDERNUTRITION
In the first step in the treatment of protein-energy malnutrition (PEM), which is also known as the initial phase/stabilization phase, the aim of treatment is to correct fluid and electrolyte abnormalities and to treat any infections (2). Macronutrient repletion or dietary treatment with F75 and F100 should be commenced within 48 hours under the supervision of nutrition specialists (2). Other treatment action in this stage includes, correcting hypoglycemia, hypothermia and dehydration among others. The second step in the treatment, referred to us the rehabilitation phase, may be delayed 24-48 h in children. The aim is to supply macronutrients by dietary therapy to rapidly replenish the energy stores depleted by malnutrition (2). After a week, intake rates should approach 175 kcal/kg and 4 g/kg of protein for children (2). A daily multivitamin should also be added (2).
Any child who is at risk of nutritional deficiency should be referred to a registered dietitian or other nutritional professional for a complete nutritional assessment and dietary counseling (2). Subspecialty referrals should be considered if the underlying cause is not poor nutritional intake e.g. if clinical findings indicate malabsorption, a gastroenterologist should be consulted (2). Children with poor nutrition as a result of inadequate intake and/or neglect should be referred to the appropriate social agencies to assist the family in obtaining resources and providing ongoing care for the child (2). The last phase which is ignored by most health workers is the follow up, its to be done at appropriate intervals to enable the child and mother/caregiver pair to have counseling and guidance.
2.7. CHILD MALNUTRITIONAL STUDIES
In a randomized community based trial of the effects of improved, centrally processed complementary foods on growth and micronutrient status, infants fed with weanimix had better iron stores and vitamin A status than those fed on nonfortified foods(13) . Therefore, mothers practicing complementary feeding should be encouraged to use fortified foods such as weanimix, NAN 1e.t. c. The study, however used limited food variety and also did not include simple local foods like groundnut paste, millet e.t.c.
As said by a case-control study, on “Risk factors for severe acute malnutrition in children under the age of five”, there is an association between severe acute malnutrition and inappropriate infant and young child feeding practices (16). This suggests that, adequate or proper child feeding practices could prevent childhood undernutrition. Hence efforts, aimed at reducing child undernutrition needs to emphasize the proper feeding of children.
In reference to a study on “undernution as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles”, significant proportion of deaths in young children worldwide is attributable to low weight-for-age (underweight). The study also showed, 52.5% of all deaths in young children were attributable to undernutrition, which is different form 44.8% for deaths because of measles to 60.7% for deaths because of diarrhea (). This shows that, the fight against childhood killer disease should involve the fight against undernutrition since it is a significant co-morbidity for child mortality.
A different study, on “a multilevel analysis of individual and community effect on chronic childhood malnutrition” , revealed that individual and community characteristics are important predictors of childhood malnutrition(). This indicates that, there are individual factors which are dependent on the child as well as environmental factors which are determined by the community. Thus the geographical location as well as individual traits could predispose a child to undernutrition.
Another study also revealed that, Household Food Security is inversely proportional to undernutrition (). This indicates that once food security levels in household’s increases, the prevalence of undernutrition decreases. Several factors affects food security, such factors includes; conflicts, war, political instability, famine, poor food storage systems e.t.c. In this regard, policies addressing these factors will improve food security levels in the country which will intern improve child undernutrition.
A crosectional study on “potentially modifiable micro-environmental and co-morbid factors associated with severe wasting and stunting in children “, identified social class and feeding practices as the significant risk factors associated with wasting (). This indicates that, improving the living standard of citizenry ultimately improves the incidence of childhood undernutrition.
A research on “Prevalence of Malnutrition and Effects of Maternal Age, Education and Occupation Amongst Children” showed high prevalence of stunting, medium wasting and underweight had no statistically significant association with educational level and occupation of the mothers(). Thus indicating that, mothers/caregivers do not need to have high educational level or white color job to prevent or reduce child undernutrition. Therefore, policies aimed at educating mothers/caregivers should be directed to everyone without prejudice of the person’s work or educational level.
2.8. CONCLUSION
Child undernutrition is a problem that affects individual, society, ethical, moral and political levels. Factors associated with it cuts across socio-demographic, health and geographical location.
CHAPTER 3
METHODOLOGY
3.1. Study design:
This was a crosectional study involving 100 child and mother/caregiver pair sampled from five health facilities randomly selected. The study was conducted over a one month period. Mothers/Caregivers of children between 6months and 24months old were eligible for participation and were randomly selected after they had consented.
3.2. Study setting:
The Cape Coast Metropolitan is bounded on the south by the Gulf of Guinea, west by the Komenda / Edina / Eguafo /Abrem Municipal, east by the Abura/Asebu/Kwamankese District and north by the Twifu/Hemang/Lower Denkyira District (4). The Metropolis covers an area of 122 square kilometers and is the smallest metropolis in the country and is also the capital city of the Central Region of Ghana (4). The total population of the cape coast metropolis is 217,032 with a population growth rate of3.1%(5).
Generally, there are two rainy seasons in the metropolis (4). The peak of the major season is in June (4). The vegetation is divided into dry coastal savanna stretching about 15 km inland, and a tropical rain forest with various reserve areas (5). The major economic activities are agriculture andfishing (5).
3.3. Samples seize:
The formular used in calculating the sample seize is:
Sample Size = n
[1 + (n/population)]
Where n = Z Ã- Z [P (1-P)/(DÃ-D)]
P = True proportion of factor in the population, or the expected frequency value
D = Maximum difference between the sample mean and the population mean,
Or Expected Frequency Value minus (-) Worst Acceptable Value
Z = Area under normal curve corresponding to the desired confidence level
The prevalence of undernutrition among children under 5 years in Ghana was 28.60% at the end .of 2008 (3). The population of children between 6months and 24 months of age registered at the health facilities within the cape coast metropolis, attending child welfare clinic is 238. The desired confidence level used was 95% with the value of Z = 1.960, from the confidence level. The confidence limit (D) of 4% (i.e. ±4).
Hence, n= 1.960Ã-1.960[0.286 (1-0.286)/(0.04Ã-0.04)] = 489.804
Therefore sample seize = 489.804 = 160.1714
[1+(489.804/238)]
Hence the sample seize was ~ 160.
3.4. Sampling:
There are ten health facilities within the cape coast metropolitan catchment area. These ten health facilities include both rural and urban Health centers, CHIP centers, University hospital, Metropolitan hospital and a Regional hospital. These health facilities were subjected to random selection and five of them were selected to participate in the study. The random selection was done by assigning all the facilities to numbers and these numbers were written separately on small sheets of papers and folded. Five different individuals, who are have no idea about the study nor were the health facilities involved, at separate times asked to pick one of the folded papers. All the health facilities had equal chance of selection. The selected health facilities included the Central Regional Hospital, Akotokyire CHPS Center, Adisadel Urban Health Ce
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