Social Factors Influencing Child Health in Ghana

Objectives Social factors have profound effects on health. Children are especially vulnerable to social influences, particularly in their early years. Adverse social exposures in childhood can lead to chronic disorders later in life. Here, we sought to identify and evaluate the impact of social factors on child health in Ghana. As Ghana is unlikely to achieve the Millennium Development Goals’ target of reducing child mortality by two-thirds between 1990 and 2015, we deemed it necessary to identify social determinants that might have contributed to the non-realisation of this goal. Methods ScienceDirect, PubMed, MEDLINE via EBSCO and Google Scholar were searched for published articles reporting on the influence of social factors on child health in Ghana. After screening the 98 articles identified, 34 of them that met our inclusion criteria were selected for qualitative review. Results Major social factors influencing child health in the country include maternal education, rural-urban disparities (place of residence), family income (wealth/poverty) and high dependency (multiparousity). These factors are associated with child mortality, nutritional status of children, completion of immunisation programmes, health-seeking behaviour and hygiene practices. Conclusions Several social factors influence child health outcomes in Ghana. Developing more effective responses to these social determinants would require sustainable efforts from all stakeholders including the Government, healthcare providers and families. We recommend the development of interventions that would support families through direct social support initiatives aimed at alleviating poverty and inequality, and indirect approaches targeted at eliminating the dependence of poor health outcomes on social factors. Importantly, the expansion of quality free education interventions to improve would-be-mother’s health knowledge is emphasised.


Introduction
Social determinants of health include the conditions in which people are born, live, work and grow, as well as measures that are put in place to curb illness [1]. The distribution of money, social resources, economies and political power shape these conditions at the national, regional and local levels [2]. Although earlier studies focused mainly on investigating social class and family income, recent studies have broadened the boundaries of what constitutes social determinants of health [1,3]. Social class encompasses factors influencing health and extends beyond simple measures of occupation and income; it includes family wealth, health literacy, education, employment, degree of autonomy in one's job and quality of housing [2]. Ethnicity is also regarded as a social determinant although emphasis is usually placed on substructures defined by race, culture, family structure and gender [4]. Additionally, social relationships influence health and are therefore included in social determinant frameworks through constructs such as social support networks, social cohesion and social exclusion [5]. Furthermore, aspects of the natural environment such as climate change and the quality of water, air and soil are sometimes classified as determinants of child health [2,3]. It has been reported, for example, that infection by helminth (a free-living organism in aquatic and terrestrial environments) during pregnancy could affect motor and cognitive development (due to poor nutrition) among oneyear-old infants [6]. However, the prescription of antihelminthics and vitamins to pregnant women in such environments during antenatal care can help to reduce anaemia by increasing haemoglobin concentration through to delivery and improving motor functions among their children [7]. This approach might be a good way to fight against childhood motor neuron diseases including Werdnig-Hoffmann disease, which can impair motor development and muscle movement later in life [8].
Scientists have been unable to provide a simple biological reason why the life expectancy at birth for men in the Calton region of Glasgow, Scotland, is fifty-four years, whereas that of men in Lenzie, just a few kilometres away, is eighty-two years, and why infant mortality rate among babies born to Bolivian women with no education is more than 100 per 1000 births compared with the less than 40 per 1000 babies born to women with at least secondary school education in the same country [1,2]. Evidence suggests that disparities of this nature could be reduced by improving the social environments within which people live and work [9]. Moreover, the rapid increase in the prevalence of diseases such as obesity is widely believed to be driven primarily by changes in lifestyle patterns [1,3]. However, in spite of the global interest in equity and social justice, knowledge on the social determinants of health has not yet resulted in the expected policy changes it deserves [3].
With early life events known to exert strong influences on health status in childhood and beyond, many child health researchers now consider a wide range of early life exposures in research on social determinants: these include caregiving and quality of parenting, maternal depression, home organisation, exposure to domestic violence and neighbourhood safety [3]. Humans possess a great deal of plasticity during the early years of life, helping to ensure rapid responses to changing environmental factors. This also makes children particularly susceptible to both positive and negative exposures [3]. Thus, when exposed to adversity, some of the ensuing changes can be maladaptive, potentially leading to bigger problems in adulthood [10]. For instance, depressed mothers are less attentive and sensitive to their newborns, failing to appropriately respond to the babies' emotional signals [11]. Some encephalography studies have shown that such infants do not only develop shorter attention spans due to decreased frontal cortex activity but they also record persistent elevated heart rates and cortisol levels, which reprogramme their internal "set point" to stress, and increase their risk of developing hypertension and coronary artery disease later in life [11][12][13]. Consequently, seemingly harmless and avoidable risks such as maternal depression could disturb human development and exert deleterious effects on lifelong health [3]. As Ghana is unlikely to achieve the Millennium Development Goals' target of reducing child mortality by two-thirds between 1990 and 2015 [14], it is necessary to identify social determinants that might have contributed to the non-realisation of this goal. This would help towards the achievement of current and future plans (such as the Ghana national newborn health strategy and action plan, which hopes to help reduce neonatal mortality from 3.2% in 2014 to 2.1% in 2018 [15]). Here, we examined the published literature in this area in order to identify social factors influencing child health in the country.

Methodology
We systematically reviewed the available literature for studies investigating social factors and their influence on child health in Ghana. The review process conformed to guidelines outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [16].

Eligibility Criteria, Data Sources and Search Strategy
Cross-sectional, retrospective and case-control studies on Ghanaian participants published in peer-reviewed journals were considered for inclusion. For the purposes of this systematic review, a "child" was defined as a person below the age of five years. ScienceDirect, PubMed, MEDLINE via EBSCO and Google Scholar were searched for published articles reporting on the influence of social factors on child health in Ghana. The search terms used included: "social determinants", "child health", "social factors influencing health" and "social determinants of child health" in combination with "Ghana", "West Africa" or "sub-Saharan Africa". As an example, the PubMed search strategy was: (("social determinants of child health Ghana" [MeSH Terms] OR "child health" [All Fields] AND "social determinants Ghana" [All Fields]) OR ("child health" [All Fields] AND "social determinants" [All Fields] AND "Ghana" [All Fields]) OR ("social factors influencing health Ghana" [MeSH Terms]) OR ("social factors" [All Fields] AND "health" [All Fields] AND "Ghana" [All Fields]) OR ("infant" [MeSH Terms] OR "adolescent" OR "child" AND "West Africa" [All Fields])). The identified articles were evaluated using their titles, abstracts and full texts to select those that would fit our inclusion criteria (Fig 1). The references cited in the identified articles were also scanned for potentially useful articles that might have been missed during our search. The inclusion criteria were that the study must (i) have reported on social determinants of health on child health, (ii) have been conducted in Ghana or focused on Ghana, and (iii) have been indexed in the databases up until 30 th May, 2015. Apart from not meeting the inclusion criteria given above, studies were also excluded if they focussed entirely on discussing the health of individuals older than five years.

Study Selection and Data Assessment
All articles meeting the criteria outlined above were selected for further analyses. Studies reporting on social determinants of health in Ghana but focused on maternal, paternal or general health rather than child health were excluded. No restrictions were made in terms of study design, although duplicates and studies conducted outside Ghana were excluded. Fig 1 illus-trates the article-selection process which followed the PRISMA guidelines (S1 PRISMA Checklist). Information extracted included publication data, study settings, study design, sample characteristics, key findings and identified social determinants.

Results and Discussion
Study selection and characteristics, and findings from individual studies A total of 98 citations were obtained from the literature search. After removing entries that did not meet the inclusion criteria, the final selection included 34 publications. The major social determinants frequently reported included maternal education, rural-urban disparities, family income and high dependency (Tables 1 and 2). Other determinants of health identified were maternal age at birth, birth interval, father's participation in childcare, alcohol and drug use by parents, childcare practices, cultural beliefs, child malnutrition, nucleation as well as training of healthcare personnel. We observed that most of these factors rarely acted in isolation; they rather usually acted in combination. With regards to this, the determinants identified in 27 articles were clustered into multiple interacting factors. Studies reporting on these aspects were published between 1988 and 2015. Twenty of these studies analysed data from nationally-representative samples, with the remaining examining data from various regions of the country, namely Eastern (2 studies), Northern (2 studies), Ashanti (3 studies), Greater Accra (2 studies), Volta (1 study), Central (1 study) and Upper East (1 study) regions. Additionally, one study was conducted among participants in the Volta and Eastern regions while another was done in the Ashanti and Eastern regions. The rest examined government policies. An intriguing aspect of the social determinants reported is that they appeared to be important for almost every disease studied. The health conditions associated with these factors included infant or child mortality, nutritional status of children, seeking treatment after burns, completion of immunisation programmes, health seeking and hygiene practices. The influence of each of the reported social determinants on child health has been discussed in Table 2

Impact of the Identified Social Determinants on Child Health in Ghana
Maternal Education. Infants are often reliant on mothers for their interactions with the environment [3]. From 1988 till date, many studies have looked at how maternal education affects the wellbeing of children in Ghana (Fig 2). In 1988, it was reported that child mortality was sensitive to maternal education [28]. However, the rate of child mortality declined as maternal education increased [28]. Later studies confirmed this positive association between low maternal education and high child mortality rates [32,42,45,49].
The association between maternal education and child mortality is not unique to Ghana; similar reports have come from other parts of the world [51]. For example, surveys conducted in some sub-saharan African countries provided initial evidence of the importance of maternal education on child survival, after controlling for socioeconomic factors such as place of residence and parents' occupation [52]. Based on data from ten developing countries, a later study confirmed the significance of both maternal and paternal education in improving child health [53]. It was estimated that the impact of parental education was more significant than the combined effect of access to health services and income [53]. Additionally, more recent studies have shown that the association between maternal education and child mortality remains strong in the developing world [54][55][56]. While maternal education has a strong positive impact on child survival [54], the exact mechanisms involved remain to be established. However, treatment-seeking behaviour of educated and non-educated mothers may provide important insights. Studies in some developing countries found particularly strong evidence for protective roles of maternal education, indicating that educated mothers were more autonomous in making child health decisions and were more likely to seek treatment from well-resourced health facilities [57,58]. Greenaway and colleagues argued that maternal education was strongly associated with health knowledge, helping to explain the association between maternal education and the use of health services [57]. In Ghana, the relationship between maternal education and health-seeking behaviour is no different. An investigation into the use of injection in treating childhood diseases reported limited interest in participating in immunisation programmes, partly due to mothers' low educational status, informing their fear of a possible link between injections and subsequent paralysis [36]. Subsequent studies showed that high maternal education had a positive association with the successful completion of immunisation programmes [34,38,44]. Another study reported that low level of maternal education was a main constraint against child feeding, health seeking and hygiene practices [29]. In line with this, two independent reports showed that strong positive correlations existed between high maternal education and nutritional status or complementary feeding of infants and children [30,40]. Additionally, van de Poel et al. [48] showed that a positive relationship existed between low maternal education and malnutrition. Similarly, a review of nationally-representative data on mothers interviewed at health facilities in Ghana concluded that efforts to improve maternal and child health services would require the promotion of education for women [21]. Taken together, the level of maternal education may inform health knowledge, complementary feeding, and mother's treatment seeking-behaviour for their children. These factors may underlie the strong impact of maternal education on child survival. Rural-Urban Disparities. Studies from some developing nations have revealed a significant impact of place of residence on child health. For example, child mortality rates were relatively lower in urban areas in Brazil compared to rural areas [59]. Reports from Kenya also showed that child mortality rates were higher in rural and urban slums compared to urban areas [60]. In Ghana, rural-urban residence is a crucial factor in determining child health outcomes. Antoine and Diouf [28] suggested that infant mortality rates were relatively lower in urban areas in Ghana, Senegal, Kenya, Benin and Cameroon [28]. Lavy et al. [19] and Wirth et al. [49] in two independent studies corroborated this finding, suggesting that eliminating rural-urban disparities by increasing access to birth services and improving water and sanitation services in rural areas would help to improve child health status. Brugha and Kevany [34] also reported that the completion of immunisation programmes within a year was positively associated with place of residence, maternal education and dependency. Similarly, subsequent studies showed that place of residence, wealth and maternal education significantly affected timeliness of child immunisation in Ghana [38,44]. Furthermore, several other studies have suggested that rural-urban disparities may be associated with various child health conditions in the country. For instance, van de Poel et al. [48] showed that rural-urban disparities interact with other factors such as poverty and maternal education to influence child malnutrition. Rural-dwelling children suffering from burns and those given first aid at home were less likely to receive care at a health facility [35]. Furthermore, a recent report suggested that place of residence in addition to other factors such as childcare practices and wealth index were significantly associated with a child's height-for-age-Z-score (HAZ) [25]. Overall, place of residence plays crucial roles not only in child mortality but also in their nutritional status and the completion of immunisation programmes. The seeming comparative advantage of urban residency over rural residency in terms of positive health outcomes may be due to the ready availability of health-influencing services such as water and sanitation infrastructure, good housing, and modern healthcare services in urban areas compared to rural areas [59]. Therefore, to reduce child mortality in Ghana will require extra focus on the provision of essential services in rural areas and urban slums to match those in urban settlements. Moreover, developing measures to retain health personnel posted to rural areas would be a good strategy to improve child health [41].
Family Income (Wealth and Poverty Index). A major theme in child health research focuses on understanding the relationship between national income and child mortality in developing countries. One such study estimated that should a country with an infant mortality of 50 per 1000 live births gain a 10% increase in the gross domestic product per capita purchasing power parity, the infant mortality rate will decrease to 45 per 1000 live births [61]. This demonstrates that wealth/poverty influences child survival. A strong impact of wealth/poverty status on child survival has also been recorded in Ghana. For example, Amugsi et al. [25] showed that children from homes with high household income had high HAZ. Hong (2007) [18] in an earlier study had reported that children in the poorest 20% of households were more than twice as likely to suffer from stunting compared to those in the richest 20% of the 6,251 households interviewed. A strong positive correlation between poverty and malnutrition has also been reported [48]. Household income is additionally a determinant of child health outcomes and child mortality [28,32], as well as the timeliness of immunisation [38] and complementary feeding of infants [40]. Together, financial status seems to be a strong determinant of malnutrition, child growth dynamics, participation in and completion of immunisation programmes, and child mortality in Ghana.
High Dependency/Multiparousity. An area given relatively less research attention is the effect of family size, polygamy, and multiparousity on child mortality [42]. However, high dependency influences child health outcomes [42]. A few studies have focused on this. Amugsi et al. (2014) [25] reported that high dependency strongly influenced a child's growth in Ghana, with children in households having numerous under five-year-olds recording lower HAZ. This implies that high dependency correlates negatively with HAZ [25]. Brugha and Kevany (1995) [34] also demonstrated that low dependency (a child's mother having less than five children) positively correlated with completion of immunisation programmes. Additionally, Kayode et al. [43] reported that children of grand multiparous mothers who were less breastfed were more likely to die during neonatal life. Furthermore, inequality in childhood mortality was closely associated with the level of dependency and the nuclear family type [27,49]

Policy Implications of the Identified Social Determinants
For health and social interventions to be more successful in addressing the impacts of the identified social determinants, these policies must be better targeted [2]. An effective approach would have to recognise that social determinants are usually clustered into multiple interacting factors. Hence, effective interventions should be comprehensive and integrated [3]. Importantly, population-based interventions might be more effective compared to individuallyfocused interventions [2,3]. Social determinants could be addressed either directly by implementing policies focused on reducing poverty, social inequality and discrimination, and promoting education or indirectly through the implementation of strategies aimed at removing the association between social risks and poor health outcomes [25,26]. The proposed direct approach would emphasise the fundamental values of social equity and fairness. In reality, a combination of the direct and indirect approaches might be preferrable. The increasing rate of child mortality and the growing influence of social factors on inequities in child health outcomes require that more fundamental changes be made in how the child health care system is structured, organised and financed in Ghana. Although a national health policy and its implementation strategy for children under five years were introduced to help reduce mortality among children within this age bracket to 4% by 2015 (in line with the Millennium Development Goal number four), this goal is unlikely to be achieved and the implementation period for the policy expires at the end of 2015 [62,63]. Possible reasons accounting for the lack of realisation of this goal should therefore be carefully sought and studied and measures to eliminate such factors incorporated in future plans. We therefore propose the following strategies to help reduce the negative impacts of social factors on children's health in Ghana.
Expand Interventions to Improve Access to Education. The Free Compulsory Universal Basic Education (FCUBE) policy was introduced in Ghana in 1995 with the aim of providing universal basic (primary and junior high school) education in the country by 2005 [64]. While the FCUBE policy was unable to achieve its target, it made significant contributions towards the improvement of basic education in the country [64]. The recent introduction of the capitation grant and the school feeding programmes has also helped to remove some barriers that poor families faced regarding their children's education, mainly through the elimination of tuition fees and the provision of meals during school hours. These initiatives have helped to improve access to, and affordability of, education [65]. Of particular interest is that there seems to be a limitation in the number of girls (who are potential mothers) benefitting from the current interventions, possibly due to the poor access to education in the most remote areas [66]. For nationwide improvement in maternal education (as a means to improve child health outcomes), further rural education interventions are encouraged. These may include the establishment of schools in communities lacking these facilities, resourcing existing schools with essential learning tools and materials, and the development of motivation packages to encourage trained teachers to accept posting to rural schools. Since high maternal education is negatively correlated with child mortality [51], expanding the FCUBE policy to include senior high schools might also be beneficial towards improving literacy rates and health knowledge of would-be-mothers.
Strengthen the Community-based Healthcare Programme. Quality child healthcare delivery is partly dependent on the equitable distribution and retention of skilled healthcare professionals. However, health workers in Ghana are concentrated in urban areas, leaving most rural facilities understaffed [67,68]. This rural-urban disparity has had significant impacts on child health outcomes [19]. Identifying and effectively addressing human resource distribution gaps through the revision of existing human resources policies are critical [15].
Ghana has made substantial progress in strengthening quality healthcare delivery in rural areas through the introduction of the Community-based Health Planning and Services (CHPS) initiative [69][70][71]. Trained community health workers provide basic preventive and curative community health services for communities with otherwise limited access to healthcare. Following an initial testing, the CHPS project scale-up was launched in 2000 and it currently covers all districts in Ghana [72]. However, the pace of scale-up within the districts has been rather slow, despite efforts such as the Ghana Essential Health Interventions Programme (GEHIP) launched in 2010 to help accelerate this process and expand the range of services provided [72]. Health centres and CHPS compounds are organised to provide primary care at the community level, while secondary and tertiary health services are provided by district, regional and teaching hospitals [73]. While the establishment of CHPS compounds has helped to improve access to healthcare [69], there are however some problems confronting this programme. These include (i) accessibility-communities that are extremely remote from CHPS compounds are not adequately served by these services, and (ii) inadequate logistics and pharmaceutical product allocation [71]. In tackling these challenges, stakeholders should periodically review the location of existing CHPS compounds in relation to human settlements and establish new compounds as appropriate.
Address the Healthcare Financing Bottlenecks. A major determinant of child health in Ghana is poverty [18,48]. To provide risk protection to poor households and improve equity in the provision of healthcare, the country has turned to social health insurance [74][75][76]. Ghana's National Health Insurance Scheme (NHIS) was launched in 2004 with the aim of providing a pro-poor healthcare finance system. The NHIS is an implementation of the World Health Assembly's resolution that urged member states to ensure financial protection to all citizens, particularly children and reproductive-aged women [75]. The implementation of the NHIS has recorded many success stories, such as helping to reduce out-of-pocket health expenditure, particularly for the aged [76,77]. Notwithstanding the significant impact of the NHIS, there are compelling evidence pointing to inequities in enrolment; the scheme is generally not reaching the poor, with enrolment from the poorest quintile in the country being lower than the richest [74,75,78]. In addition, the need to provide risk protection and reduce financial barriers to maternal services led to a fee-exemption policy for antenatal care [79]. However, the rich has benefitted more than the poor for whom the policy was primarily introduced [79,80]. Moreover, only the first postnatal visit is reimbursed, leaving parents to directly fund subsequent visits through out-of-pocket interventions [15]. To ultimately achieve equitable financial protection for all citizens, reduce health-related financial risks, and ultimately improve child health services, NHIS enrolment and financing strategies should be revised to better accommodate and/or guarantee pre-payment for the poorest and most vulnerable households.
Establish Parent-Professional Partnerships with an In-built Common Accountability Framework. Efforts by the Government alone may not be enough to improve child health and survival in Ghana [81]. Effective transformation of the current healthcare system would require the efforts of all stakeholders, particularly healthcare professionals and families [17]. Family members are first-hand witnesses to the actual impacts of social determinants on child health, and often have insights into which improvements would be the most beneficial for their local communities [82]. This knowledge can, therefore, be harnessed via a community-based participatory research approach and parent-professional collaborative initiatives to design and implement population-specific interventions [81]. Creation of a web-based social networking technology for local measurement of social risks impacting health outcomes of children would also provide a means of empowering parents to act on behalf of their children both as individuals and as community members [2,3]. Establishing a parent-professional relationship as a reciprocal partnership with common health targets could contribute to reforming the healthcare system to improve quality and reduce cost [82]. A potentially-viable approach here would be to build on the initial success of the CHPS programme to forge stronger relationships between families, communities and healthcare professionals towards improving child health outcomes especially at the rural community level [72]. Moreover, efforts to improve child health and survival might be enhanced by the development of a common accountability framework. Although the implementation of the Ghana national child health policy and child health strategy has helped in reducing child mortality to an appreciable extent [14], incorporation of an accountability framework might have helped to further reduce the mortality rates. The development of a more effective approach for the measurement of outcomes may help in aligning existing disparate programmes along a set of common goals which may encourage crosssector collaborations. For example, the development of the Every Child Matters Framework has enabled the United Kingdom to achieve a common accountability framework [2]. The framework stipulates five outcomes, namely (i) be healthy (ii) achieve and enjoy (iii) stay safe (iv) make a contribution, and (v) achieve economic well-being [2]. The framework also provides sets of quality-of-care measures (satisfaction of parents who care for children with disabilities) and quality-of-life indicators (breastfeeding and obesity prevalence) [2]. Such shared accountability at the local or community level could be useful in facilitating cross-sector innovation and improvement efforts, which are essential if healthcare and other service providers are to join forces in addressing the fundamental causes of adversity and provide systemic kinds of support [83].
Raise Community Awareness and Map Populations Based on Social Risks. Some community beliefs, cultural practices and attitudes have detrimental impacts on child health in Ghana [23,84]. For example, some communities promote the exclusive use of (i) traditional medicine as first-line treatment for sick children, and (ii) untrained traditional birth attendants in childbirth services [85,86]. Some traditional neonatal illnesses are often classified as non-clinically treatable [87]. An example is that 15% of infant deaths were attributed to a belief in "chichuru" or spirit children [23]. These beliefs and practices can cause significant delays in childtreatment seeking. In order for child health-related knowledge to be better translated into action, there is the need to increase awareness beyond healthcare practitioners and researchers [1]. Families, community members and opinion leaders need to be made better aware of the prevailing social risks in their communities and the influence that these risks have on health outcomes [3]. This would require that more community education activities be conducted at the national, regional and local levels. Currently, the existing community engagement capacity to advocate for behavioural changeis inadequate, notwithstanding the inclusion of such measures in reproductive, child and maternal health policies [15]. Further measures are therefore required.
Geographic information system mapping tools would also be useful for stakeholders to monitor patterns of disease epidemiology and social risks across local populations. Notable examples of the usefulness of this approach can be found in Canada and Australia, where an Early Development Instrument was developed to address the need for a uniform methodology for assessing the level of child development in the first year of schooling [88]. This serves as a good prototype for such an approach in Ghana. Data obtained from such mapping exercises might show the impact of gradients in social risk, providing communities with the needed information to tackle social issues especially through intervention and preventive strategies.

Limitations
Most of the studies included in this review analysed data from nationally-representative surveys with individual and household response rates of about 96% and 99% respectively [43]. Although recall bias in this type of data collection is usually low, and appropriate stastistical methods were often used [43], there could be a problem with unobserved confounders in the studies using such data. For example, in estimating the impact of social factors on child mortality, it is possible that some infants may have died so early after birth that no social factor may have necessarily contributed to their death in which case the estimated dependence of their death on specific social factors may have been over-estimated. Moreover, because only surviving mothers had the opportunity to be interviewed, there remains a possibility that the association between child health and social factors may have been under-reported. Another limitation is that this review excluded some promising studies that were published solely in the abstract form (for example, in conference proceedings) as well as publications that were not indexed in the selected databases. This implies that the actual impact of some of the identified social factors may have been over-or under-stated and that perhaps some potentially high-impact social factors on child health in Ghana may have been missed.

Conclusion
The available evidence shows that the major determinants of health that affect child health in Ghana include maternal education, rural-urban disparities (place of residence), family income levels (wealth/poverty) and high dependency. An intriguing aspect of these social determinants is that they appear to be important for various kinds of diseases, ranging from obesity to autism. However, in Ghana, these social determinants are reported to be heavily linked to child mortality, nutritional status of children, completion of immunisation programmes, health seeking behaviour and hygienic practices. Although evidence on the influence of social determinants on the health of children has been documented over one and halif decades ago and some policies have been introduced to address these determinants, more policy changes and better implementation strategies are required. In designing a strategy to address this problem, stakeholders would have to recognise that social determinants are usually clustered into multiple interacting factors. We propose that developing a national child health policy agenda which supports families via both direct and indirect approaches would be crucial in addressing social determinants of health inequalities and improving child health outcomes in the country.
Supporting Information S1 PRISMA Checklist. A checklist of PRISMA guidelines followed in this systematic review. (DOC)